Chronic Liver DiseaseSimon Lynes

Definition

• Progressive destruction and regeneration of the liver parenchyma leading to fibrosis and cirrhosis

Aetiology

• Vascular – Budd Chiari• Infectious – viral hepatitis B and C• T• Autoimmune – PBC/PSC, autoimmune hepatitis• Metabolic – Wilsons, Haemochromatosis, fatty liver• Iatrogenic - meds• Neoplasm • C• Drugs – e.g. ALCOHOL, antibiotics, methotrexate, amiodarone

Presentation – 2 types• Compensated:

• Stigmata of chronic liver disease• Gynaecomastia• Spider Naevi• Clubbing

• May have no symptoms or vague:• RUQ pain• Pruritis• Fatigue• Oedema

• Synthetic function tests e.g. PT, albumin may be NORMAL• Some abnormalities of LFTs e.g. ALT

• Decompensated• Encephalopathy• Jaundice• Ascites• Asterisks

Investigations• Bedside• BM

• Bloods• Serology • Autoantibodies• Ceruloplasmin, ferritin/transferrin/TIBC• Alpha fetoprotein

• Imaging• USS and doppler of portal vein

• Special Tests• Biopsy• OGD - ?varices• Ascitic tap

A LIVE CATCH

Alpha fetoproteinLFTsIgsViral hepatitisEthanolCeruloplasminAutoantibodiesTransferrin and FerritinCMV/EBVHIV

Management• Conservative• Salt restriction• Avoid alcohol• Vaccinations

• Medication• Diuretics• Calcium/Vit D

• Surgical• Paracentesis• Transplant• TIPSS

• *3-6 monthly screening for HCC*

Prognosis• Child-Pugh classification• PT• Albumin• Bilirubin• Ascites• Encephalopathy

• ‘Pour Another Beer At Eleven’

Interpreting LFTs• Hepatic vs. post hepatic/obstructive• ALT vs alk phos/gamma GT

• Synthetic function• Albumin – chronic• PT - acute

• Bilirubin

• Gamma GT – for alcohol (if alk phos normal)

Clinical scenario54 year old gentleman presents to his GP with increasing swelling of his abdomen and feet over the last 2 months. He has been increasingly tired over this time and feels nauseous and is off his food. His wife has commented that his eye have turned yellow over the last few days. He works in a warehouse and smokes 10 cigarettes a day. He admits to drinking 4 cans of lager a night. His wife says he drinks at least 8 cans a night and a bottle of whiskey a week. On examination he is jaundiced but has no hepatic flap and is orientated in time, place and person. His abdomen is distended but soft and non-tender. There is no palpable organomegaly but there is shifting dullness

• Differential Diagnoses?

• Investigations?

• Management?

Complications

• Decompensation• Encepalopathy• Jaundice

• Hepatocellular carcinoma

• Increased portal pressure• Varices/GI bleed – exacerbated by decreased clotting• Ascites

• SBP

• Hepatorenal syndrome

Encephalopathy• Key features:

• Reversal of sleep patterns

• Confusion/drowsiness

• Asterisks and positive babinski

• Due to ammonia

• Treat with lactulose

SBP• Suspect in sudden deterioration/pyrexia in patient with ascites

• Therepeutic tap• >250 neutrophils per microlitre

• Broad spectrum antibiotics

• Albumin

GI Bleed• Signs and symptoms:• Haematemesis/malaena• Signs and symptoms of anaemia• +/- abdominal pain• +/- haemodynamic instability

• Blood tests:• Low Hb – and raised urea

• Management• A-E• Rockall/Blatchford score• Terlipressin, broad spectrum antibiotics for varices• Endoscopy

• Any questions?