Week 3: GastroenterologyChronic Liver Disease

Dr Ben Robinson F2

Plan for session

• Introduction• Functions of liver• Causes of chronic liver disease• Symptoms and signs of chronic liver disease• Case based discussion• Complications of liver disease• Questions/comments

Background

• 5th commonest cause of death in the UK

• UK is one of few developed countries in the world with increasing mortality from liver disease

• Liver disease morbidity and mortality is largely preventable

• Liver disease accounts for 60% of inpatient gastroenterology activity

British Society of Gastroenterology:http://www.bsg.org.uk/clinical/commissioning-report/management-of-patients-with-chronic-liver-diseases.html

Group Exercise 1

1. Functions of the liver2. Causes of chronic liver disease

3 minutes!!!

Functions of the liver

Storage

- Glucose (in form of glycogen)- Vitamins (A, D, K and B12)- Iron and copper

Synthesis

- Gluconeogenesis- Glycogenesis- Amino acid and protein synthesis- Lipogenesis, cholesterol synthesis- Coagulation factors- Bile- Growth factors e.g IGF-1

Breakdown

- Drug and toxin metabolism (glucuronidation, methylation)

- Ammonia (urea cycle)- Bilirubin metabolism- Glycogenolysis

Immunological effects

- Immunologically active cells, antigens carried to it through reticuloendothelial system

Aetiology of chronic liver diseaseCOMMONAlcohol History of excess alcoholChronic hepatitis B HBsAg +/- HBeAg in serumChronic hepatitis C HCV antibodies and HCV RNA in serum

OTHERS

Autoimmune

Primary biliary cirrhosis Serum antimitochondrial antibodies

Autoimmune hepatitis Circulating autoantibodies

Inflammatory

Sclerosing cholangitis Serum pANCA, IBD

Metabolic

Wilson’s disease Low serum caeruloplasmin and copper

Alpha 1-antitrypsin deficiency Low alpha 1-antitrypsin, emphysema

Aetiology of chronic liver disease

OTHERS

Drugs Methotrexate, paracetamol

Hereditary haemochromatosis Family history, increased ferritin

Non-alcoholic fatty liver disease Metabolic syndrome, hyperechoic liver

Budd-Chiari syndrome Risk factors, liver USS

Important definitions

Cirrhosis

- Histological diagnosis- End stage of chronic liver disease where normal liver

architecture is replaced with diffuse fibrosis and nodules.

Decompensated hepatic failure

- Severe liver dysfunction leading to jaundice, encephalopathy and coagulopathy.

Symptoms and signs of chronic liver disease

Body Diagram

Group Exercise 2

5 minutes!!!

Presentation – symptoms and signsSigns of chronic liver disease:ABCDEA sterixisB rusiesC lubbingD upuytren’sE rythema (palmar)

plus Malnourished Facial telangiectasia Parotid enlargement Spider naevi Gynaecomastia Hepatomegaly or cirrhosis Jaundice Caput medusa Encephalopathy (hepatic foetor, liver flap,

drowsiness, disorientated or unable to draw a 5 point star)

Digestive Problems

Immune Dysfunction

Abnormal Metabolism of Fats

Blood Sugar Problems

Hormonal Imbalance

Symptoms of chronic liver disease:

Varied and vague!

Case based discussion

On examinations he is jaundiced but has no hepatic flapOrientated in time, place and person Abdomen is distended but SNTNo palpable organomegaly but there is shifting dullness

54 year old gentleman presents to his GP with increasing swelling of his abdomen and feet over the last 2 months

Increasingly tired, feels nauseous and off food

Wife says eyes have turned yellow over last few days

Works in a warehouse and smokes 10 cigarettes a day

Admits to drinking 4 cans of lager a night. Wife says he drinks at least 8 cans a night and a bottle of whiskey a week.

Case based discussion

• Group 1: Further history/examination• Group 2: Investigations• Group 3: Management options (how would

you manage if there were signs of decompensation?)

Group Exercise 3

5 minutes!!!

Further history/examination

• Length of alcohol use• Alcohol withdrawal?• Recent travel, risk factors for BBV?• Bruising/bleeding?• PMH of IBD, autoimmune disease etc?• Drug history • FH of liver disease

Other features of chronic liver disease O/E

Investigations

Invasive tests: Liver biopsy Ascitic tap ERCP OGD

Bedside tests: Blood glucose

Blood tests: FBC, clotting, U&E, LFTs, iron studies (ferritin, iron), viral serology Others: Alfa-1 antitrypsin, caeruloplasmin, antimitochondiral antibodies, antinuclear

antibodies (ANA) and SMA, paracetamol levels

Imaging: Liver USS MRCP CT head

Interpreting LFTs

‘Liver biochemistry’ better term:Bilirubin Aminotransferases (liver cell damage)Alkaline phosphatase ALP (cannalicular and sinuosoidal membranes of liver)Gamma GT – liver microsomal enzyme induced by alcohol or drugs

‘Liver function tests’ misleading

Think hepatitic or cholestatic picture?Synthetic function best measured by albumin and clotting

Management of decompensated liver disease

• Resuscitation• Treat the cause if possible • Encephalopathy prevention/treatment• Hypoglycaemia treatment• Coagulopathy treatment• Ascitic drainage• Gastric mucosa protection• Manage alcohol withdrawal• Antibiotic prophylaxis• Nutrition

Alcoholic liver disease Alcoholic fatty liver

Usually asymptomaticGamma GT/MCV elevatedReversible if stop drinking

Alcoholic hepatitis

Necrosis of liver cellsAsymptomatic to very ill with hepatic failureElevated bilirubin and transaminasesLow albumin and deranged clotting

Alcoholic cirrhosis

End stage diseaseDestruction and fibrosis of liverManagement directed at complications

Complications of chronic liver disease

• Hepatic encephalopathy• Acute variceal bleeding• Spontaneous bacterial peritonitis (SBP)• Hepatorenal syndrome

Hepato-renal syndrome

Key points

• Causes of chronic liver disease• Investigations in liver disease• Management of decompensated liver failure• How to manage an acute variceal bleed

Thank you

Any Questions?