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 IgGAutoimmune 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 )Ξ±-fetoprotein (hepatocellular carcinoma )Metabolic/infiltrative: ferritin and transferrin saturation (haemochromatosis ), serum copper and caeruloplasmin Β± 24-hour urinary copper (Wilsonβs disease ), fasting glucose and lipids (fatty liver disease ), Ξ±1 -antitrypsin (Ξ±1 -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 /CTLiver biopsy if cause unclear
Long-term management
Treat cause General: optimise nutrition, alcohol abstinenceMonitoring Ξ±-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
NB: elastography may be used to non-invasively grade liver cirrhosis.
A patient presents to ED with chest pain and this trace. What would you do?
Interpretation management
Covered in OSCE Stations
Acute complications
Decompensation
Signs: jaundice, ascites, encephalopathyCauses: 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 Β± 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
Abdominal exam Chronic liver disease I Chronic liver disease II Find more here