11.1 Chronic Liver Disease

Question 1

a) List the commonest causes of chronic liver disease in adults. (15%)

Answer 1

Most common:
» Alcoholic liver disease.

> > Non-alcoholic fatty liver disease
(caused by obesity, diabetes).

> > Viral hepatitis, B and C.

Also:
» Autoimmune causes:
primary biliary cholangitis,
sclerosing cholangitis.

> > Metabolic disease:
Wilson’s,
haemochromatosis,
alpha-1-antitrypsin deficiency.

> > Toxins,
drugs.

> > Right heart failure.

Question 2

b) Outline the effects of chronic
liver disease on organ systems.
(60%)

a + b

Answer 2

Airway:
» Risk of reflux due to raised
intra-abdominal pressure due to ascites.

Respiratory:

> > Diaphragmatic splinting due to ascites,
resulting in basal atelectasis,
V/Q mismatch,
reduced functional residual capacity.

> > Pleural effusions.

> > Hepatopulmonary syndrome:
pulmonary arteriovenous malformations
causing right to left shunt.

Causes platypnoea 
(shortness of breath
relieved by lying down) 

and orthodeoxia
(decreased oxygen
saturations on sitting up).

Question 3

b) Outline the effects of chronic liver disease on organ systems. (60%)

C

Answer 3

Cardiac:
» Hyperdynamic circulation with
high cardiac output,
low blood pressure,
and low systemic vascular resistance (SVR)
(portal hypertension triggers excessive vasodilatory mediator action in peripheral and splanchnic circulation).

> > Porto-pulmonary hypertension.

> > Cirrhotic cardiomyopathy.

> > Low SVR may mask underlying
coronary artery disease.

> > Pericardial effusion.

Question 4

b) Outline the effects of chronic liver disease on organ systems. (60%)

Neuro

GI

Answer 4

Neurological:
>> Hepatic encephalopathy. 
May be precipitated by
gastrointestinal bleed,
infection, 
sedative drugs, 
hypoglycaemia, 
excessive protein intake,
hypotension, 
hypoxia.

> > Wernicke’s encephalopathy
due to thiamine deficiency
associated with
alcoholic liver disease.

Gastrointestinal:
>> Delayed gastric emptying 
in the presence of raised 
intra-abdominal
pressure due to ascites.

> > Risk of varices and gastric
erosions, associated with blood loss.

Question 5

b) Outline the effects of chronic liver disease on organ systems. (60%)

H

I

Answer 5

Haematological:
>> Anaemia due to chronic blood loss
from gastrointestinal tract,
hypersplenism-induced haemolysis, 
chronic illness, malnutrition.

> > Coagulopathy due to failure to
synthesise clotting factors.

> > Thrombocytopaenia and
platelet dysfunction.

Immune, infection:
» Reduced immune function, infection prone.

Question 6

b) Outline the effects of chronic liver disease on organ systems. (60%)

Renal

Answer 6

Renal:
» Hepatorenal syndrome

(renal dysfunction occurring 
as a result of chronic poor 
perfusion due to the 
disproportionately low SVR in relation
to circulating volume. 

Renal arteries vasoconstrict in 
response to the 
activation of the 
renin–angiotensin–aldosterone system 
and sympathetic nervous system, 
but renal perfusion remains inadequate nonetheless).

> > Secondary hyperaldosteronism
contributes to ascites,
effusions and peripheral oedema.

Question 7

b) Outline the effects of chronic liver disease on organ systems. (60%)

Answer 7

Metabolic:
» Depletion of hepatic and muscle
glycogen stores increases risk of hypoglycaemia.

Question 8

c) What elements constitute the Child–Pugh scoring system? (25%)

Answer 8

bilirubin, 
albumin, 
prothrombin time,
encephalopathy 
and ascites