Week 3: Gastroenterology
Chronic Liver Disease
Plan for session
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Introduction
Functions of liver
Causes of chronic liver disease
Symptoms and signs of chronic liver disease
Case based discussion
Complications of liver disease
Questions/comments
Background
• 5th commonest cause of death in the UK
• UK is one of few developed countries in the world with
increasing mortality from liver disease
• Liver disease morbidity and mortality is largely
preventable
• Liver disease accounts for 60% of inpatient
gastroenterology activity
British Society of Gastroenterology:
http://www.bsg.org.uk/clinical/commissioning-report/management-of-patients-with-chronic-liver-diseases.html
Group Exercise 1
1. Functions of the liver
2. Causes of chronic liver disease
3 minutes!!!
Functions of the liver
Storage
Synthesis
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Glucose (in form of glycogen)
Vitamins (A, D, K and B12)
Iron and copper
Breakdown
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Drug and toxin metabolism
(glucuronidation,
methylation)
Ammonia (urea cycle)
Bilirubin metabolism
Glycogenolysis
Gluconeogenesis
Glycogenesis
Amino acid and protein synthesis
Lipogenesis, cholesterol synthesis
Coagulation factors
Bile
Growth factors e.g IGF-1
Immunological effects
- Immunologically active cells, antigens
carried to it through reticuloendothelial
system
Aetiology of chronic liver disease
COMMON
Alcohol
History of excess alcohol
Chronic hepatitis B
HBsAg +/- HBeAg in serum
Chronic hepatitis C
HCV antibodies and HCV RNA in serum
OTHERS
Autoimmune
Primary biliary cirrhosis
Serum antimitochondrial antibodies
Autoimmune hepatitis
Circulating autoantibodies
Inflammatory
Sclerosing cholangitis
Serum pANCA, IBD
Metabolic
Wilson’s disease
Low serum caeruloplasmin and copper
Alpha 1-antitrypsin deficiency
Low alpha 1-antitrypsin, emphysema
Aetiology of chronic liver disease
OTHERS
Drugs
Methotrexate, paracetamol
Hereditary haemochromatosis
Family history, increased ferritin
Non-alcoholic fatty liver disease
Metabolic syndrome, hyperechoic liver
Budd-Chiari syndrome
Risk factors, liver USS
Important definitions
Decompensated hepatic failure
- Severe liver dysfunction leading to jaundice,
encephalopathy and coagulopathy.
Cirrhosis
- Histological diagnosis
- End stage of chronic liver disease where normal liver
architecture is replaced with diffuse fibrosis and
nodules.
Symptoms and signs of chronic liver
disease
Group Exercise 2
Body Diagram
5 minutes!!!
Presentation – symptoms and signs
Symptoms of chronic liver disease:
Varied and vague!
Digestive Problems
Immune Dysfunction
Abnormal Metabolism of Fats
Blood Sugar Problems
Hormonal Imbalance
Signs of chronic liver disease:
ABCDE
A sterixis
B rusies
C lubbing
D upuytren’s
E rythema (palmar)
plus
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Malnourished
Facial telangiectasia
Parotid enlargement
Spider naevi
Gynaecomastia
Hepatomegaly or cirrhosis
Jaundice
Caput medusa
Encephalopathy (hepatic foetor, liver flap,
drowsiness, disorientated or unable to draw a 5
point star)
Case based discussion
54 year old gentleman presents to his GP with increasing swelling of his
abdomen and feet over the last 2 months
Increasingly tired, feels nauseous and off food
Wife says eyes have turned yellow over last few days
Works in a warehouse and smokes 10 cigarettes a day
Admits to drinking 4 cans of lager a night. Wife says he drinks at least 8 cans
a night and a bottle of whiskey a week.
On examinations he is jaundiced but has no hepatic flap
Orientated in time, place and person
Abdomen is distended but SNT
No palpable organomegaly but there is shifting dullness
Case based discussion
Group Exercise 3
• Group 1: Further history/examination
• Group 2: Investigations
• Group 3: Management options (how would
you manage if there were signs of
decompensation?)
5 minutes!!!
Further history/examination
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Length of alcohol use
Alcohol withdrawal?
Recent travel, risk factors for BBV?
Bruising/bleeding?
PMH of IBD, autoimmune disease etc?
Drug history
FH of liver disease
Other features of chronic liver disease O/E
Investigations
Bedside tests:
 Blood glucose
Blood tests:
 FBC, clotting, U&E, LFTs, iron studies (ferritin, iron), viral serology
 Others:
 Alfa-1 antitrypsin, caeruloplasmin, antimitochondiral antibodies, antinuclear
antibodies (ANA) and SMA, paracetamol levels
Imaging:
 Liver USS
 MRCP
 CT head
Invasive tests:
 Liver biopsy
 Ascitic tap
 ERCP
 OGD
Interpreting LFTs
‘Liver function tests’ misleading
‘Liver biochemistry’ better term:
Bilirubin
Aminotransferases (liver cell damage)
Alkaline phosphatase ALP (cannalicular and
sinuosoidal membranes of liver)
Gamma GT – liver microsomal enzyme induced
by alcohol or drugs
Think hepatitic or cholestatic picture?
Synthetic function best measured by albumin and clotting
Management of decompensated liver
disease
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Resuscitation
Treat the cause if possible
Encephalopathy prevention/treatment
Hypoglycaemia treatment
Coagulopathy treatment
Ascitic drainage
Gastric mucosa protection
Manage alcohol withdrawal
Antibiotic prophylaxis
Nutrition
Alcoholic liver disease
Alcoholic fatty liver
Usually asymptomatic
Gamma GT/MCV elevated
Reversible if stop drinking
Alcoholic hepatitis
Necrosis of liver cells
Asymptomatic to very ill with hepatic failure
Elevated bilirubin and transaminases
Low albumin and deranged clotting
Alcoholic cirrhosis
End stage disease
Destruction and fibrosis of liver
Management directed at complications
Complications of chronic liver disease
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Hepatic encephalopathy
Acute variceal bleeding
Spontaneous bacterial peritonitis (SBP)
Hepatorenal syndrome
Hepato-renal syndrome
Key points
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Causes of chronic liver disease
Investigations in liver disease
Management of decompensated liver failure
How to manage an acute variceal bleed
Thank you
Any Questions?