Transcript Symptom Control in Palliative Care

End of Life Care
in Liver Disease
Dr Allister Grant
Consultant Hepatologist
Leicester Liver Unit
East Leicestershire and Rutland CCG PLT 3rd Sept
Death rates for liver disease
Facts
 Liver
disease is the 5th largest cause of
death in the U.K.
 The
average age of death from liver
disease is 59 years, compared to 82-84
years for heart & lung disease

UK is one of few developed nations with
an upward trend in mortality.
Cirrhosis
Expanded Portal Tracts
(Blue)
Prognosis- Child Pugh Score
Score
1
Encephalopathy
Ascites
Bilirubin (µmol/l)
Albumin (g/l)
INR
0
Absent
<34
>35
<1.3
Child-Pugh class
A6
B = 7–9
C 10
2
I/II
Mild-moderate
34–51
28–35
1.3–1.5
3
III/IV
Severe
>51
<28
>1.5
Prognosis
1 Year Survival
– Child Pugh A
– Child Pugh B
– Child Pugh C
80 - 100%
60 - 80%
35 - 45%
Complications of End Stage Liver
Disease

Decompensated Cirrhosis




Variceal bleeding
Ascites
Encephalopathy
Other



Sepsis (SBP)
Hepatorenal syndrome
Hepatocellular carcinoma
Disease Progression
100%
Liver function
A
B
Cirrhosis
Years
C Liver Failure
Transplant
Death
Disease Progression
Liver function
50%
Cirrhosis
Liver Failure
Transplant
Death
Months
Portal
Circulation
Oesophageal varices
Management of Bleeding Varices

Prevention

Resuscitation

Endoscopy -

Pharmacotherapy- Terlipressin

Balloon Tamponade

TIPS/Transplantation
Band Ligation
Sclerotherapy
Oesophageal varices
Bleeding Gastric Varices
Variceal Bander
Variceal Band Ligation
Variceal Band Ligation
Variceal Bleeding in Palliative Care

May be occult and present as encephalopathy
-Gastric
-Duodenal
-Colonic



Resuscitate if appropriate
Correct coagulopathy
Give Terlipressin if known varices




As effective as balloon tamponade
As effective as endoscopic therapy
?Give PPI / sucralfate / tranexamic acid
Colonic varices- rectal balloon tamponade
Ascites
Causes of Ascites
20% of patients with ascites have a non hepatic cause
5% of patients with hepatic ascites have a second cause
Peritoneal disease- carcinomatosis, TB
Heart failure
Diabetic nephropathy
Hypoalbuminaemia of other causes
The Development of Ascites
Peripheral arterial dilatation
Reduced effective blood volume
Hypoalbuminaemia
Activation of renin-angiotensin-aldosterone system
Sympathetic nervous system
ADH
NaCl
Na retention
&
Water retention
Ascites and Oedema
Low urinary Na
Dilutional hyponatraemia
Plasma volume expansion
Ascites
Schrier et al Hepatol
General Management
Hepatic Ascites and Oedema

Salt restriction

Diuretics
spironolactone
frusemide

Water restriction if sodium < 125 mmol

Paracentesis
diagnostic (SBP, tumour)
therapeutic (Total vs partial + colloids)

Daily weight
Sampling of Ascites

Coagulopathy is not a contraindication to diagnostic paracentesis
(unless clinically evident fibrinolysis or DIC)

FFP/platelets are not required

In uncomplicated hepatic ascites request cell count and [Albumin]
PMN>250 cells/mm3 indicates SBP
transudate/exudate <25g/L/>25g/L
serum/ascites albumin gradient >11g/L= Portal Hyp
Runyon et al Ann Int Med 1992
Spontaneous Bacterial Peritonitis
Definition“SBP is a bacterial infection of ascitic fluid which arises
in the absence of any other source of sepsis within the
peritoneum or adjacent tissues”
PMN>250 cells/mm3
Mortality rate similar to that of a variceal bleed (20-40%)
Secondary prevention of SBP

Patients who survive SBP have a 1y recurrence rate of
40-70%

Norfloxacin 400mg/day reduces recurrence from 68% to
20%

Locally we use Septrin 960mg od Mon-Fri

Median survival of these patients is 9mo

These patients should be considered for liver
transplantation/ GSF
Sepsis in Cirrhosis
 Incidence1% of all admissions to hospital are due to sepsis
30-50% of cirrhotic patients admitted to hospital due to
sepsis
Once admitted 15-35% of cirrhotics develop infection
(c.f. 5-7% general hospital population)
General Management
Encephalopathy
Treat precipitants
• Sepsis
• GI bleed
• Medications (over-diuresis)
• Stop sedatives, hypnotics, opiates
• Constipation
Lactulose (NG/PR/PO)
Metronidazole/ Rifaximin/ neomycin -deafness
Acute Kidney Injury in CLD




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Exclude urinary infection
Exclude obstructive uropathy
Trial of volume
Avoid nephrotoxins
• NSAIDs
• IV contrast
Avoid over-diuresis
Avoid hypotension
Hepatorenal Failure carries grave prognosis
Hepatorenal Syndrome

Hepatorenal Syndrome is a severe complication of end
stage liver disease associated with an 80%-95%
mortality at 2 weeks.

The only interventions that have been shown to improve
survival are liver transplantation, the vasopressin
analogues and TIPS

Type 1 (Acute)

Type 2 (Chronic)
HRS Survival
Gines et al Lancet 2003
The Development of HRS
Increases
Reduced effective blood volume
↓
NSAID
Aminoglycosides
Diuretics
Sepsis
Terlipressin
Albumin
Peripheral arterial dilatation
Splanchnic
vasoconstriction
Activation of renin-angiotensin-aldosterone system
Sympathetic nervous system
ADH
NaCl
↓ Renal vasoconstriction
Reduced GFR
↑Renal
Perfusion
X
HRS
Na retention
&
Water retention
Ascites and Oedema
Low urinary Na
Dilutional hyponatraemia
Plasma volume expansion
Ascites
Schrier et al Hepatol
↓
Hepatocellular Carcinoma
 All
UK cirrhotic patients undergo 6 monthly
HCC surveillance with USS and AFP
 AFP
>400 is diagnostic of HCC
 Focal

lesion – MRI/triple phase CT
Arterialised nodule, washout in venous phase
Surveillance in Cirrhosis
 Surveillance
for Hepatoma
6 monthly AFP and USS
Pruritis
After exclusion of other causes of Itching consider

Biliary Obstruction
 PBC in the absence of Jaundice
 Cholestasis/Jaundice
 Drugs
Pruritis
 Biliary




Obstruction
Stones
Stricture
1 or 2 Tumour
Nodes
MRCP
ERCP
ERCP
Drugs for Pruritis

Non-Specific Management




Lubricants/Topical agents
Reduce irritation
Prevent scratching
Systemic Anti-pruritics
• Atarax
• Fexofenidine etc

Liver Disease





Cholestyramine
Ursodeoxycholic acid
Rifampicin
Opioid antagonists, naloxone , naltrexone
Ondansetron
Other Treatments
•
Ultraviolet light exposure
•
Plasmapheresis
•
Liver Transplantation
Future

Liver disease is an important cause of mortality in the
U.K. In 2000 it killed more men than Parkinson’s disease
and more women than cancer of the cervix.

~1% of population HCV positive

Mortality from Alcoholic liver disease doubled in 10 years

Incidence of liver cancer has doubled in 10 years

4% of the population have abnormal liver function

50% people with colorectal cancer develop liver
metastases, 20% resectable
The End
“All right, let's not panic.
I'll make the money by selling one of my livers.
I can get by with one “
Doh!