Long Case Approach to Chronic Liver Disease

Identify the Aetiology & their Risk Factors

1. Infections Hepatitis B, C
2. Alcohol / drugs (MTX, amiodarone)
3. Metabolic
a. DO NOT mention haemochromatosis. Gene not found in local population
b. Wilsons disease
c. Alpha1 antitrypsin deficiency
4. Congenital / hereditary biliary atresia
5. Autoimmune usually female
6. Cryptogenic
Diagnosing CLD based on:
1. Stigmata of CLD jaundice, clubbing, leukonychia, palmar erythema, spider naevi,
gynaecomastia, testicular atrophy
2. Symptoms of CLD jaundice, ascites, pedal edema, Cx of CLD, non-specific
symptoms (LOW, LOA, malaise)
3. Radiological/ Histological results
4. LFT
Assessing CLD

Is the CLD
i.
Compensated
ii.
Decompensated presence of Cxs of CLD

Child-Pugh score for prognostication & assessment of CLD severity

Criteria
Points
Total S. Bilirubin
1
<2
(mg/dl)
2
2-3
3
>3
S. Albumin
1
>3.5
(g/dl)
2
2.8-3.5
3
<2.8
INR
1
<1.70
2
1.71-2.20
3
>2.20
Ascites
1
No ascites
2
Ascites controlled medically
3
Ascites poorly controlled
Encephalopathy
1
No encephalopathy
2
Encephalopathy medically controlled
3
Encephalopathy poorly controlled
Child Class
Prognosis

A (5-6 pts)
Life expectancy 15-20
yrs
Abdo Sx peri-op
mortality: 10%

B (7-9 pts)
Indicated for liver
transplant evaluation
Abdo Sx peri-op
mortality: 30%

C(10-15 pts)
Life expectancy 1-3 yrs
Abdo Sx peri-op
mortality: 82%

Identify Complications of CLD (ABCDE + HP)

Albumin (hypo)

Bilirubin - jaundice

Coagulopathies

Distension (ascites)

Encephalopathy

HCC

Hepatorenal synd

Hepatopulm synd

Heart failure

Portal HTN varices

Portal vein thrombosis

Common Presentations
i.
Swelling ascites, pedal edema
ii.
Abdominal pain
iii. Upper GI bleed due to bleeding oesophageal varices or Mallory-Weiss tear after
alcoholic binge
iv. Encephalopathy
v. CCF secondary to CLD
vi. HCC enlarged abdominal mass
History
Common presenting complaints:
Jaundice
GI bleed ddx: peptic ulcer, drugs, Mallory Weiss, CA
Petechiae many present initially ITP-like
Ascites ddx: cardiac, renal, malabsorption
Encephalopathy ask about pptg causes (hemorrhage/ hypoxia/ hypnotics/ hard stools/
infections/ CA see below for complete list)
Symptoms of
CLD
Abdominal pain

Jaundice
Non-specific symptoms (LOW,
pruritis
LOA, malaise)
If viral hepatitis usually due to malignancy or SBP
If EtOH hepatitis usually due to stretching of liver capsule or pancreatitis
(often after alcoholic binge).
Complications of CLD (ABCDE+ portal HTN + CA)
hypoAlb
Abdominal swelling
LL swelling
Bilirubin
jaundice
pruritis
Coagulopathy
Bruising
Menorrhagia
Epistaxis
Bleeding gums
Distension
Ascites
SBP
Encephalopathy Lethargy / drowsiness / LOC
Sleep-wake cycle reversal
Limb rigidity & hyperreflexia
Personality change
Sensory neuropathy
Seizures
Asterixis

Portal HTNs
varices

Cancer

Causes of CLD
Alcohol

Hepatitis

Hemetemesis oeso variceal bld

Symptoms of shock dizziness,
Melaena black, tarry formless
LOC, SOB
stool
LOW/ LOA
Is regular f/u done? U/S, AFP DGIM Last updated March 2005
CAGE questionnaire
Present drinking hx no. of
units/wk >14 male, >7 female
Past drinking hx
Hx of hepatitis & treatment
Hx of Hepatitis B vaccination

Signs to look for in CLD

CLD & complications
Hands
Clubbing
Pallor
Cyanosis
Leuconychia
Arms / chest
Bruises / petechiae
Gynaecomastia
Head
Jaundice
Pallor
Alopecia
Abdomen /
Ascites
pelvis
tenderness SBP,
pancreatitis, malignancy, liver
capsule stretch
Legs
Rectum

Hepatic
Encephalopathy

Other cx of
alcoholism

Pedal oedema
Melaena

Occupation esp bartender,

waiter, seamen, military
Recent alcoholic binge

IVDA/Tattoos/transfusions
CSW/ Homosexuality

Palmar erythema EtOH liver dz

Dupuytrens contractures
Asterixis
Postural tremors EtOH liver dz
Spider naevi >5 in area of
drainage of SVC
Parotid enlargement EtOH liver
dz
Fetor hepaticus
Caput medusae
Hepatomegaly tenderness, note
especially if liver irregular, hard
Splenomegaly
Testicular atrophy

Hard stools (encephalopathy)

Test for orientation to TPP

4 stages of encephalopathy
Stage I: sleep-wake reversal, slurred speech, slow mentation
Stage II: irritability, asterixis, lethargy, disorientation, personality
Stage III: confusion, sleepy by responds to pain & voice
Stage IV: coma, unresponsive to voice pain
Cardiac
displaced apex
CCF
Neuro/Psy
Neuro examPeripheral neuropathy,
--Wernickes encephalopathy (NOA+confusion)
o
Horizontal nystagmus
o
Ophthalmoplegia
o
Ataxia (test gait)

MMSE dementia
--Korsakoffs psychosis
o
Impaired recall & learning abilities
o
Confabulation
o
Intact consciousness

Investigations

To confirm dx

To look for etiology

To look for complications

FBC

Hypersplenism HB, leucocytes, pltlets

Anaemia megaloblastic (Vit B12 or folate deficiency), Fe

deficiency

Infections SBP
LFT

Confirm dx

GGT suggests alcoholic liver disease

S. albumin and bilirubin for Child-Pugh classification

PT/aPTT

INR for Child-Pugh classification

AFP

HCC
U/S HBS

HCC
CXR

Malignancies
Liver biopsy

Confirm dx

HCC
Paracentesis

Microscopy, C/S, amylase

Malignant cells, infections (SBP), pancreatitis

Hepatitis serology

Cause of CLD
Other causes of

Autoantibodies
CLD

Urinary Cu (Wilsons disease)

Management of CLD
1. Ascites / pedal oedema

2.

Spontaneous Bacterial
Peritonitis

3.

Varices

Non pharmacological
Fluid & salt restriction
I/O charting, daily wt measurement
Pharmacological
Diuretics spironolactone +/- frusemide
Procedural
Paracentesis diagnostic & therapeutic (SOB)
If leucocyte count >250cells/mm3, give fluoroquinolone
Acute onset abdominal pain, rebound tenderness, absent
bowel sounds and fever in the presence of ascites &
cirrhosis
Invx: paracentesis cloudy fluid with neutrophils count
>250/mm3
Usually enteric organisms, esp E. Coli
Rx: cefuroxime + metronidazole
Prophylaxis with ciprofloxacin
Acute variceal bleed

4.

Encephalopathy

5.

HCC

6.

Malnutrition

Resuscitate, stabilize, optimize for endoscopy

ABC
Fluid resus 2 large bores
Bloods FBC/ PT/aPTT/ GXM/ UECr/ LFT
Get ready FFP/VitK/pRBC
IV omeprazole, also somatostatin (Ocreotide)/ terlipressin
if GI bleed suspected to be varices
Urgent endoscopy for banding/ligation
IV glypressin
90% can be treated by endoscopy
DGIM
5% need re-endoscopic
tx Last updated March 2005
5% need surgical TIPS/ esophageal resection/ gastric
repair
Identify precipitating factor and treat it hemorrhage/
hypoxia/ hypercarbia/ hard stools/ hypnotics/ infections/
progression to CA
Low protein diet
Lactulose aim to achieve at least 2-3 loose stools/day
MARS (Membrane Adsorbent Recirculating System) for
acute liver failure. Able to restore liver function only to
pre-morbid state
Sx resection preferred but only for
o
Child A/B,
o
unilobar CA with no portal vein
involvement
Therapeutic radiology only if Sx impossible
o
Transarterial chemoembolism (TACE)
o
Percutaneous ethanol injection
Liver transplant indications
o
ESLD
o
Fulminant
o
HCC
o
Metabolic disease
Contraindications
o
Mets
o
Severe comorbidities
o
HIV
o
Active HBV
o
Alcohol dependence
Vit K injection
Vit D and Ca supplements

Extra information
Factors precipitating Hepatic encephalopathy

Uraemia spontaneous or diuretic

induced

K+

Drugs sedative/narcotics,
antidepressants, hypnotics
GI bleeding
Excessive dietary protein
Constipation

Paracentesis (>3-5L) leads to

hypovolaemia and K+
Infections
Trauma / Sx
Portasystemic shunts
EtOH binge

DGIM Last updated March 2005