Chronic liver disease

The signs of chronic liver disease are described here.

Most common causes of chronic liver disease in the UK

1. Alcohol
2. Non-alcoholic fatty liver disease
3. Viral hepatitides
4. Autoimmune (e.g. autoimmune hepatitis, primary biliary cholangitis)
5. Metabolic (e.g. haemochromatosis)

Investigating the cause

• Viral screen: hepatitis B surface antigen, hepatitis C IgG
• Autoimmune liver screen: anti-smooth muscle (autoimmune hepatitis type 1), anti-mitochondrial (primary biliary cholangitis), anti-liver-kidney microsomal (autoimmune hepatitis type 2, hepatitis C/D, drug-induced hepatitis), antinuclear (autoimmune hepatitis type 1, SLE)
• α-fetoprotein (hepatocellular carcinoma)
• Metabolic/infiltrative: ferritin and transferrin saturation (haemochromatosis), serum copper and caeruloplasmin ± 24-hour urinary copper (Wilson’s disease), fasting glucose and lipids (fatty liver disease), α₁-antitrypsin (α₁-antitrypsin deficiency)
• Immunoglobulins and protein electrophoresis (IgM raised in primary biliary cholangitis, IgA raised in alcoholic liver disease, IgG raised in autoimmune hepatitis)
• Tissue transglutaminase antibody (Coeliac disease)
• Abdominal ultrasound/CT
• Liver biopsy if cause unclear 

Long-term management

• Treat cause
• General: optimise nutrition, alcohol abstinence
• Monitoring
  • α-fetoprotein every 6 months (for liver function and hepatocellular carcinoma) 
  • USS every 6 months (for hepatocellular carcinoma, hepatic vein thrombus, reversed portal flow) 
  • Upper GI endoscopy every 3 years (for varices) 
• Treat/prevent complications
  • Varices: banding, carvedilol, transjugular intrahepatic portosystemic shunt (for refractory ascites/varices/hepatic pleural effusion)
  • Ascites: spironolactone, low salt diet, fluid restriction 
  • Encephalopathy: lactulose, rifaximin 
  • Coagulopathy: vitamin K

NB: elastography may be used to non-invasively grade liver cirrhosis.

Acute complications

Decompensation

• Signs: jaundice, ascites, encephalopathy
• Causes: spontaneous bacterial peritonitis/sepsis, dehydration/AKI, upper GI bleed/constipation, others (portal vein thrombosis, drugs, liver ischaemia, hepatocellular carcinoma, alcoholic hepatitis, ischaemic liver injury)
• Management: treat cause, lactulose ± enemas (aim 2-3 stools/day), avoid sedatives, nurse in intensive care if required

Hepatorenal failure 

• Worsening renal function in advanced chronic liver disease with no other cause (and no response to fluids)
• Management: fluid balance monitoring and daily weights, suspend diuretics and nephrotoxic drugs, human albumin solution (to increase effective intravascular blood volume), arterial vasoconstrictors (e.g. terlipressin)

Spontaneous bacterial peritonitis

• Sepsis/signs of infection in patient with ascites
• Management: diagnostic ascitic tap, IV antibiotics, human albumin solution (to prevent renal dysfunction)

NB: if there is a history of alcohol excess, prescribe Pabrinex and oxazepam/chlordiazepoxide for withdrawal.

Questions

Please list three causes of chronic liver disease

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How would you investigate a patient with decompensated liver disease?

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How would you manage a cirrhotic patient with an acute upper GI bleed?

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Try some OSCE stations

1. Abdominal exam
2. Chronic liver disease I
3. Chronic liver disease II
4. Find more here