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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

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concerns
Considercommunity-basedassistedwithdrawal.
Drinking >30 unitsalcohol/day OR score >30 onSADQOR significant physical or psychiatric comorbidities OR patient safety concerns (e.g. experience of withdrawal-related seizures or delirium tremens during previous assisted withdrawalprogrammes)
Considerinpatient-basedwithdrawal.
Patienteducation
Agreeatarget.Abstinenceisusuallymostappropriate,butsomepatientsmayprefertomoderate theirintake.Alwaysconsideroutcomesofanyprevioustreatment.
Lifestyleandsimpleinterventions
Provideinformationaboutself-helpgroups(e.g.AlcoholicsAnonymousorSMARTRecovery) Considerresidentialrehabilitation.
Psychologicalinterventions
Considercognitivebehaviouralorsocialtherapies.
Pharmacologicalmanagement
Community
Use a benzodiazepine such as chlordiazepoxide, or carbamazepine, using a fixed-dose weaning regimen Titrateinitialdosetoseverityofdependence/consumption Monitorthepatienteveryotherdayandprescribenomorethan2daysofmedicationatonetime Graduallyreducebenzodiazepinedosesover7–10days Afamilymemberorcarershouldpreferablyoverseetheadministrationofmedication Adjustthedoseifseverewithdrawalsymptomsoroversedationoccurs.
Inpatient
Useabenzodiazepinesuchaschlordiazepoxideusingeitherfixed-doseorsymptom-ledregimens (basedonCIWA-Arscore)andusinglocalprotocol Graduallyreducethedoseover5–10days.
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Alcoholwithdrawalseizures
Usearapidlyactingbenzodiazepine,e.g.4mgIVlorazepam Reviewthewithdrawalregimentoreducethechanceoffurtherseizures.
Deliriumtremens(acuteconfusionwithhallucinations,usuallywithin3daysofalcohol
withdrawal)
First-linemanagement: lorazepam (parenteral iforal is declined), e.g.1–4mg orallyin divided doses(0.5–2mgindivideddosesifelderly) Second-linemanagement:parenteralhaloperidol If deliriumtremens develops duringtreatmentforacutealcoholwithdrawal,reviewthepatient’s withdrawaldrugregimen.
Wernicke’sencephalopathy
Prescribeparenteralthiamine,e.g.Pabrinex®,2–3pairsofampoules,TDSfor3–5daysandthen 1pairofampoulesODforafurther3–5days Oralthiaminetreatmentshouldfollowparenteraltherapy.
Bothcommunityandinpatients
Adjunctstoaidreductioninalcoholintake(if>15onSADQ)
Aftersuccessfulwithdrawal, consideracamprosateor oral naltrexonealongside apsychological intervention Cautionwithnaltrexone(opioidantagonist)ifpatientistakingopioidtherapies Prescribeforupto6monthsandmonitormonthly Disulfiramcanbeusedasanalternativebutiscontraindicatedinpregnancyorifthepatienthasa severementalhealthorcardiovasculardisorder Alcohol,includingtheamountincludedinsomefoods,interactswithdisulfiramwhichmaycause complicationsincludingarrhythmias Disulfirammayalsorarelycausehepatotoxicity.CheckLFTandU&Epriortoprescribing.
Nutritionalsupplementation
Offerprophylacticoralthiaminetoharmfulordependentdrinkerswhenthey:
Aremalnourishedoratriskofmalnourishment Havedecompensatedliverdisease Areinacutealcoholwithdrawalorabouttostartawithdrawalprogramme.
Psychosocialconsiderations
Consider referral to the psychiatry team for those patients with a significant comorbid
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mentalhealthdisorderandthoseassessedtobeathighriskofsuicide.
Ifapatientismalnourishedorhasdecompensatedalcoholicliverdiseaseandtheyare admitted to hospital with an acute illness, they should be given parenteral thiamine initially,followedbyoralthiamine.
Complicationsofharmfulalcoholintake
Wernicke–Korsakoffsyndrome(Box35.2) Alcoholiccardiomyopathy Renalfailure(IgA-inducednephropathy) Nervoussystem(centralandperipheralneuropathy) Chronicpancreatitis ArLD(seeChapter34).
Specialconsiderations
Family
Recognize the impact on family members; provide information on alcohol misuse and how to supporttheirrelative Considertheeffectofaparent’sdrinkingonanychildwhoisintheircareanddiscusswithsocial servicesiftherearesafeguardingconcerns.
Pregnancyandbreastfeeding
Alcoholinpregnancycanaffectfetaldevelopmentandcanalsocrossintobreastmilk.
Furtherreading
1.SherKJ,TalleyAE,LittlefieldAK,etal.(2011).Alcoholuseandalcoholusedisorders.In:Friedman HS (ed) The Oxford Handbook of Health Psychology (pp. 686–737). Oxford: Oxford University Press. Available at:https://www.oxfordhandbooks.com/view/10.1093/oxfordhb/9780195342819.001.0001/oxfordhb-
9780195342819-e-028
2.NICE.Alcoholusedisordersoverview.Available at:https://pathways.nice.org.uk/pathways/alcohol-
use-disorders
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1 Victor M, Adams RD, Collins GH. The Wernicke-Korsakoff syndrome: a clinical and pathological
studyof245patients,82withpost-mortemexaminations.ContempNeurolSer.1971;7:1–206.
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Chapter36
Livercirrhosis
Guidelines:EuropeanAssociationfortheStudyoftheLiver(EASLClinical
Practice Guidelines for the management of patients with decompensated cirrhosis): https://www.journal-of-hepatology.eu/article/S0168-
8278(18)31966-4/fulltext
NICE NG50 (Cirrhosis in over 16s: diagnosis and management):
https://www.nice.org.uk/guidance/ng50
Baveno VI Faculty (Expanding consensus in portal hypertension):
https://www.journal-of-hepatology.eu/article/S0168-8278%2815%2900349­9/fulltext
European Association for the Studyof the Liver,American Association for theStudyofLiverDiseases(Hepaticencephalopathyinchronicliverdisease: 2014PracticeGuideline):https://www.journal-of-hepatology.eu/article/s0168-
8278(14)00390-0/fulltext
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Liver cirrhosis is characterized by progression from a stable, asymptomatic state of ‘compensated’disease,to a‘decompensated’phasemarked by theclinicalconsequences ofliverfailure.Thistransitionrepresentsasharpdeclineinprognosis,withareductionin median survival from 12 to 2 years. Many patients attending hospital acutely with complicationsofliverdiseasehavefeaturesofdecompensation.
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Diagnosis
Decompensated cirrhosis is usually clear from the patient’s history, examination, and biochemistry.Imagingmayhelpconfirmthediagnosis.
Consider using an admission checklist such as the ‘BSG-BASL Decompensated Cirrhosis Care Bundle—First 24 Hours’ (see Further reading) to ensure timely and comprehensive management for any patient admitted as an emergency with decompensatedcirrhosis.
History
Considerriskfactorsforcirrhosis,including:
Alcoholexcess HepatitisBorC Obesity(non-alcoholicfattyliverdisease(NAFLD)) T2DM.
Rarercausesincludehaemochromatosis,Wilson’sdisease,PSC,primarybiliarycirrhosis,and autoimmunehepatitis.
Considersymptomsthatmayreflectdecompensation:
Jaundice Abdominalswelling Alteredmentalstate OvertGIbleeding.
Ifdecompensationisevident,considerpossibletriggers:
Infection GIbleed Recentalcoholexcess Constipationordehydration Drugs(diuretics,opiates).
Examination
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Hands:clubbing,palmarerythema,Dupuytren’scontracture Asterixis(‘liverflap’):lookfor‘flapping’ofhandswhenwristsarehyperextended Face:xanthelasma,yellowsclera Limbsandbody:sarcopenia(lossofmusclebulk) Chest:gynaecomastia,spidernaevi Abdomen:ascites,hepatomegaly,splenomegaly Legs:peripheraloedema DRE:melaena.
Investigations
Bedside
Diagnosticparacentesis(‘ascitictap’)
Ifascitesispresent,performASAP Sendforneutrophilcount,culture,albumin,andtotalprotein Do not wait for bloods results (including the coagulation profile) before obtaining the diagnostictap
Weight/BMI.
Bloods
FBC:
↓haemoglobin(GIbleed,anaemia) ↓platelets(hypersplenismfromportalhypertension) ↑whitecellcount(infection)
↑CRP(infection):
CRPresponsemaybeattenuatedinpatientswithsevereliverdysfunction
Renalfunction:
AKI—see‘Hepatorenalsyndrome’ ↑urea:creatinineratio(GIbleed)
LFT:
↑bilirubin,↑ALP,↓albumin(impairedliverfunction) ↔/↑ALT/AST(indicateliverinflammation,canbenormalincirrhosis)
Coagulationprofile:
↑PT/INR(impairedliverfunction) Bloodcultures Consideranon-invasiveliverscreeniffirstpresentationofcirrhosis(Table36.1).
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Table36.1Componentsofanon-invasiveliverscreen
Test Disease
HBsAg HepatitisB
Anti-hepatitisCantibodies HepatitisC
Ferritin(checktransferrinsaturationsifferritinelevated) Haemochromatosis
Alpha-1antitrypsinlevel Alpha-1antitrypsindeficiency
Fastingglucose/high-densitylipoprotein/triglyceride Metabolicsyndrome/NAFLD
Liverautoantibodyscreen Primarybiliarycirrhosis(anti-
mitochondrialantibody) Autoimmunehepatitis(ANA)
SMA(anti-SMA) LKMA(anti-LKMA)
Immunoglobulins Autoimmuneliverdisease
Caeruloplasmin±serumcopper(usuallyonlyifage<40years,resultsmay bemisleadingindecompensatedliverdisease)
Wilson’sdisease
Imaging
Transientelastography(‘Fibroscan®’)
Usesultrasoundtomeasureliverstiffness <10kPaplusabsenceofclinicalsigns:excludescirrhosis >15kPa:↑probabilityofcirrhosis Nottechnicallyfeasibleifpatienthassignificantascites.
Ultrasound
Candemonstratefattyliver/cirrhosisandliverlesions(includingHCC) Detectsportalorhepaticveinthrombosis.
CTliverwithtriplephasecontrastorMRIliver
Detaileddelineationofvascularanatomy Characterizationofliverlesions.
Other
Liverbiopsy:
Invasiveprocedure
Usedtoclarifydiagnosisifaetiologyorseverityofdiseaseisunclear.
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Management
Patienteducation
Educatepatientson the cause, prognosis, and potential complications ofcirrhosis, and lifestyle factorsthatmayaffectthedisease(e.g.alcoholexcess,IVdruguse,obesity).
Lifestyleandsimpleinterventions
Ifpossible,theaetiologicalfactor(s)causingliverinjuryshouldberemovedortreated:
Cessationofalcoholuseandtreatmentofviralhepatitisisassociatedwithimprovedsurvival
andlowerriskofdecompensation Ensuregoodnutrition:
Malnutritionleadstopoorerprognosisandhigherriskofcomplications
Dieticianassessment
Encouragefrequent,smallmeals.
Psychologicalinterventions
Alcoholabstinence:
Refertohospitalalcoholcareteamifavailableorcommunityalcoholservices
Motivationalinterviewingtoencouragepatient’sbeliefintheirabilitytochange
ConsiderCBTorreferraltocommunitysupportgroups(e.g.AlcoholicsAnonymous).
Pharmacologicalmanagement
AvoidNSAIDs,sedatives,andopioidanalgesiawherepossible Dailymultivitamintablet.
Interventionalradiology
Transjugularintrahepaticportosystemicshunt(TIPSS)
Radiologically placed stent inserted between portal and hepatic veins, creating a shunt that reducesportalhypertension Indications:
Refractoryascites
Uncontrolledorrecurrentvaricealbleeding Contraindications: right-sided heart failure, pulmonary hypertension, active sepsis, hepatic encephalopathy,extensiveHCC.
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Surgicalmanagement
Livertransplantation
Definitivetreatmentofdecompensated cirrhosis andselectedcases ofHCCwherethelength or quality of life with transplantation is expected to exceed that without; average 5-year survival followinglivertransplantationisinexcessof80% Indicationsforlivertransplantationincirrhosisarepatientswithcomplicationsofcirrhosisinthe context of a qualifying UKELD score (prognostic score used in CLD to predict the need for transplant):
Refractoryascites
Recurrent,overthepaticencephalopathy
Othercomplicationsofportalhypertensionnotresponsivetoothertherapy PrioritizedinUKbasedonclinicalneed,stratifiedbyUKELD Contraindications include extrahepatic malignancy, severe cardiorespiratory disease, systemic sepsis,expectednon-compliancewithdrugtherapy,ongoingalcoholconsumption.
Psychosocialconsiderations
If required, attempts should be made to help patients find stable accommodation, attend appointments,andmanageaddictivebehaviours.
Complications
Gastricoroesophagealvarices
Diagnosis:
Patients with cirrhosis should be risk stratified for the presence of clinically significant
varices:
Baveno VI criteria include liver stiffness <20kPa and platelet count >150 × 109/L. Patientswhosatisfythesecriteria haveaverylow riskofhaving clinicallysignificant varicesandthereforescreeningendoscopyisnotrequired
Managementandprophylaxis:
Fortreatmentandprophylaxisofacutevaricealbleeds,seeChapter27.
Ascites
SeeTable36.2.
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