Definition
Chronic liver disease is a process whereby there is progressive disease and destruction to the liver resulting in fibrosis and eventually cirrhosis.
Signs
General signs include: Cachexia, bruising, pallor, and excoriations
Hands signs: leuconychia, finger clubbing, dupuytrens contracture, palmar erythema and asterixis
Chest/abdo signs: – spider naevi (4 or more is pathological), distended abdominal veins and/or caput medusa, decreased body hair, gynaecomastia, testicular atrophy, ascites
Hepatic signs – there may be a mass in the RUQ which moves with respiration, which you are unable to get above and is dull to percussion. If hepatomegaly is present estimate its size in cm below the costal margin and describe its consistency for example craggy/nodular hepatomegaly may represent cirrhosis, smooth may represent hepatic congestion, or pulsatile suggests tricuspid regurgitation in CCF
Signs of underlying cause of CLD: Tattoos and injection marks may suggest viral hepatitis, obesity suggesting non-alcoholic fatty liver disease, tremor suggesting alcoholic liver disease
Lastly, comment on whether the liver disease is compensated or decompensated: the presence of jaundice, ascites or encephalopathy suggest decompensated liver disease
To complete: mention that you would want to perform a PR examination and examine the external genitalia
Symptoms include:
Fatigue and drowsiness which may suggest encephalopathy
Nausea and vomiting
Abdominal pain
Development of ascites or oedema – the patient may initially perceive this as weight gain
Jaundice
Pruritus
Causes
The 3 most common causes of CLD in UK are:
Alcohol
Viral hepatitis
Non-alcoholic fatty liver disease – therefore comment on the patient’s BMI
Other causes:
Autoimmune causes such as autoimmune hepatitis and primary biliary cirrhosis (PBC). Both of these are much more common in female patients – PBC occurs most commonly in middle aged women and autoimmune hepatitis, particularly affects those aged between 15 and 40 but it can occur in any age group. Therefore always include these in the differential if the patient is female in a CLD station
Metabolic causes e.g. hereditary haemochromatosis and Wilsons disease – look for skin pigmentation associated with haemochromatosis, and Kaiser Fleischer rings in the eyes which are seen in Wilsons disease
Drugs e.g. methotrexate and amiodarone – signs of rheumatological disease or is a pacemaker present
Some causes of chronic liver disease are idiopathic
Investigations
A Full liver screen should be sent including:
FBC/U+E/LFT/clotting/CRP/glucose/Gamma GT
Hep B/Hep C/EBV/CMV serologies
Ferritin
Autoantibody screen including (ANA, antmitochondrial, antiLKM antibodies, anti-smoothmuscle antibodies)
Serum caeruloplasmin/copper/24 hour urinary copper
Alpha-1 antitrypsin
Alpha Fetoprotein
USS abdo
Ascitic tap if ascites present and diagnosis unclear
Liver biopsy
MRCP/ERCP
Management
Management of Chronic Liver Disease includes:
Alcohol abstinence
Replacement of vitamins and thiamine
Optimise nutrition
Salt restriction
Diuretics if oedema or ascites present- start with spironolactone and then add in loop diuretics if further diuresis is still required – aim to achieve approximately 1kg of weight loss/day, with careful monitoring of renal function and electrolytes.
Prophylactic agents may be necessary such as propranolol if varices are present
Regular laxatives to avoid encephalopathy (aim for 3 soft stools/day)
Avoid hepatotoxic medications
Further management considerations may include a TIPS procedure or a liver transplant
A TIPS procedure is a transjugular intrahepatic portal shunt. A shunt is inserted directing blood from the hepatic portal vein to the hepatic vein, reducing pressure over the liver and alleviating portal hypertension. They are inserted by interventional radiologists.
Top tip
When faced with a patient with chronic liver disease try to establish the cause if possible. For example in a middle aged lady suggest PBC as differential. Also specify whether the liver disease is compensated or decompensated. Most likely the disease will be stable and compensated for patients used in the exam but sometimes you can be caught out.
Chronic liver disease is a common station and the examiners can ask many related questions once you have presented your findings.
What are common precipitants of decompensated liver disease?
- Infection
- Increased alcohol intake
- GI bleed
- Underlying malignancy
- Constipation
- Dehydration or increased salt intake
- Hepatotoxic drugs
What are the complications of CLD?
- Portal hypertension and varices which can cause severe GI haemorrhage
- Ascites
- Jaundice
- Encephalopathy
- Spontaneous bacterial peritonitis
- Hepatorenal syndrome
- Hepatopulmonary syndrome
- Hepatocellular carcinoma
What are the commonest causes of palmar erythema?
- Chronic liver disease
- Rheumatoid Arthritis
- Thyrotoxicosis
- Pregnancy
- Polycythaemia
What are the abdominal causes of finger clubbing?
- Inflammatory Bowel Disease
- Cirrhosis
- Coeliac disease
- Hepatocellular Carcinoma
Written by Jo Corrado
Resources used to write this document are listed in the references section of this webpage