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Chronic liver disease (CLD) – compensated

 

Definition of chronic liver disease (CLD)

  • Progressive destruction of the liver parenchyma over a period greater than 6 months leading to fibrosis and cirrhosis

 

Epidemiology of chronic liver disease (CLD)

  • Literature on the incidence and prevalence of liver cirrhosis is scarce but figures suggest that around 0.1% of the population in Europe is affected
  • The figures vary depending on the aetiology

 

Causes of chronic liver disease (CLD)

  • Non-alcoholic fatty liver disease (NAFLD)/ Non-alcoholic steatohepatatis (NASH)
    • Due to diabetes, metabolic syndrome
      • DM type II, Hypertension, Obesity, Hyperlipidaemia
    • Investigations
      • AST:ALT usually <1 (i.e. low)
      • Biopsy: microvesicular steatosis
  • Viral
    • Hepatitis B, C and D
  • Alcohol
    • Commonest cause of CLD in the UK
  • Genetic
    • Cystic fibrosis
    • Hereditary haemachromatosis
      • Excessive iron absorption leading to iron deposition in the liver and other organs
      • HFE gene on chromosome 6 – variable penetrance
      • Carrier prevalence 1 in 10 in northern Europe
      • Leads to liver cirrhosis, diabetes, skin discolouration, hypogonadism, arrhythmias, heart failure
      • Treat with regular venesection or desferrioxamine
    • Wilson’s
      • Autosomal recessive disorder leading to copper accumulation
      • Leads to liver cirrhosis, neuropsychiatric symptoms including parkinsonism, cardiomyopathy, arrhythmias
      • Low serum caeruloplasmin and high urinary copper
      • Treat with copper chelators such as penicillamine
    • Glycogen storage diseases
  • Autoimmune
    • Females > males
    • 2 peaks
      • Peri- and post- menopausal (types I and III)
      • Teenage/early twenties (predominantly type II)
    • Genetic predisposition thought to combine with unknown environmental trigger to set it off.
    • Associated with other autoimmune disease
      • PA, thyroiditis and autoimmune haemolytic anaemia.
    • Three types
      • Type I: Anti-nuclear and/or anti-smooth muscle antibodies
      • Type II: Anti liver/kidney microsomal (anti-LMK1)
      • Type III: With soluble liver antigen (course same as type I)
    • Investigations
      • Ant- smooth muscle abs
      • IgG usually up as well
    • Treatment
      • Prednisolone 60mg AND/OR azathioprine
  • Drugs
    • Isoniazid, methotrexate, amiodarone, phenytoin, sodium valproate, nitrofurantoin
  • Vascular
    • Budd-Chiari
  • Idiopathic/Cryptogenic

 

Presentations of chronic liver disease (CLD)

  • Fatigue
  • Encephalopathy
  • Hands
    • Dupuytren’s contracture, palmar erythema, leuconychia
  • Asterixis
  • Face
    • Jaundiced sclera
    • Fetor hepaticus
  • Chest
    • Spider naevi, gynaecomastia
  • Abdomen
    • Hepatomegaly, splenomegaly (due to portal hypertension)
    • Ascites, caput medusa
  • Polyneuropathy

 

Scoring systems for chronic liver disease (CLD)

There are various scoring systems, each used by different institutions in slightly different situations. The basic parameters of these scores are below but you can click here for an external site that calculates any or all of these scores (MELD, UKELD or Childs-Pugh) from variables you enter.

 

Initial management of chronic liver disease (CLD)

  • Bloods
    • FBC: normocytic normochromic  anaemia with leukopenia and thrombocytopenia often present
    • LFTs: deranged across the board. Note can be normal in very advanced disease.
    • Coagulation
    • Note that the tests of synthetic liver function are albumin, PT and platelets
      • If these are deranged suspect severe disease
    • U+Es can be deranged in hepatorenal syndrome or excess diuretic therapy in response to ascites and oedema
    • Viral screen: Hep B,C and delta, HIV 1&2
    • Autoantibodies (PBC/PSC)
    • Serum Immunoglobulins
    • Iron studies and ferritin (Haemochromatosis)
    • Copper and Ceruloplasmin (Wilson’s)
    • Alpha-1 antitrypsin level (deficiency)
    • Severity assessment
    • Search for causes
  • Imaging
    • Can demonstrate fatty liver, nodularity of cirrhosis, distortion of architecture, and can detect HCC
    • Hepatosplenomegaly; triple-phase scan will show contrast-enhancing HCC
    • USS
    • CT
  • Endoscopy
    • All patients should have a screening gastroscopy to check for oeseophageal varices
    • If varices present patient should be enrolled on a banding programme or commenced on a non-selective beta-blocker (e.g. propranolol)
  • Abstinence from alcohol
    • Important for other causes of cirrhosis, not just alcohol-related CLD
  • Treat cause
    • Antiviral treatment; steroids; ursodeoxycholic acid etc

 


Video explaining Liver Function Tests (LFTs)

 

Further management of chronic liver disease (CLD)

  • 6-monthly USS
    • 3-monthly if haemochromatosis) and ALP to screen for hepatocellular carcinoma
  • Liver Biopsy
    • Shows type and severity of disease
    • Can be used for staging prior to consideration of liver transplantation
  • Liver transplantation

 

Complications of chronic liver disease (CLD)

  • Variceal bleeding
  • Ascites
    • Spontaneous bacterial peritonitis
  • Encephalopathy
  • Hepatorenal syndrome
  • HCC

 

Prognosis of chronic liver disease (CLD)

  • Varies depending on cause and severity
  • Poor prognostic factors include grade III or IV encephalopathy, age >40, drug-induced hepatic failure, high INR

 

Click here for medical student OSCE and PACES questions about Compensated Chronic liver disease

Common Compensated Chronic liver disease (CLD) exam questions for medical students, finals, OSCEs and MRCP PACES

 

Click here to download free teaching notes on Compensated Chronic liver disease: Chronic liver disease – Compensated

Perfect revision for medical students, finals, OSCEs and MRCP PACES