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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

  • 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
    •  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

Investigations

  • Bloods: FBC, U&Es, LFTs, CRP, coagulation screen, glucose, blood cultures (if any signs of infection)
  • Chest X-ray
  • Urine dip and MSU
  • Abdominal USS
  • Ascitic tap (if ascites present)

Types

  1. Decompensation
    1. Signs: jaundice, ascites, encephalopathy
    2. 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)
    3. Management: treat cause, lactulose ± enemas (aim 2-3 stools/day), avoid sedatives, nurse in intensive care if required
  2. Hepatorenal failure 
    1. Worsening renal function in advanced chronic liver disease with no other cause (and no response to fluids)
    2. 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)
  3. Spontaneous bacterial peritonitis
    1. Sepsis/signs of infection in patient with ascites
    2. 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

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