Pharmacotherapy of Liver cirrhosis

1. Liver Cirrhosis
• RVS Chaitanya Koppala

2. Functions of liver

3. Causes of liver disease
Viral infections: HAV, HBV,
HCV, HDV, HEV
Alcohol
Non alcohol induced liver disease
(obesity , DM and other metabolic
disorders)
Immune disorders:
Autoimmune hepatitis (anti kidney,
anti smooth muscle antibodies)
Primary biliary cirrhosis (Anti
mitochondrial and granulomatous
destruction of lobular bile duct)
Primary sclerosing cholangitis( biliary
strictures, cholestatic and cirrhosis)
Vascular abnormalities
Metabolic and genetic
disorders:
 Hemochromatosis
 Wilson’s disease
 Alpha antitrypsin deficiency
 Glycogen deficiency
Drugs

4. Complications and symptoms

5. Investigations
Biochemical test:
simple, inexpensive and easy to perform
Aminotransferases (aspartate transaminases, alanine
transaminase): enzymes present in hepatocytes released
in blood only in case of liver damage (acute liver disease)
Alkaline phosphatase (present in cananicular and
sinusoidal membranes of liver and also in other sites like
bones, levels seen in chronic liver disease)
Gamma glutamyl transpeptidase (confirms the hepatic
origin of elevated levels of alkaline phosphatase enzyme)

6. Laboratory investigation of aetiology
• Derangement of liver functions should be investigation for Hepatitis
A, B and C
• Auto antibodies or immune globulins to screen for autoimmune
disease screening should be done
Serum ferratin
Ceruloplasmin
Alpha1 antitrypsin
Lipid profile

7. Imaging techniques
Ultrasound techniques for assessment of size, shape and texture , dilatation
of biliary duct
Patency of portal vein to check for portal hypertension (increased spleen ,
ascites) For checking Hepatocellular carcinoma, hepatobiliary malignancies
CT and MRI scan
Live biopsy:
Invasive procedure associated with mortality and morbidity
Remains the gold standard for diagnosis of liver damages and severity of
chronic liver disease
Recent advanced technique in liver biopsy is non invasive like
FIBROSCAN , effective in patients with HCV
In acute live dysfunction the liver biopsy is not necessary

8. Patient care
1. PRURITIS:
Prominent and distressing symptom in chronic liver disease and
tends to be most debilitating in cholestatic conditions.
Deposition of bile salts in the skin is primary contribution for pruritis.
Relief of biliary obstruction by endoscopy, radiology and surgical
means is indicated in patients with obstructed biliary systems
In some cases
Plasmapheresis (removing blood plasma from Blood)
Molecular Absorbants Recirculating Systems (MARS) (albumin
dialysis)
Liver transplantation recommended

9. Treatment
ANION EXCHANGE RESINS (Cholestyramine and Colestipol
4g/day/once or twice)
ANTIHISTAMINES (Cetirizine 10mg, Loratidine 10mg)
URSODEOXYCHOLIC ACID (10mg/kg daily in two doses)
RIFAMPICIN (↑Bile flow / 600mg/day/2-3wks)
OPIOID ANTAGONISTS (Naloxone , Naltrexone & Nalmefene)
TOPICAL PREPARATIONS (calamine lotion / menthol 2% in aq
cream)

10. Management of pruritis

11. 2. Clotting abnormalities
• 70% patients with chronic liver disease and 100% of patients with
acute liver disease
• Majority of Clotting factors (except factor V) depends on the Vit-K
• Patients with liver disease receive Phytomenadione (vitamin k)
10mg/daily / 3days
• Doesn’t improve the prothrombin time, because liver cannot utilize
vitamin to synthesize the clotting factors

12. Clotting abnormalities : pathophysiology

13. Precautions
Aspirin, NSAIDS and anticoagulants should be avoided in all patients
risk of antiplatelet action, GIT bleeding and ulceration
NSAIDS also implicated in Renal dysfunction and Vericeal bleeding in
patients with chronic liver disease
COX-2 inhibitors causes less risk , but still they are prohibited in
patients with liver disease

14. 3. Ascites
• The aim in treatment is to mobilise the
abnormal collection of third space fluid (intra
abdominal fluid)
• Achieved by ↓sodium intake (60-90mEq/day)
+ delayed reaccumulation of fluids (1-
1.5L/day)
• Aggressive fluid reduction in absence of
peripheral edema may leads to intravascular
fluid depletion and renal dysfuntion
• Potassium sparing diuretics, loop diuretics
and paracentasis (perforation in a cavity to
remove the fluids)/ colloid replacement

15. Approach in management of ascites
(chronic stage)

16. Management of ascites in patients

17. 4. Hepatic encephalopathy
• Reversible neuropsychiatric complication that occurs with significant
liver function
• Main cause unknown , but there are three main factors which affect the
hepatic encephalopathy
Portosystemic shunting
Metabolic dysfuntion
Alteration of Blood brain barrier
• Agents which causes this conditions
Ammonia
Free fatty acids
GABA
Glutamate

18. Hepatic encephalopathy

19. Treatment of hepatic encephalopathy

20. Thank you