34- Liver problems

Diagnosis

Without lab and other hospital facilities, liver problems have to be consider when you observe:

• Icterus (jaundice)
• Ascites/edema
• Hepatomegalia
• Hemorrhagic problem
• Dark urine with yellow/white stools
• ...but general conditions are one of the best indicator of the liver status. If patient is icteric and has mild ascitis but run, jump and eat a lot, don't worry too much about his liver.

Less common signs

• Flapping tremor
• Dementia
• Palmar erythema

Following argument help to confirm that liver is origin of problems

• History of hepatitis
• History of injectable drug addiction
• History of alcoolism
• Many hepatotoxic drugs in current treatment

What to do?

In our condition of work, after assuming that the cause of the problem is the liver, we suggest :

• Reduce or stop the amount of hepatotoxic drugs. (see below)
• Do nothing... if symptoms are not severe, just wait. It is common, for instance, that Rifampicin induces ictérus. But it is rare that we have to stop rifampicin in spite of icterus ; often, after+/- one month the icterus disapears without any specifical action.
• Symptomatic treatment: lasix/spironolactone, for edema and ascitis,

Reduce the amount of hepatotoxic drugs

The most common hepato-toxic drugs that we use in a poor HIV hospice are:

RIF, PZA, Ketonazole, Fluconazole, NVP... (EFV and INH can also be considered as hepatotoxic but less.)

In case of mild hepatic failure you should reduce hepatotoxic medicines. In case of severe hepatic failure you must stop all hepatotoxic drugs. Each patient has his own specificity. For one PZA is the main cause of problems, for another RIF, for another NVP... Impossible for us to predict but we feel that PZA, RIF & NVP are the most probable sources of problems.

We try reduce vital medicine only if impossible or not enough time (patient dying) to reduce other hepatotoxic drugs first... 2-3 days are often enough to know by the clinical signs if reduction of some medicines are useful or not.

Specific contexts:

• Change TB treatment
  • Stop PZA or stop RIF or stop INH or stop PZA&RIF...etc. (And the following drugs to replace the medicine you stopped: STREPTO or EMB or OFLOX)
  • or
  • Stop all TB treatment assuming that patient is now unable to take it (you have to consider that to give not enough anti-TB drug can be more dangerous for the patient and for everybody (resistance) than not give TB treatment at all)
• Change ARV treatment
  • Change NVP if possible. EFV is less toxic but more expensive and also a little bit toxic... In such condition, if you give EFV, you should try to reduce other hepat-toxic drugs as well.

 

Stop all hepatotoxic drugs if life is in danger... don't wait too long! Unfortunately, we often have to stop all hepatotoxic drugs. When liver recover we usualy reintroduce only the most vital hepatotoxic drugs (fluco? EFV?...).