02__SIROSIS HEPATIS

7/23/2019 02__SIROSIS HEPATIS

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Liver Cirrhosis

Dr. Soegiarto Gani, SpPD


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Causes of Cirrhosis Viral hepatitis; B, D, and C

Alcohol

Metabolic

Haemochromatosis

Wilsons disease

lpha!"!antitr#psin deficienc#

Chronic biliary obstruction

$%trahepatic &iliar# o&struction

'ntrahepatic &iliar# o&struction

Venous outflow obstruction

(eno!occlusive disease

)udd!Chiari s#ndrome

Cardiac failure Autoimmune chronic active hepatitis

Drug and toxins


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Complications of Cirrhosis

Variceal bleeding

Ascites, refractory ascites

Hepatorenal syndrome

Hepatic encephalopathy

Spontaneous bacterial peritonitis Hepatocelluler carcinoma


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Causes of death

Variceal hemorrhage

pontaneous bacterial peritonitis

epsis

!iver failure

"epatic coma #unctional renal failure

"epatocelluler carcinoma


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Continuing Liver damage

Nodular regeneration

Fibrosis

Increased sinusoidal

pressure

Portal Hypertension

Splancnic vasodilatation Increased gastroesophageal

collateral

Formation of

oesophagogastric varices

Decreased effective bloodvolume

Variceal rupture

Variceal bleeding

Increased sodium retention

scites

Portal H#pertension S#ndrome


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(ariceal )leeding


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A.A. Bleeding from varises is reported in about 20 60Bleeding from varises is reported in about 20 60

% of case whit cirrhosis.% of case whit cirrhosis.

B.B. Mortality of the first bleeding episode is around 0Mortality of the first bleeding episode is around 0%%

!.!. "p to #0 % $f atient &hoo do not receive"p to #0 % $f atient &hoo do not receive

treatment die within ' year of the initial bleedingtreatment die within ' year of the initial bleedingepisodeepisode

reventime measure rationalto avoid developmentreventime measure rationalto avoid developmentof (arices and bleeding )rimary proplylaris*.of (arices and bleeding )rimary proplylaris*.

+he ,fforts in preventing bleeding seems to be+he ,fforts in preventing bleeding seems to becrucial )secondary- prophylais*crucial )secondary- prophylais*


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!onsensus in ortal /ypertension Baveno !onsensus in ortal /ypertension Baveno

Monitoring for the 1evelopment of (arices in the

ortal /ypertensive atient.'. All cirrhotic patients should be screened for thepresence of varices at the time of the initialdiagnosis of cirrhosis.

2. n compensated patients without varices- endoscopy

should be repeated at 23 year intervals toevaluate the development of varices.

3. n compensated patients with small varices-endoscopyshould be repeated at 2 year intervals to

evaluate progression of varices.4. +here is no indication for subse5uent evaluationsonce large varices are detected.


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Algorithm for cirrhosis $ithout Bleeding

Algorithm ForCirrhosis Without

BleedingCirrhosis

!stablished

Reguler Interval

Usually one week

"pper !ndoscopy

%o varices mall or Medium

VaricesLarge Varices

#bserve#bserve

$% & ' years !valuation(Primary )leeding

Prophyla*is

%on electne Bloc&ers

'and (or long actmy %itrates) !igation

(2 3 years Evaluation)

lgorithm *or )leeding Cirrhotis


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lgorithm *or )leeding Cirrhotis

Algorithm #or

Bleeding CirrhotisResuscitaeBegin Octreotide

(or Vasopressin)

Early endoscopy

on!"ortal

#ypertensiveCause

Gastric (arices Esop$agel

Varices"ortal

#ypertensive

%astropat$y

+reat appropriatelyContinue octreotide * days)egin beta,bloc-er .hen stable

)and ligation or in+ection

Sclerotheraph#

)allon amponade

-e&leeding o re&leeding

'$unt ($ild )

*i"''+ or,iver transplantation ($ild B or )

ontinue treat-ent

"reventation o. Re&leeding Pharmacological +reatment/ Ligation /Sclerotheraphy

Reguler Interval

Usually one week

Repeated Endoscopy

3 0 -ont$

Eradication

'$unt ($ild )

*I"'' or ,iver transplantation($ild B or )

Re&leeding


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Dosis dan cara pem&erian o&at!o&at vasoatif pada

perdarahan varises+bat Cara pemberian Dosis !ama

pemberianVasopressin

'V) -

%itroglyserin

'%.)

V/ i0v infus

%./

percutaneus,

bolus

V/

1,233(menit

24 5am

6erlipressin i0v, bolus 7 mg(2 5am

selama 72824

5am pertama,

&emudian 9

mg( 2 5am

78* hari

omatostatin i0v bolus dan

infus

7*1 ug dii&uti

7*18*11 ug(5am

78* hari

+ctreotide i0v, bolus dan

infus

*1 ug dii&uti

*1 ug(5am

78* hari


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Spontaneus )acterialis

Peritonitis


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Cirrhotic patients at high ris of S)P

Hospitali/ed cirrhotic patients 0ith ascites and lo0 ascitic

fluid total protein 12 " g3dl4

Cirrhotic patients 0ith gastrointestinal hemorrhage

Cirrhotic patients 0ith lo0 ascitic fluid total protein 12 "

g3dL4 and 3 or high serum &iliru&in 156.7 mg3dl4

Survivors of an episode of S)P.


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Pasien sirosis hati dengan asites

Nyeri perut panas 0e1ala menyertai2Syo-3 perdarahan3 gangguan

-esadaran3 gangguan

motilitas3 hipotensi3 dll

simtomati-4

Pungsi asites

Pungsi asites2peri-sa2 P5N

6ultur

Sel P5N 7 '89 Sel P5N : '89

)5NN

$)a-terasites 5onomi-robial

Non,Neutrosisti-(

6ultur ; 5onomi-robial

P)S

6ultur ; 5onomi-robial

"langi pungsi

'< 1am

Diagnosis Peritonitis )aterialis Spontan


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P)S simtomati- Profila-sis P)S

#flo-sasinSiproflo-sasin

Dosis standar

8,= hari

ntibioti- pilihan 2

Sefota-sim %,' gram/hari selama 8,= hari

mo-sisilin;sam -lavulanat selama 8,= hari

Parasentesis ulang setelah '< 1am

antibioti-

Sel P5N Sel P5N

0anti antibioti-ntibioti-

diterus-an

Penatalasanaan Peritonitis )aterialis Spontan


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H$P8-$9L S:9D-8;$

P h i f H l S d


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Cirrhosis

Splanchnic vasodilatation

rterial underfilling

)aroreceptor,mediated

activation of systemic

Vasoconstriction factors

>enal vasoconstriction

Hepatorenal syndrome

>educed renal

vasodilator factors

Increased intrarenal

vasoconstriction

factors

Sinusoidal portal

hypertension

Pathogenesis of Hepatorenal S#ndrome


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H$P8C$LL


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reatment of HCC depends on

1. Local resources2. Stage of the disease

3. Presence of cirrhosis

Liver ransplantation

Hepatic resection treatment of choice for the

fe0 patients 0ith HCC and normal liver.

rans rterial Chemo $m&oli/ation

C#tostatica

'nterferon


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*ive #ears survival of pts 0ith HCC treated

transplantation in =6 $uropeans centers &et0een ">== and

+une ">>?

:ndication to transplantation atients Alive

HCC 0ith Cirrhosis @A" ?A

HCC 0ithout cirrhosis ??A @?

Cirrhosis 0ith HCC "BA 7?

p .?

from $uropean ransplantation -egister


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E$S';P


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02__SIROSIS HEPATIS