Chronic liver disease

Question 1

What is chronic liver disease also known as?

Answer 1

Cirrhosis.

Question 2

What does chronic liver disease most commonly result from?

Answer 2

Chronic hepatitis C and B, alcohol misuse and alcoholic fatty liver disease.

Question 3

What is the pathophysiology for chronic liver disease?

Answer 3

· Activation of hepatic stellate cells.
· Accumulation of type I and III collagen.
· Hepatic sinusoids lose fenestration, altering the exchange between hepatocytes and plasma.
· Liver blood flow is disrupted, causing increased portal venous pressure and shunting blood away from the liver.
· This leads to portal hypertension, which underlies ascites and varices.
· Loss of functional hepatocytes causing loss of normal protein production.
· This leads to malnutrition and a reduction in clotting factors.
·The liver also detoxifies portal blood, and when impaired, intestinal products bypass the liver, reach the brain, and contribute to hepatic encephalopathy.

Question 4

What is the prognosis for chronic liver disease?

Answer 4

Median survival rate is 10 years.

Question 5

What are the risk factors for chronic liver disease?

Answer 5

Cirrhosis can derive from any chronic liver disease:
· Chronic hepatitis B and C.
· Alcoholic liver disease.
· Metabolic disorders - NAFLD, obesity, haemochromatosis.
· Cholestatic and autoimmune - PBC, PSC and autoimmune hepatitis.
· Biliary obstruction - mechanical, biliary atresia, CF.
· Hepatic venous outflow obstruction - Budd-Chiari syndrome, right-sided heart failure.
· Drugs and toxins - amiodarone and methotrexate.

Question 6

What are the 2 types of classification for chronic liver disease?

Answer 6

Compensated + decompensated cirrhosis.

Question 7

What is compensated cirrhosis?

Answer 7

Biochemical, radiological or histological findings consistent with cirrhosis.

Question 8

What is decompensated cirrhosis?

Answer 8

Evidence of complications of liver dysfunction with reduced hepatic synthetic function.

Question 9

What is the presenting history of a patient with suspected chronic liver disease?

Answer 9

· Asymptomatic but may have fatigue, weakness and weight loss.

· Compensation - abdominal distension, coffee ground vomitus, black stool, altered mental status, lower extremity swelling, jaundice and pruritis.

Question 10

What social history might a patient with suspected chronic liver disease have?

Answer 10

· IVDU, unprotected intercourse and tattoos.
· Detailed alcohol history.
· Travel history.

Question 11

What past medical history might a patient with suspected chronic liver disease have?

Answer 11

· Metabolic syndrome - diabetes, dyslipidaemia, obesity, HTN.
· Hepatotoxic drugs.
· Previous history of blood transfusion.

Question 12

What investigations should be done in a patient with suspected chronic liver disease?

Answer 12

· LFT’s.
· U&E’s.
· FBC and clotting.
· Viral serology.

Question 13

What might the LFT results show in a patient with chronic liver disease?

Answer 13

· AST and ALT increase with hepatocellular damage.
· Total bilirubin may be normal in compensated patients. May rise in decompensated.
· GGT represents enzyme activation and can be induced by alcohol and certain drugs&raquo_space;> GGT elevated.
· Albumin may decrease with hepatic synthetic dysfunction.

Question 14

What might a patient’s U&E’s show if they have chronic liver disease?

Answer 14

Hyponatraemia is common in cirrhosis with ascites.

Question 15

What might a patient’s viral serology show if they have chronic liver disease?

Answer 15

· ANTIBODIES TO HEP C VIRUS: present.

· HEP B SURFACE ANTIGEN: present.

Question 16

List some differential diagnoses.

Answer 16

· Constrictive pericarditis.
· Budd-Chiari syndrome.
· Portal vein thrombosis.
· Splenic vein thrombosis.
· IVC obstruction.
· Schistosomiasis.
· Sarcoidosis.

Question 17

What is the treatment for chronic liver disease?

Answer 17

· 1st line - treatment of underlying chronic liver disease and prevention of superimposed hepatic insult.
· Plus - monitoring for complications.
· Adjunct - sodium restriction and diuretic therapy for ascites.
· 2nd line - liver transplantation.

Question 18

What complications may arise?

Answer 18

· Ascites.
· Varices.
· Hepatocellular carcinoma.
· Hepatic hydrothorax.
· Portosystemic encephalopathy.
· Hepatorenal syndrome.
· Hepatopulmonary syndrome.

Question 19

What would you educate a patient suffering from chronic liver disease on?

Answer 19

· Weight loss.
· Good nutrition.
· Regular exercise.
· Avoidance of alcohol and other hepatotoxins such as NSAID’s and high doses of paracetamol (>2g a day).