Chronic Liver Disease

Question 1

Define cirrhosis in pathological terms?

Answer 1

Necrosis of hepatocytes followed by bridging fibrosis and nodule formation.

Micro (alcohol/billary tract) or macronodular (chronic hepatitis)

Question 2

Describe the initial investigation of a patient with suspected cirrhosis?

Answer 2

Bloods:
LFT’s (Liver enzymes may be normal due to death of all hepatocytes)
FBC
Clotting (synthetic function of the liver)
Ferretin (haemochromatosis)
Hepatitis Serology

Liver US/CT

Liver Biopsy

Ascitic tap

Question 3

Outline the clinical features of cirrhosis?

Answer 3

Loss of synthetic function:

Hypoproteinanaemia (albumin) aka ascites and peripheral oedema.

Reduced clotting factors, increase bleed risk.

Hypoproteinanaemia can lead to to hypovolaemia which can leads to reduced perfusion of the kidneys. Therefore more renin is released stimulating the RAA system.

Portal Hypertension: Signs:

High Oestrogen: (increased production by adrenals and reduced clearance by liver)
Spider naevi
Gynaecomastia
Palmar erythema

Varices:
Oesophageal 
Caput Medusae
Umbilical 
Haemorrhoids

In severe decompensated liver there can be:

Encephalopathy due to the build up of nitrogenous waste which is usually metabolised and excreted in the liver.

Question 4

Outline the different causes of cirrhosis?

Answer 4

Hepatitis C and Alcoholic liver disease are the 2 most common causes in western countries.

Hepatitis B is most common in sub-saharan Africa and Asia.

NAFLD (or NASH Nonalcoholic steatohepatitis) are other common causes in developed countries.

Other causes include:

• Metabolic conditions (haemochromatosis and Wilsons)
• Alpha 1 anti trypsin disease

Question 5

Describe the general management of chronic liver disease?

Answer 5

Treat any underlying cause for the disease:

• Treatment for hepatitis viruses
• Alcohol cessation
• Weight loss in NASH

Ensure adequate nutrition: alcoholics specifically are often deficient in many vitamins (give Pabrinex provides several B vitamins)

Manage complications which may arise:

• Oesophageal varices may need ligating
• Anaemia may be due to folate deficiency
• Ascites may need draining for symptomatic relief and due to the risk of spontaneous bacterial peritonitis.