Liver Disease Complications

9/7/2016

Adapted from Pouya Gharahdaghi's Grand Rounds Lecture, September 7th, 2016

A discussion of acute liver disease, hepatitis, hepatic encephalopathy and coagulopathies and complications of liver disease

Viral Hepatitis

Hepatitis B: Frequently sexually transmitted or parental transmission. Usually vaccinated for in the US. If exposed to Hepatitis B blood, ensure the patient is appropriately vaccinated. If they are not appropriately vaccinated, then the patient should receive HBIG as well as the Hep B vaccine at 0, 1, and 6 months.

Hepatitis C: Frequently transmitted by IV drug use, asymptomatic in most initially infections, however 75% will progress to chronic hepatitis.

Hepatitis E: Associated with Hep B and results in fulminant hepatitis.

Toxic Hepatitis

Acetaminophen: Causes 40% of liver failure

150mg/kg is considered toxic
Levels 4 hours after ingestion should be pulled
Treatment with N-acetyl cysteine per poison control

Alcoholic Liver Failure
Medications
Amantia & Phalloides mushrooms

Chronic Hepatitis and Cirrhosis

Cirrhosis becomes symptomatic when 80% of the liver is damaged & cirrhotic. Symptoms will frequently include esophageal varicies, ascities, hemorrhoids.

Further evaluation for liver disease complications includes abdominal ultrasound, chest X-ray, and laboratory evaluation.

Spontaneous Bacterial Peritonitis

Identification of SBP by paracentesis requires 30-40cc of ascites. Lab evaluation should include;

Anaerobic & Aerobic Cultures
pH, chemistry
Cell Count
LDH, tumor markers

Patients with ascites have a 20-40% likelihood of having SBP. 13% of those with SBP will be asymptomatic. Treatment is with a 3rd generation cephalosporin. If the patient has a recent history of abdominal surgeries, Metronidazole should be added.

Hepatic Encephalopathy

A diagnosis of exclusion, seen with chronic liver failure due to failure of the liver to process ammonia. Although an ammonia level is useful in acute failure, ammonia levels are less useful for trending in chronic liver failure. Normally, ammonia is converted to Urea and removed by the GI tract. When ammonia is elevated, it is modified to glutamine, which crosses the blood-brain-barrier causing swelling and altered mental status.

Treatment is lactulose by naso-gastric tube if altered and unable to take PO, or rectally. This can be combined with Rifaximin to increase the rate of resolution and mortality.

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