Plan for session
• 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
Functions of the liver
Storage
- Glucose (in form of glycogen)- Vitamins (A, D, K and B12)- Iron and copper
Synthesis
- Gluconeogenesis- Glycogenesis- Amino acid and protein synthesis- Lipogenesis, cholesterol synthesis- Coagulation factors- Bile- Growth factors e.g IGF-1
Breakdown
- Drug and toxin metabolism (glucuronidation, methylation)
- Ammonia (urea cycle)- Bilirubin metabolism- Glycogenolysis
Immunological effects
- Immunologically active cells, antigens carried to it through reticuloendothelial system
Aetiology of chronic liver diseaseCOMMONAlcohol History of excess alcoholChronic hepatitis B HBsAg +/- HBeAg in serumChronic 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
Cirrhosis
- Histological diagnosis- End stage of chronic liver disease where normal liver
architecture is replaced with diffuse fibrosis and nodules.
Decompensated hepatic failure
- Severe liver dysfunction leading to jaundice, encephalopathy and coagulopathy.
Presentation – symptoms and signsSigns of chronic liver disease:ABCDEA sterixisB rusiesC lubbingD upuytren’sE rythema (palmar)
plus 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)
Digestive Problems
Immune Dysfunction
Abnormal Metabolism of Fats
Blood Sugar Problems
Hormonal Imbalance
Symptoms of chronic liver disease:
Varied and vague!
Case based discussion
On examinations he is jaundiced but has no hepatic flapOrientated in time, place and person Abdomen is distended but SNTNo palpable organomegaly but there is shifting dullness
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.
Case based discussion
• Group 1: Further history/examination• Group 2: Investigations• Group 3: Management options (how would
you manage if there were signs of decompensation?)
Group Exercise 3
5 minutes!!!
Further history/examination
• 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
Invasive tests: Liver biopsy Ascitic tap ERCP OGD
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
Interpreting LFTs
‘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
‘Liver function tests’ misleading
Think hepatitic or cholestatic picture?Synthetic function best measured by albumin and clotting
Management of decompensated liver disease
• 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 asymptomaticGamma GT/MCV elevatedReversible if stop drinking
Alcoholic hepatitis
Necrosis of liver cellsAsymptomatic to very ill with hepatic failureElevated bilirubin and transaminasesLow albumin and deranged clotting
Alcoholic cirrhosis
End stage diseaseDestruction and fibrosis of liverManagement directed at complications
Complications of chronic liver disease
• Hepatic encephalopathy• Acute variceal bleeding• Spontaneous bacterial peritonitis (SBP)• Hepatorenal syndrome
Key points
• Causes of chronic liver disease• Investigations in liver disease• Management of decompensated liver failure• How to manage an acute variceal bleed