Thanks Dan for presenting an interesting case of a middle age man with HCV cirrhosis c/b HCC in the ICU after a motor vehicle accident with altered mental status, hyperkalemia, and volume overload. Dr. Cello gave us some awesome pearls!
- Of all the causes of cirrhosis there is one that will not progress to HCC: Congestive hepatopathy from heart failure
- There is no role for beta-blocker treatment to prevent recurrent variceal bleeds after banding has been performed because the varices have a very low incidence of bleeding. These patients may have upper GI bleed from other causes (gastritis, PUD, portal hypertensive gastropathy)
- Treating individuals with HCV who are actively using drugs is part of the End Hep C SF Initiative! Patients should be counseled about the risk of re-infection
- There are 5 reasons a cirrhotic will have worsening hepatic encephalopathy: increased gut protein load, infection, drugs, azotemia, or hypokalemia
Physical Exam in cirrhosis
- Spider angiomata: the number and size of spider angiomata correlate with the severity of liver disease
- Nail findings
- Muehrcke nails = horizontal white bands
- Terry’s nails = proximal 2/3 of the nail bed is white and distal 1/3 of nail bed is red
- This is different from half-and-half nails seen in renal failure where the proximal 1/2 of the nail bed is white and the distal 1/2 of the nail bed is red
- Both are due to hypoalbuminemia
- Per Dr. Cello: A cirrhotic liver from alcohol is often big and feels like cooked ham whereas a cirrhotic liver from viral causes is often small and not palpable below the costal margin
Treatment of Varices
- Pre-primary prophylaxis: Preventing variceal bleed by preventing varices.
- Current goal is to treat underlying cause of cirrhosis leading to portal hypertension. There is no data suggesting beta-blockers can prevent the developemnt of varices
- We should continue screen patients with cirrhosis for varices
- Primary prophylaxis: Preventing variceal bleeding by treating varices
- Can treat with beta-blockers or endoscopic variceal ligation. Studies have shown similar efficacy
- Beta-blockers reduce portal hypertension by decreasing portal venous inflow
- Variceal ligation should be repeated until the varices are obliterated. After they are obliterated they have a low risk of re-bleeding.
Treating HCV in IVDU
- If the goal is to eliminate HCV then we need to treat the population most affected
- Studies have shown successful (~95%) sustained virologic response in individuals treated with the direct-acting antivirals even when actively using drugs.
- After treatment positive antibodies do not project against from re-infection
- Reinfection rates in perviously cured individuals using drugs are ~5-10 per 100 person-years
- SFDPH is actively treating individuals using drugs as part of their End Hep C SF Initiative
5 causes to look out for in a patient with hepatic encephalopathy
- Protein load in the gut either from diet but more commonly from GI bleed
- Drugs – especially drugs that have their first pass through the liver such as benzos
- Hypokalemia worsening uremia