IN P RIMARY C ARE S ETTING Thwin Maung Aye National University - PowerPoint PPT Presentation

E ND S TAGE L IVER D ISEASE IN P RIMARY C ARE S ETTING Thwin Maung Aye National University Hospital 18 th October 2014

R OLE OF F AMILY PHYSICIAN  Understanding natural history of cirrhosis and shared care with the institution  Prevention of liver cirrhosis  Understanding tumor (HCC) biology and surveillance  Understanding role of liver transplant and timely referral

O BJECTIVES OF THE TALK  To acknowledge the common scenarios, outline management plan and appreciate role of primary physician  To update new DAA for hepatitis C  To understand the rationale and indication of transplantation for appropriate referral

C OMMON SCENARIOS ? 1. Known fatty liver, regular follow up with LFT and USG which was reported as nodular surface 2. First time diagnosis of HBsAg+ve in view of abnomal LFT. USG reported as nodular surface 3. Patient present with leg swelling. Blood tests showed abnormal LFT and nodular liver surface

C OMMON SCENARIOS ? 4. Patient known cirrhotic but defaulted follow up and came to see you with bleeding PR 5. Known cirrhotic patient, on diuretics, lactulose and propranolol and come to see with confusion and worsening of ascites before hospital appointment 6. Patient came for weight loss, jaundice and palpable mass in RHC

C ASE SCENARIO FOR ESLD  50 years old man, Mr Ng, came to see you as a routine follow up for her hypertension, diabetes and hyperlipidaemia. He has been taking amlodipine, glipizide and simvastatin. He had no compliant. His BP was 140/90 mmHg and BMI was 30. Other clinical examination were unremarkable. USG done was reported as early cirrhosis and mild splenomegaly. His blood tests were as followed.  Hb 12, TWC 5.2, Platelet 120  Na 135, K 3.5, Urea 7, creatinine 98,  AST 80, ALT 68, Albumin 32, Bilirubin 8, AFP 5, INR 1.2  HBA1c 7.8, LDL 3.2, cholesterol 5.8, Tg 1.2

W HAT ARE YOU GOING TO DO NEXT ? A) Review history & investigations and optimize the control his metabolic syndrome and review in 3-6 months B) Refer to hospital in view of USG finding C) Refer to hospital in view of transaminitis D) A+B E) A+C 0% 0% 0% 0% 0% D) A+B E) A+C A) Review his... B) Refer to ho... C) Refer to ho... 15 Countdown

I F YOU PLAN TO REFER , WHAT WILL YOU DO BEFORE REFERRAL ? A) Further relevant history including social history B) Hepatitis marker C) Dietician review D) Compliance to medication E) All of above 0% 0% 0% 0% 0% C) Dietician review B) Hepatitis marker E) All of above D) Compliance to medic... A) Further relevant hist... 15 Countdown

I F HB S A G + VE , WHAT IS POSSIBLE DIAGNOSIS ? A) NASH B) HepB liver cirrhosis C) Cryptogenic cirrhosis D) Alcoholic cirrhosis D) A+B 0% 0% 0% 0% 0% . B H . . . . . . + . . S c c r A A i e n c N ) v i e D l i o g l ) A o B h t o 15 p p c e y l H A r C ) ) B D ) C Countdown

W HAT IS / ARE YOUR PLAN ( S ) OF MANAGEMENT ? A) Life style modification (dietician review , exercises) B) Optimization of his metabolic syndrome control C) Further evaluation of hepatitis B / other aetiologies D) Referral to hospital for evaluation of possible cirrhosis E) All of above 0% 0% 0% 0% 0% A) Life style ... B) Optimizatio... C) Further eva... D) Referral to... E) All of abov... 15 Countdown

M R N G WAS REFERRED TO NUH DC Here are the tests / evaluation done in NUH Confirmed Child A cirrhosis after the followings. Hepatitis B viral load: 6 log, HBeAg-ve, HBeAb+ve Hepatitis C (-)ve, HIV (-)ve, Autoimmune screening (-)ve Fibroscan: 19.8 kpa Liver biopsy: NI 4/16, Fibrosis 5/6 Tenofovir was started OGD: Small 2 column of varices, for surveillance Advice on low salt diet Advice for regular 6 monthly follow up in NUH

M R N G HAS REGULAR FOLLOW UP WITH YOU FOR HIS METABOLIC SYNDROME . W HAT IS YOUR CONCERN REGARDING HIS CIRRHOSIS ? A) No concern as he has appointment with NUH B) Adequate control of his metabolic syndrome C) make sure he has regular follow up for varices and HCC D) All above E) All above except A 0% 0% 0% 0% 0% B) Adequate co... C) make sure h... D) All above E) All above e... A) No concern ... 15 Countdown

B EFORE HIS NUH APPOINTMENT , YOU SAW HIM FOR HIS REGULAR CLINIC . M R N G SAID HE NOTICED ABDOMINAL DISTENSION WITHIN 1-2 WEEKS . W HAT IS YOUR IMPRESSION ? A) ascites from cirrhosis progression B) Portal vein thrombosis / HCC C) Poor compliance to diet particularly salt intake 0% 0% 0% 0% 0% D) To rule out Cardiac / E) All of above B) Portal vein thrombosis.. C) Poor compliance to di.. A) ascites from cirrhosis ... Renal failure D) To rule out Cardiac / ... E) All of above 15 Countdown

W HAT WILL YOU DO NEXT ? A) Start diuretics straightaway and review again B) Further evaluation including blood tests and USG C) Bring forward his appointment with NUH D) All above 0% 0% 0% 0% 0% E) All above except A B) Further ev... C) Bring forw... D) All above E) All above e... A) Start diur... 15 Countdown

M R N G HAS USG AND BLOOD TESTS DONE BY YOU . T HE RESULTS WERE AS FOLLOWED .  USG: moderate ascites, no focal lesion in the liver was reported  Albumin 28  INR 1.5  Creatinine 98, Na 130  Bilirubin 10, ALP 150  AFP 7.5,  Hb 10.5, TWC 3.8, Platelet 110  Child B

W HAT IS YOUR NEXT PLAN OF MANAGEMENT ? A) Start Diuretics and review in 1-2 weeks B) To monitor his weight and renal function C) Dietary advice together with salt restriction D) Send to NUH for 0% 0% 0% 0% 0% further management rather than bringing E) All above except D B) To monitor his weigh... C) Dietary advice togeth.. A) Start Diuretics and re... D) Send to NUH for fur... forward E) All above except D 15 Countdown

M R N G WAS SEEN BY NUH AS APPOINTMENT WAS BROUGHT FORWARD  NUH made minor adjustment of diuretics for ascites Dignostic paracentesis showed neutrophil count of > 250 and ciprofloxacin was started  Repeat OGD: Moderate varices 2 columns and beta propranolol was started  Appointment was given in 3 months to review (with scan and blood tests)

W HAT IS YOUR CONCERN NOW ? A) Cirrhosis care must be under NUH B) Joint care with you is still possible titrating diuretics, monitoring compliant of meds and diet and follow up 0% 0% B) Joint care with you is s... A) Cirrhosis care must b... 15 Countdown

J UST BEFORE APPOINTMENT WITH NUH , HIS SON CALLED YOU TO TELL YOU THAT M R N G IS CONFUSED AND VERY SLEEPY . W HAT DO THINK THE POSSIBLE CAUSE ( S )? A) Hepatic encephalopathy B) Stroke C) Sepsis D) Dehydration and ureamic encephalopathy E) Possible all above 0% 0% 0% 0% 0% B) Stroke C) Sepsis E) Possible all above A) Hepatic encephalopathy D) Dehydration and ure... 15 Countdown

W HAT WILL YOU DO NEXT ? A) Review the patient to find out precipitating causes B) Advice to send to NUH straightaway 0% 0% A) Review the ... B) Advice to s... 15 Countdown

T HE FOLLOWINGS ARE FINDINGS WHEN YOU REVIEW .  GCS 15/15, drowsy but orientated to time, place , person  BP 100/70mmHg, HR 90/min, afebrile, HC 7, neurology: NAD, PR: stale maleana  Bloods: Na 130, Urea 18, Creatinine 180, CRP 15, INR 1.5, Hb 10.2, platelet 120  No new drugs were taken lately

W HAT IS YOUR IMPRESSION ? A) Electrolyte imbalance B) Grade I encephalopathy C) Variceal Bleeding D) Sepsis E) Possible all of above 0% 0% 0% 0% 0% D) Sepsis C) Variceal Bleeding A) Electrolyte imbalance E) Possible all of above B) Grade I encephalopathy 15 Countdown

W HAT IS YOUR NEXT ACTION ? A) Give stat dose of broad spectrum antibiotics B) Stop diuretics C) 2 large bore IV plug and IV drip D) Advice to go to ED, NUH ASAP E) All of above 0% 0% 0% 0% 0% E) All of above B) Stop diuretics C) 2 large bore IV plug an... A) Give stat dose of bro.. D) Advice to go to ED, ... 15 Countdown

M R N G WAS ADMITTED TO NUH. H E WAS TREATED FOR VARICEAL BLEEDING BY EVL, ANTIBIOTICS , PPI . ELECTROLYTE WAS CORRECTED . H E HAD REPEAT USG SCAN DURING ADMISSION .  USG showed suspicious lesion in segment 6 about 1.2 cm and confirmed HCC with CT after his AKI settled  Further blood tests: Bill 34, INR 1.8, Creatinine 132, Albumin 27, Moderate ascites, Ecolic in blood  Multidisciplinary team discussion on risk of treatment of HCC in view of his Child C status vs liver transplant option as of MELD 20 (MELD 20-29: mortality 76% 3 months) once infection is under control

L EARNING POINTS  Natural history of cirrhosis  stable but can be suddenly deteriorating  Joint care will optimize patient’s condition  Adjusting threshold of both sides for optimizing care  Recognition of primary care involvement in cirrhosis  Antiviral reduced risk of HCC not prevent HCC

R OLE OF FAMILY PHYSICIAN  Shared care of patients with institution  Ascites, hepatic encephalopathy, GI bleeding  HCC surveillance / understanding of tumor biology  6-12 monthly scan and LFT, AFP  Timely referral to liver transplant centre  Clinical indications (CP score, bleeding, ascites, HE, HCC)  MELD ≥15  Prevention of cirrhosis  Alcohol abuse, screening for viral hep, control risk factors for NAFLD  Vaccination programme

N ATURAL HISTORY OF E ND S TAGE L IVER D ISEASE Cirrhosis 18-20% Decompensation 20-30% HCC 6-15% Death Fattovich et al . Hepatology 1995; Liaw et al . Liver 1989; Ikeda et al . J Hepatol 1998 .