Post hepatitis cirrhosis

1-Feature of the cause

2-LCF
3-Portal hypertension
Liver
amebic hepatitis?? /

Cardic cirrhosis
liver
Liver
Congestion

Systemic congestion
Right side heart
Right side heart failure
Tricuspid stenosis
Tricuspid regurge
Pericardia effusion
Constrictive pericarditis


Liver

hepatic vein inferior vena cava

embolus inferior vena cava

congestion liver
cirrhosis
embolus inferior vena
cava hepatic vein
????? hepatic vein
liver ????? liver
hepatic vein liver liver
1

 Liver Budd-Chiari Syndrome

liver veno occlusive syndrome

congestion

liver


jaundice ?????cardic patient
cardic cirrhosis -1
hepatitis

Hemochromatosis
)(Bronze diabetes

4
hemosidrosis
hemochromatosis Organs
Organ liver


liver




hemochromatosis carcinogenic

intestine Mucosal
block


deficit mucosal block

6 clinical picture of
hemochromatosis

mental disturbances
hemochromatosis

-1 Liver liver cirrhosis
-2 heart cardio myopathy
-4 -3 hemochromatosis bronzed diabetes
diabetes diabetes
pigmentation


stimulation of the melanocytes
-5 mental disturbances
-6 testicular atrophy
Investigations
1-investigation for the cause

Binding capacity
2- Investigation for the liver cell failure
3-investigation of portal hypertension

Treatment
500 250

250
hemochromatosis
60
56

56 12

repeated venesection iron chelator
desferal
hemochromatosis highly carcinogenic
hepatoma %30 hemochromatosis

)Wilson's disease (hepatolenticular degeneration

ceruloplasmin ceruloplasmin

tissue tissues Liver
Clinical pictures

-1 Liver hepatitis later on cirrhosis
-2 kidney acute tubular damage
-3 ) (hepatolenticular degeneration lenticular
lens kayser-Fleisher ring

) (hepatolenticular degeneration
lentiform nucleus basal ganglia
extra pyramidal manifestions
4

Investigations
Liver
liver ceruloplasmin
Treatment
chelating

Liver cell failure

Liver L C F

-2
-3

end stage
-1
Infection chronic hepatitis
chemical DHPI
L C F DDT, Halothane, Paracetamol,INH
physical sever burn
-4

Clinical pictures
Manifestions
11




f
1-fatigue,anorexia and loss of weight
fever -2 Low grade fever prolonged
fever jaundice hepatitis
fever fever jaundice L C F
chronic fever prolonged jaundice
???????fever
fever


manifestation Liver intestine
toxins Liver portal vein Liver

liver LCF liver
intestine Manifestation fever
intestine
toxins bacteremia
fever
fever
liver pyrogens

Manifestations
fetor hepatica -3
?????fetor hepatica
Intestine toxins toxins methyl
)mercaptan (which is normally absorbed from intestine
liver liver
saliva
manifestations specific LCF
Jaundice, Ascites and Encephalopathy
Liver

Ascites

Ascites
Ascites
hypoalbuminaemia

hypoalbuminaemia edema

2 portal hypertension
portal hypertension hypoalbuminaemia Ascites
-3 Liver aldosterone
Liver
liver salt and water
retention edema
portal hypertension

 aldosterone mechanism 2
Liver Liver aldosterone

hypoalbuminaemia hypovoluemia
renal blood flow kidney rennin rennin
aldosterone
-4 ADH Liver liver
ADH water retention edema
-5 liver weeping lymph
lymphatic obstruction lymph ) (Lymphorrhea
associated factors -6 TB peritonitis
Liver recurrent infection
TB peritonitis

Spontaneous bacterial peritonitis (SBP) %15 -10

infection immunity
Ecoli peritoneum Spontaneous
)bacterial peritonitis (SBP
prognosisvery bad
aspiration of peritoneal white blood cells
WBCs 250 cells/mm3 clinical manifestations
liver cirrhosis complicated e' SBP Liver
cirrhosis
* aspiration 1000 WBCs SBP
clinical manifestations

Treatment

Cefotaxime: 2gm 3t.d.s IV or Ciprofloxacin 400mg/12h for 5-10days.
WBCs 250


liver cirrhosis

SBP
Clinical fever and abdominal pain
-1
SBP Ascites
Ascites Refractory Ascites Ascites

Ascites
6
1 2 s

Salt restriction
Spirnolactone diuretics
aldosterone antagonist drug of choice

In full dose 100-400mg/day

cardio
lasix
)*( )))))
(((((
)(40-160 mg/d

side effect hypokalemia

sever hypokalemia
Ascites 40
500 cc
urine
urine )
(

aspiration aspiration
Ascites

 Ascites

aspiration



encephalopathy
Ascites

aspiration Ascites
lung fluid

Ascites urine

diuretics diuretics kidney
Ascites kidney

aspiration Ascites
-1 sampling
-2 relieve respiratory compression
-3 relieve renal compression
albumin
Ascites hypoalbuminaemia



.
aspiration

Ascites inferior
vena cava Peritoneum vein
Ascites
infection circulation
Liver Liver
Ascites

Investigation in case of Ascites

aspiration sampling
investigation cause

cultures cell count WBCs
250 SBP
amylase pancreatitis
Ascites

Encephalopathy

-1 Encephalopathy
-2 clinical picture coma
-3
liver
Encephalopathy
It's a neuropsychiatric syndrome that is seen in patients with acute or
chronic liver cell failure or protosystemic shunting.
Encephalopathy





Encephalopathy
Encephalopathy
Ammonia
creb's cycle
glutamic acid glutamine
CNS inhibition

10

 ) intestine
Intestine
liver
Liver
Encephalopathy

high ptn in diet
-1

-2 bleeding
bleeding

Encephalopathy

liver GIT
bleeding

liver
liver

-3 old blood transfusion very very
very fresh blood transfusion


Encephalopathy

Encephalopathy


hypoglycemic coma

-1 Spirnolactone
Hypokalemia
-2

-3 aspiration Ascites
Encephalopathy clinical pictures
precoma coma irritable

coma neuro
11

 coma warning signs

coma
2ASD
D
-1 Disorientation Encephalopathy
Disorientation

Disorientation

-2

-1

-1

-2

Disorder of behavior behavior

disorder D disorder


liver
disease
S
Sleep
) (inverted sleep rhythm


encephalopathy
Speech: slow, slurred or monotonous
-2
A
Apathy


) Asterixis(flapping tremor Asterixis
A

Treatment

-1 ICU endoscope
encephalopathy
bleeding endoscope bleeding

12


encephalopathy
-6 liver transplant
Diet -2 Fats
liver
Pre coma
Diabetes




pre coma


fat fat

fat nausea

Enema -3

-4 Enema Antibiotic
oral
IV

lactulose -5 laxative
lactulose H ions H ions
NH3 NH4 Ammonium
-1
-2
-3
-4
-5

Skin manifestation
)Cardiovascular manifestations (VDM
Endocrinal manifestations
Hematological manifestations
Hepato-renal Syndrome

skin cardic

skin cardic
)(VDM skin
VDM VDM Vaso Dilator material
13

 liver Liver
vasodilatation
skin manifestation cardic manifestations
skin
palmar erythema -1 root of metacarpal
thennar hypothennar
Spider naevi -2 arteriole
radiating capillaries arteriole capillaries
VDM
arteriole capillaries

nipple line

nipple line
White nail: white zone at the tip of the nail. -3
paper money skin -4

liver
numerous
small vessels scattered in skin over bony areas. Dorsum of foot,
hand, forehead and chest
varicose vein
-1

-2

cardic
Hyper dynamic circulation
liver
VDM
Cyanosis& clubbing

Cyanosis
liver

Cyanosis
cyanosis
cyanosis VDM A.V fistula
lung intra pulmonary A.V. shunt artery vein
shunt VDM
cyanosis
14

 shunt pulmonary portal

cyanosis
Ascites
cyanosis
Endocrinal manifestations
liver
ADH
Liver Liver
testosterone


Gynecomastia -1 unilateral
Gynecomastia estrogen
Gynecomastia Bilateral unilateral )
Gynecomastia ( unilateral or bilateral
Female distribution of suprapubic hair. -2
Impotence, -3 libido testicular atrophy

-1
-2

Breast atrophy libido
Amenorrhea & sterility

Blood manifestations

bleeding
Anemia
-1
Microcytic chronic blood loss
Normocytic Toxins inhibition of bone marrow
hypersplenism portal hypertension
Macrocytic Vit.B12 deficiency 12
liver

Bleeding tendency
-2
platelets hypersplenism portal
hypertension

15

 coagulation factors 10.9.7.2 fibrinogen

Liver k

Hepato renal Syndrome

Acute renal failure with no renal pathology in patients with sever
liver disease
kidney
prognosis % 80
NO

16