Liver Cirrhosis
Dr. Rudy Dwi Laksono
Causes of Cirrhosis
Viral hepatitis; B, D, and C Alcohol Metabolic Haemochromatosis Wilsons disease Alpha-1-antitrypsin deficiency Chronic biliary obstruction Extrahepatic biliary obstruction Intrahepatic biliary obstruction Venous outflow obstruction Veno-occlusive disease Budd-Chiari syndrome Cardiac failure Autoimmune chronic active hepatitis Drug and toxins
Complications of Cirrhosis
Variceal bleeding Ascites, refractory ascites Hepatorenal syndrome Hepatic encephalopathy Spontaneous bacterial peritonitis Hepatocelluler carcinoma
Causes of death
Variceal hemorrhage Spontaneous bacterial peritonitis Sepsis Liver failure Hepatic coma Functional renal failure Hepatocelluler carcinoma
Portal Hypertension Syndrome
Continuing Liver damage
Nodular regeneration
Fibrosis Increased sinusoidal pressure Portal Hypertension
Splancnic vasodilatation Decreased effective blood volume Increased sodium retention
Increased gastroesophageal collateral Formation of oesophagogastric varices Variceal rupture
Ascites
Variceal bleeding
Variceal Bleeding
A. Bleeding from varises is reported in about 20 60 % of case whit cirrhosis. B. Mortality of the first bleeding episode is around 50 % Preventime measure rationalto avoid development of Varices and bleeding (Primary proplylaris). C. Up to 70 % Of Patient Whoo do not receive treatment die within 1 year of the initial bleeding episode The Efforts in preventing bleeding seems to be crucial (secondary, prophylaxis)
Consensus in Portal Hypertension Baveno III
Monitoring for the Development of Varices in the Portal Hypertensive Patient. 1. All cirrhotic patients should be screened for the presence of varices at the time of the initial diagnosis of cirrhosis. 2. In compensated patients without varices, endoscopy should be repeated at 2-3 year intervals to evaluate the development of varices. 3. In compensated patients with small varices, endoscopyshould be repeated at 2 year intervals to evaluate progression of varices. 4. There is no indication for subsequent evaluations once large varices are detected.
Algorithm for cirrhosis Without Bleeding
Algorithm For Cirrhosis Without Bleeding
Cirrhosis Established
Upper Endoscopy
No varices
Small or Medium Varices
Large Varices
(2 3 years Evaluation)
Observe
(1 2 years Evaluation)
Observe
Primary Bleeding Prophylaxis
Reguler Interval Usually one week
Non Selectne Blockers (and /or long actmy Nitrates) Ligation
Algorithm For Bleeding Cirrhotis
Algorithm For Bleeding Cirrhotis
Resuscitae
Begin Octreotide (or Vasopressin) Early endoscopy Esophagel Non-Portal Gastric Varices Portal Varices Hypertensive Cause Hypertensive Gastropathy Treat appropriately
Continue octreotide 5 days
Begin beta-blocker when stable
Band ligation or injection Sclerotheraphy Ballon Tamponade Rebleeding No rebleeding Continue treatment Shunt (Child A) Preventation of Rebleeding TiPSS. or Pharmacological Treatment Liver transplantation (Child B or C) Ligation /Sclerotheraphy Reguler Interval Usually one week Eradication Repeated Endoscopy 3 6 month Rebleeding Shunt (Child A) TIPSS or Liver transplantation (Child B or C)
Dosis dan cara pemberian obat-obat vasoaktif pada perdarahan varises
Obat Vasopressin (VP) + Nitroglyserin (NG) Terlipressin Cara pemberian Dosis VP: i.v infus NG: percutaneus, bolus i.v, bolus VP: 0,4UU/menit Lama pemberian 48 jam
Somatostatin Octreotide
i.v bolus dan infus i.v, bolus dan infus
2 mg/4 jam 2-5 hari selama 24-48 jam pertama, kemudian 1 mg/ 4 jam 250 ug diikuti 2-5 hari 250-500 ug/jam 50 ug diikuti 50 ug/jam 2-5 hari
Spontaneus Bacterialis Peritonitis
Cirrhotic patients at high risk of SBP
Hospitalized cirrhotic patients with ascites and low ascitic fluid total protein (< 1 g/dl) Cirrhotic patients with gastrointestinal hemorrhage Cirrhotic patients with low ascitic fluid total protein (< 1 g/dL) and / or high serum bilirubin (>2.5 mg/dl) Survivors of an episode of SBP.
Diagnosis Peritonitis Bakterialis Spontan
Pasien sirosis hati dengan asites Pungsi asites
Nyeri perut panas
Gejala menyertai: Syok, perdarahan, gangguan kesadaran, gangguan motilitas, hipotensi, dll Asimtomatik.
Pungsi asites: periksa: PMN Kultur
Sel PMN > 250 Kultur + Monomikrobial
Sel PMN < 250 Ulangi pungsi 24 jam Kultur + Monomikrobial
PBS
BMNN (Bakterasites Monomikrobial Non-Neutrosistik)
Penatalaksanaan Peritonitis Bakterialis Spontan
PBS simtomatik Profilaksis PBS
Antibiotik pilihan : Sefotaksim 1-2 gram/hari selama 5-7 hari Amoksisilin+Asam klavulanat selama 5-7 hari
Ofloksasin Siprofloksasin Dosis standar 5-7 hari
Parasentesis ulang setelah 24 jam antibiotik
Sel PMN
Sel PMN
Antibiotik diteruskan
Ganti antibiotik
HEPATORENAL SYNDROME
Pathogenesis of Hepatorenal Syndrome
Cirrhosis
Sinusoidal portal hypertension
Splanchnic vasodilatation
Arterial underfilling
Reduced renal vasodilator factors
Baroreceptor-mediated activation of systemic Vasoconstriction factors Renal vasoconstriction
Increased intrarenal vasoconstriction factors
Hepatorenal syndrome
HEPATOCELLULAR CARCINOMA
Treatment of HCC depends on
1. Local resources 2. Stage of the disease 3. Presence of cirrhosis
Liver Transplantation Hepatic resection treatment of choice for the few patients with HCC and normal liver. Trans Arterial Chemo Embolization Cytostatica Interferon
Five years survival of pts with HCC treated by transplantation in 82 Europeans centers between 1988 and june 1994
Indication to transplantation Patients % Alive
HCC with Cirrhosis HCC without cirrhosis Cirrhosis with HCC p = 0.0004
361 446 176
46 34 54
from European Transplantation Register
KESIMPULAN
Sirosis hati, stadium terakhir dari penyakit hati kronis yang manifestasi kliniknya mengenai berbagai macam sistem dan organ tubuh. Komplikasi yang tersering adalah: Asites, Perdarahan varises, SBP, Ensepalopati hepatik, HCC. Penanganannya masih merupakan masalah yang menyulitkan Pengelolaan yang menyeluruh adalah hal yang terbaik
