Overview
Chronic liver disease is a common condition most often caused by alcohol, fatty liver disease or viral hepatitis. This condition can be difficult to diagnose, and the examination is crucial for identifying evidence of portal hypertension, oestrogen excess encephalopathy and other complications of cirrhosis.
Pathogenesis
Causes of Cirrhosis
- Chronic hepatitis - B or C
- Alcoholic liver disease
- Non-alcoholic fatty liver disease
- Autoimmune hepatitis
- Obstructive disease - primary biliary cirrhosis, primary sclerosing cholangitis, chronic biliary obstruction
- Infiltration - haemochromatosis, Wilson's disease, alpha-1 antitrypsin deficiency, sarcoidosis, glycogen storage disease type IV
- Hepatocellular carcinoma
- Drugs - methotrexate, methyldopa, amiodarone
- Budd-Chiari syndrome (hepatic vein occlusion)
- Right heart failure (cardiac cirrhosis)
Manifestations
Complications of Cirrhosis
- Ascites (due to portal hypertension, RAAS activation and splanchnic vasodilatation)
- Varices (due to portal hypertension)
- Splenomegaly (due to portal hypertension)
- Hepatic encephalopathy (due to ammonia buildup)
- Spontaneous bacterial peritonitis (due to gut translocation)
- Hepatorenal syndrome (due to splanchnic vasodilatation)
- Hepatic hydrothorax (due to leakage of ascitic fluid into the pleural space)
- Portopulmonary hypertension (due to portal hypertension)
- Hepatopulmonary syndrome (due to vasodilation / shunting)
- Malnutrition / sarcopaenia
- Coagulopathy (due to poor synthetic function + vitamin K malabsorption)
- Thrombocytopaenia (due to splenic sequestration)
- Hepatocellular carcinoma (HCC)
Diagnosis
Signs of Chronic Liver Disease
General Signs
- Sarcopaenia
- Jaundice (a late sign)
- Leukonychia
Signs Suggesting a Cause
- Obesity (NAFLD)
- Scratch marks (cholestasis)
- Tattoos (viral hepatitis)
- Kayser-Fleischer rings (Wilson's disease)
- Cerebellar signs (alcohol misuse)
Signs of Complications
- Portal hypertension - splenomegaly, caput medusae
- Ascites - shifting dullness, fluid thrill
- Oestrogen excess - palmar erythema, spider naevi, gynaecomastia
- Encephalopathy - confusion, asterixis
- Hepatic hydrothorax - reduced breath sounds, dull percussion note
- Spontaneous bacterial peritonitis - fever, rigid / tender abdomen
- Coagulopathy / thrombocytopaenia - bruising, bleeding
Signs of Management
- Dressing over recent abdominocentesis site
- Liver transplant scar
Management
Pearls
- Treat the underlying cause of cirrhosis - e.g. treat viral hepatitis, alcohol cessation, weight loss
- Treat complications
- Monitor for further complications - varices and HCC
Management Options
Non-Pharmacologic
- Diet - high protein, high energy; salt restriction
- Alcohol cessation
Treatment of Complications
- Ascites - salt restriction, diuretics, paracentesis, TIPS
- Varices - emergency management of bleeding, banding, beta blocker
- Encephalopathy - identify and treat trigger, high protein diet, branched chain amino acids, lactulose, rifaximin
- Spontaneous bacterial peritonitis - antibiotics, 20% albumin
- Hepatorenal syndrome - exclude other causes of AKI, 20% albumin, terlipressin
- Hepatopulmonary syndrome - liver transplant
- Coagulopathy - consider vitamin K / factor replacement prior to procedures
Surveillance
- Variceal surveillance - gastroscopies
- HCC surveillance - liver ultrasound
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