Chronic Liver Disease/Cirrhosis

Chronic liver disease (CLD) is characterised by a diffuse, progressive fibrosis and structural abnormality of the liver. The end-stage of it is called Cirrhosis. The most common cause of it is Alcohol, Hepatitis B and C, and NAFLD. Other causes include:

• Autoimmune

• Drugs e.g. amiodarone, methotrexate

• Genetics e.g. a1 anti-trypsin deficiency, haemochromatosis, wilson disease

Compensated cirrhosis - Where sufficient liver function remains to keep the patient systemically well. Typically presents with:

• Fatigue and poor appetite

• Clubbing

• Mild RUQ pain/discomfort

• Spider naevi

• Gynaecomastia

• Caput medusa

Decompensated cirrhosis - Typically presents with:

• Jaundice

• Portal hypertension

  • Ascites

  • Encephalopathy (drowsiness, liver flap, hyperventilation)

  • Varices

• Palmar erythema

• Easy bruising

Complications:

• Ascites - This is due to portal hypertension and hypoalbuminaemia

• Portal hypertension - Leads to oesophageal varices and haemarrhoids

• Spontaneous bacterial peritonitis (SBP) - This occurs in patients with ascites and often atypically presents with no abdominal tenderness/guarding. It should be suspected in any patient who deteriorates suddenly with no other obvious cause.

  • It's most common caustive organisms are E.coli and Klebsiella

  • Needs to be investigated with an ascitic tap, which will show neutrophils > 250mm³

• Liver failure - Presents with hepatic encephalopathy and coagulopathy

Investigations:

• Bloods - FBC, U&E, LFT, INR, Albumin, AFP (cancer marker)

• Ascitic tap if appropriate (check for SBP)

• FibroScan and USS

• Liver biopsy

N.B. PT/INR is the best test to demonstrate the synthetic function of the liver.

Management:

The most important aspect when managing these patients is that they have total alcohol abstinence and good nutrition.

Management of complications:

• Ascites - Fluid restriction +/- low-salt diet, or spironolactone (furosemide can be added if no improvement)

• Encephalopathy - Prophylactic lactulose and rifaximin

• SBP - Prophylactic Abx if high risk

Definitive treatment is with a liver transplant.