Chronic Liver Disease
For final year medical students 2014
Dr Rosalind Pool GPST1

Objectives
• List signs and symptoms of CLD
• List causes of CLD
• Understand LFTs
• How to investigate CLD
• Management of CLD
• Apply knowledge to a case study.

Why might you suspect liver
failure?

Why might you suspect liver
failure?
Drowsiness / Encephalopathy
Jaundice
Ascites / Oedema
Excess alcohol
Drugs
Liver flap (use imagination!)

Causes of CLD
• Write down causes
• Try to structure your list.

Causes of liver disease
• Toxins
– Alcohol
– Drugs e.g. paracetamol overdose, co-amoxiclav etc
• Infections
– Viral hepatitis, EBV, CMV
• Metabolic
– Wilson’s, Haemochromatosis, Alpha 1 antitrypsin deficiency
• Neoplastic
– Hepatocellular carcinoma, liver secondaries
• Autoimmune
– Autoimmune hepatitis
– PBC, PSC
• Vascular
– Budd chiari

‘Liver screen’
• What is included in a liver screen?
• Think about your differential diagnoses.

Liver screen
• LFTs
• FBC, U&E, clotting
• Hepatitis serology
• EBV, CMV
• Immunoglobulins
• Glucose
• Ceruloplasmin
• ANA, AMA, alpha-1 antitripsin antibodies
• AFP
• Ferritin

Interpreting LFTs
• Buzz groups
List LFTs in the following categories
• Hepatic
• Cholestatic
• Synthetic

LFTs
• Hepatic
– Transaminase enzymes (ALT, AST, GGT)
• Cholestatic
– ALP, Bilirubin
• Synthetic
– Albumin, INR

Investigations
• Bedside tests
• Bloods
• More complex biochemistry
• Radiology
• Endoscopy

Investigations
• Daily weights
• Liver screen
• USS doppler liver
– portal blood flow and masses, hepatic vein patency
• Ascitic tap
– Microscopy and culture
– Cell count
– Biochemistry
– Cytology
• OGD
– urgent if suspected UGIB otherwise surveillance.
• Liver biopsy

Complications of CLD

Complications of CLD
• Infection:
– Spontaneous bacterial peritonitis
– Sepsis
• Ascites
• Dehydration
• respiratory distress
• AKI
• Encephalopathy
• Bleeding
– Oesophageal varices
– Clotting abnormalities
• Renal failure
– AKI
– Hepato-renal syndrome
• Malnutrition
– High risk of refeeding syndrome

Management
• Conservative
– Low salt, high protein diet, avoid alcohol
• Medical
– Diuretics
– Human albumin solution
– Paracentesis
– Vitamins
• Surgical
– TIPS (Transjugular intrahepatic portosystemic shunt)
– Transplant

What is this and why?
Gynaecomastia…
from spironolactone

Case study
• 54 year old gentleman presents to his GP with:
• 2/12 Hx increasing swelling of his abdomen and feet
• Tired over this time and feels nauseous and is off his food.
• His wife has commented that his eye have turned yellow over the last few
days.
• He works in a warehouse and smokes 10 cigarettes a day.
• He admits to drinking 4 cans of lager a night. His wife says he drinks at
least 8 cans a night and a bottle of whiskey a week.
• On examination he is jaundiced but has no hepatic flap and is orientated
in time, place and person. His abdomen is distended but soft and non-
tender. There is no palpable organomegaly but there is shifting dullness

• What are your main differential diagnoses for this gentleman?
(include all important differentials that must be ruled out)
• How would you investigate this gentleman?
• What would your management plan be for this gentleman?

• What are the features of hepatic encephalopathy?
• How do you manage hepatic encephalopathy?
• What are the complications of CLD?
• What is Spontaneous Bacterial Peritonitis?
• How would you manage an acute GI bleed (in the context of CLD)?

Summary
• Signs, symptoms, causes, investigations
and management of CLD
• Understanding LFTs
• Case study to apply your knowledge.
Any questions?

Many thanks
• Please fill in an evaluation form!