Table of Contents
The signs of chronic liver disease are described here.
Most common causes of chronic liver disease in the UK
- Alcohol
- Non-alcoholic fatty liver disease
- Viral hepatitides
- Autoimmune (e.g. autoimmune hepatitis, primary biliary cholangitis)
- 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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