Chronic Liver Disease/Cirrhosis (2)

Question 1

What is it?

What’s the end-stage of it called?

What are its most common causes?

What are some of the other causes?

Answer 1

➊ Diffuse, progressive fibrosis and structural abnormality of the liver

➋ Cirrhosis

➌ • Alcohol
• Hepatitis B and C
• NAFLD

➍ • Autoimmune
• Drugs
• Genetics e.g. a1 anti-trypsin deficiency, Haemochromatosis, Wilson disease

Question 2

What does it mean for the cirrhosis to be compensated?

How does compensated cirrhosis present?

How does decompensated cirrhosis present?

Answer 2

➊ Where sufficient liver function remains to keep the patient systemically well

➋ • Fatigue and anergia
• Clubbing
• Abdominal pain
• Spider naevi
• Gynaecomastia
• Caput medusa

➌ • Jaundice
• Portal hypertension
‣ Ascites
‣ Encephalopathy (drowsiness, liver flap, hyperventilation)
‣ Varices
• Palmar erythema
• Easy bruising

Question 3

Complications:
What does the Ascites result from?

What is Spontaneous bacterial peritonitis (SBP)?
→ How is it diagnosed?
→ What’s its most likely causative organism?

What does Liver failure present with?

What does the portal HTN lead to?

Answer 3

➊ Portal HTN and hypoalbuminaemia

➋ Occurs in pts with ascites. Often presents with no abdominal tenderness/guarding, and should be suspected in pts who deteriorate suddenly with no other obvious cause.
→ Ascitic tap with neutrophils >250mm³
→ E.coli and Klebsiella

➌ Hepatic encephalopathy and coagulopathy

➍ Lower oesophageal varices and haemarrhoids

Question 4

What are the investigations to do?

What is important when managing these pts?

How are the complications managed?

Answer 4

➊ * Bloods - FBC, U&E, LFT, INR, Albumin, AFP
* Peritoneal tap if ascites (check for SBP)
* FibroScan and USS
* Liver biopsy

➋ Total alcohol abstinence and good nutrition

➌ * Ascites can be managed with fluid restriction +/- low-salt diet, or spironolactone (furosemide can be added if no improvement)
* Recurrent episodes of encephalopathy can be reduced in frequency by the use of prophylactic lactulose and rifaximin.
* Pts at high-risk of SBP can be given prophylactic Abx
* Definitive treatment is a liver transplant