KOMPLIKASI

SIROSIS HATI
Dr. Shahrul Rahman, Sp.PD

Departemen Ilmu Penyakit Dalam

Fakultas Kedokteran
Universitas Muhammadiyah Sumatera Utara

Complications of Cirrhosis

Variceal bleeding
Ascites, refractory ascites
Hepatorenal syndrome
Hepatic encephalopathy
Spontaneous bacterial
peritonitis
Hepatocelluler carcinoma

Portal Hypertension Syndrome

Continuing Liver damage

Nodular regeneration

Fibrosis
Increased sinusoidal
pressure
Portal Hypertension

Splancnic vasodilatation

Increased gastroesophageal
collateral

Decreased effective blood

volume

Formation of
oesophagogastric varices

Increased sodium retention

Variceal rupture

Ascites

Variceal bleeding

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

of case with cirrhosis.
B. Mortality of the first bleeding episode is around 50
%
Prevention measure rationale to avoid development
of Varices and bleeding (Primary prophylaxis).
C. Up to 70 % Of Patient who do not receive treatment
die within 1 year of the initial bleeding episode
The Efforts in preventing bleeding seems to be
crucial (secondary, prophylaxis)

Consensus in Portal Hypertension Baveno III

Monitoring for the Development of Varices in the
Portal Hypertensive Patient.
1. All cirrhotic patients should be screened for the
presence of varices at the time of the initial
diagnosis of cirrhosis.
2. In compensated patients without varices, endoscopy
should be repeated at 2-3 year intervals to
evaluate the development of varices.
3. In compensated patients with small varices,
endoscopy should be repeated at 2 year intervals to
evaluate progression of varices.
4. There is no indication for subsequent evaluations
once large varices are detected.

Algorithm for cirrhosis Without Bleeding

Algorithm For
Cirrhosis Without
Bleeding
Cirrhosis
Established
Upper Endoscopy

No varices

Observe

(2 3 years Evaluation)

Small or Medium
Varices

Observe

(1 2 years Evaluation)

Large Varices

Primary Bleeding
Prophylaxis
Reguler Interval
Usually one week

Non Selectne Blockers

(and /or long actmy Nitrates)
Ligation

Algorithm For Bleeding Cirrhotis

Algorithm For
Bleeding Cirrhotis
Resuscitae

Begin Octreotide
(or Vasopressin)
Early endoscopy
Esophagel
Non-Portal
Gastric Varices
Portal
Varices
Hypertensive Cause
Hypertensive
Gastropathy
Treat appropriately

Continue octreotide 5 days

Begin beta-blocker when stable

Band ligation or injection

Sclerotheraphy
Ballon Tamponade
Rebleeding

No rebleeding
Continue treatment

Shunt (Child A)
Preventation of Rebleeding
TiPSS. or
Pharmacological Treatment
Liver transplantation (Child B or C)
Ligation /Sclerotheraphy
Reguler Interval
Usually one week
Eradication
Repeated Endoscopy
3 6 month
Rebleeding
Shunt (Child A)
TIPSS
or
Liver
transplantation

ASITES :

PENUMPUKAN CAIRAN YANG BERLEBIHAN

DIDALAM RONGGA PERITONIUM.

GAMBARAN KLINIS :
PUCAT, DEHIDRASI, KULIT & LIDAH KERING, MATA
CEKUNG , EKSTREMITAS KECIL, PERUT MENONJOL.
PEMERIKSAAN ASITES :
1. TIDAK SAKIT.
2. LINGKAR PERUT BERTAMBAH.
3. BISA TERDETEKSI SECARA P.D. BILA > 500 CC.
< 500 CC --> PUDDLE SIGN.
< 50 CC --> USG.
TERAPI : TUJUAN MENGHAMBAT PROGRESIFITAS.
MENCEGAH KOMPLIKASI.

Ascites

Tentukan batas area

beda/pekak dgn area
timpani

Shifting dullness
dijumpai jk pasien dimiringkan ke
salah satu sisi

Test for a fluid wave (undulasi cairan).

Shifting Dullness (real patient)

- UKUR LINGKARAN PERUT & BB TIAP HARI.

- PENGELUARAN CAIRAN ASITES TIDAK > 1 LITER / HARI.
PADA ASITES + UDEMA.
- PADA ASITES SAJA MAX. 0,5 L / HARI.
YANG UTAMA : 1. ISTIRAHAT TOTAL.
2. RESTRIKSI AIR 1 - 1,5 L / HARI.
GARAM 250 - 500 mg / HARI.
3. KOREKSI ALBUMIN.
4. DIURETIK ; SPIRONOLAKTON 1x100 mg
NAIKKAN BERTAHAP TOTAL 400 mg
GABUNG DGN FUROSEMIDE 1x40 mg
NAIKKAN BERTAHAP TOTAL 160 mg
5. PARASINTESA CAIRAN ASITES.
ASITES REFRAKTER :
TERAPI KONFENSIONAL & INTENSIF RESPONS ( - ).
10 - 20% --> STADIUM TERMINAL.

PENANGANAN ASITES REFRAKTER:

1. PARASINTESE BERULANG .
2. REINFUS CAIRAN ASITES.
3. PORTO CAVAL SHUNT ( BEDAH )
4. PERITONEO VENOUS SHUNT ( LEVEEN SHUNT )
5. TRANSPLANTASI HATI.
KOMPLIKASI ASITES:
1. PERITONITIS BAKTERIAL SPONTAN --> 8 - 22%.
2. EFUSI PLEURA --> 6%.

Pathogenesis of Hepatorenal Syndrome

Cirrhosis
Sinusoidal portal
hypertension

Splanchnic vasodilatation

Arterial underfilling
Reduced renal
vasodilator factors

Baroreceptor-mediated
activation of systemic
Vasoconstriction factors
Renal vasoconstriction
Hepatorenal syndrome

Increased intrarenal
vasoconstriction
factors

Definition

Hepatic encephalopathy or
portosystemic encephalopathy
(PSE) = reversible decline in
neurologic function associated with
impaired hepatic function.

Hepatic Encephalopathy

A syndrome characterized by
personality changes, intellectual
impairment and depressed level of
consciousness
Present in 50 to 70 percent of
patients with cirrhosis
Approx. 30% of patients dying of
end-stage liver disease experience
significant encephalopathy,
approaching coma

Pathogenesis

Still lack a clear understanding of

pathogenesis.
Role for inhibitory neurotransmission
through GABA receptors in CNS and
changes in central neurotransmitters and
circulating amino acids.

PATHOGENESIS OF HEPATIC
ENCEPHALOPATHY
Hypothesis :
- Hyperammonemia
- False Neurotransmitter

- GABA (Gamma Amino Butyric Ac

Sign & Symptoms

Wide variety of clinical conditions.

Clinical Signs of Hepatic Encephalopathy

Mental status disorder

Clinical Signs of Hepatic Encephalopathy

Flapping tremor= asterixis

Treatment

Treatment of precipitating causes

Treatment based upon the
ammonia hypothesis
Treatment based upon the false
neurotransmitter hypothesis.
Treatment based upon GABA
hypothesis.

Approach to the patient with hepatic

encephalopahty
Initial Evaluation
* Exclude other causes of disordered mentation
* Identify precipitant and correct
* Determinant electrolytes, BUN, creatinine, NH3,
Glucose

Protein restriction
Laxative, e.g., Lactulose 30-120 ml, 1 to 4 times
daily until 4 stools/day
Inadequate response?

Broad-spectrum antibiotics (e.g., neomycin 500

mg qid, or metronidazole 250 mg tid)

Inadequate response?
Consider liver transplatation

PERITONITIS BAKTERIAL SPONTAN

(SBP):
PALING SERING.
SUMBER INFEKSI TIDAK ADA.
( INFEKSI INTRA ABDOMINAL, ABSES ATAU PERFORASI )

ETIOLOGI BIASANYA E. COLI , STREPTOCOC. PN.

ATAU KLEBSIELA PN.
PENDERITA DGN. ASITES BILA MEMBURUK DGN:
DEMAM > 50%, ABDOMEN TEGANG, NAUSEA , ANOREKSIA , DIARE,
ILEUS ATAU AZOTEMIA.
13

SBP MECHANISM
Immunity Defect
Bacterial
Overgrowth
Bacterial
translocation

Bacterimia
02/12/16

35

VICIOUS CYCLE

02/12/16

Hepatic
dysfunct.

Portal
Hypertens

Bachterial
translocation

Bowel
permeable.

36

02/12/16

37

ENTERIC
BACTERI
Other source
(skin, urine,
Respiration)

Portal Vein
Limfnode
Bacteremia

Ascites infectious
SPONTANEOUS
BACTERIAL
PERITONITIS
02/12/16

38

GEJALA KLINIS:
1. DEMAM TIBA -TIBA, MENGGIGIL, NYERI ABDOMEN
TANDA PERITONITIS, PERISTALTIK HILANG.
2. CAIRAN ASITES KUMAN (+).
3. IKTERUS, HIPOALB., PROT. TIME MEMANJANG,.
4. SRG. PADA STADIUM TERMINAL PENYAKIT HATI.
DIAGNOSA :
1. GOLD STANDARD KULTUR CAIRAN ASITES.
2. PMN > 250 CELL / mm3 BERI TERAPI.
3. AB. YG. SPEKTRUM LUAS.
PENYEBAB SBP : BAKTERI ENTERIK GRAM ( - ) / SERING.
PADA YG BERESIKO TINGGI NORFLOKSASIN.
MORTALITAS : TERGANTUNG STADIUM PENYAKIT HATI.
PROGNOSA : JELEK YANG BERHASIL BAIK < 5%

14

Treatment of HCC depends on

1. Local resources
2. Stage of the disease
3. Presence of cirrhosis

Liver Transplantation
Hepatic resection treatment of choice
for the few patients with HCC and
normal liver.
Trans Arterial Chemo Embolization
Cytostatica
Interferon

Five years survival of pts with HCC treated by

transplantation in 82 Europeans centers between
1988 and june 1994

Indication to transplantation
% Alive

HCC with Cirrhosis

HCC without cirrhosis
34
Cirrhosis with HCC

Patients

361

46
446

176

54

p = 0.0004
from European Transplantation Register

KESIMPULAN

Sirosis hati, stadium terakhir dari penyakit

hati kronis yang manifestasi kliniknya
mengenai berbagai macam sistem dan
organ tubuh.
Komplikasi yang tersering adalah: Asites,
Perdarahan varises, SBP, Ensepalopati
hepatik, HCC.
Penanganannya masih merupakan masalah
yang menyulitkan
Pengelolaan yang menyeluruh adalah hal
yang terbaik