Week 3 Gastroenterology Chronic Liver Disease Dr Ben

Week 3: Gastroenterology Chronic Liver Disease Dr Ben Robinson F 2

Plan for session • • Introduction Functions of liver Causes of chronic liver disease Symptoms and signs of chronic liver disease Case based discussion Complications of liver disease Questions/comments

Background • 5 th commonest cause of death in the UK • UK is one of few developed countries in the world with increasing mortality from liver disease • Liver disease morbidity and mortality is largely preventable • Liver disease accounts for 60% of inpatient gastroenterology activity British Society of Gastroenterology: http: //www. bsg. org. uk/clinical/commissioning-report/management-of-patients-with-chronic-liver-diseases. html

Group Exercise 1 1. Functions of the liver 2. Causes of chronic liver disease 3 minutes!!!

Functions of the liver Storage Synthesis - - Glucose (in form of glycogen) Vitamins (A, D, K and B 12) Iron and copper Breakdown - Drug and toxin metabolism (glucuronidation, methylation) Ammonia (urea cycle) Bilirubin metabolism Glycogenolysis Gluconeogenesis Glycogenesis Amino acid and protein synthesis Lipogenesis, cholesterol synthesis Coagulation factors Bile Growth factors e. g IGF-1 Immunological effects - Immunologically active cells, antigens carried to it through reticuloendothelial system

Aetiology of chronic liver disease COMMON Alcohol History of excess alcohol Chronic hepatitis B HBs. Ag +/- HBe. Ag in serum Chronic hepatitis C HCV antibodies and HCV RNA in serum OTHERS Autoimmune Primary biliary cirrhosis Serum antimitochondrial antibodies Autoimmune hepatitis Circulating autoantibodies Inflammatory Sclerosing cholangitis Serum p. ANCA, IBD Metabolic Wilson’s disease Low serum caeruloplasmin and copper Alpha 1 -antitrypsin deficiency Low alpha 1 -antitrypsin, emphysema

Aetiology of chronic liver disease OTHERS Drugs Methotrexate, paracetamol Hereditary haemochromatosis Family history, increased ferritin Non-alcoholic fatty liver disease Metabolic syndrome, hyperechoic liver Budd-Chiari syndrome Risk factors, liver USS

Important definitions Decompensated hepatic failure - Severe liver dysfunction leading to jaundice, encephalopathy and coagulopathy. Cirrhosis - Histological diagnosis - End stage of chronic liver disease where normal liver architecture is replaced with diffuse fibrosis and nodules.

Symptoms and signs of chronic liver disease Group Exercise 2 Body Diagram 5 minutes!!!

Presentation – symptoms and signs Symptoms of chronic liver disease: Varied and vague! Digestive Problems Immune Dysfunction Abnormal Metabolism of Fats Blood Sugar Problems Hormonal Imbalance Signs of chronic liver disease: ABCDE A sterixis B rusies C lubbing D upuytren’s E rythema (palmar) plus § § § § § Malnourished Facial telangiectasia Parotid enlargement Spider naevi Gynaecomastia Hepatomegaly or cirrhosis Jaundice Caput medusa Encephalopathy (hepatic foetor, liver flap, drowsiness, disorientated or unable to draw a 5 point star)

Case based discussion 54 year old gentleman presents to his GP with increasing swelling of his abdomen and feet over the last 2 months Increasingly tired, feels nauseous and off food Wife says eyes have turned yellow over last few days Works in a warehouse and smokes 10 cigarettes a day Admits to drinking 4 cans of lager a night. Wife says he drinks at least 8 cans a night and a bottle of whiskey a week. On examinations he is jaundiced but has no hepatic flap Orientated in time, place and person Abdomen is distended but SNT No palpable organomegaly but there is shifting dullness

Case based discussion Group Exercise 3 • Group 1: Further history/examination • Group 2: Investigations • Group 3: Management options (how would you manage if there were signs of decompensation? ) 5 minutes!!!

Further history/examination • • Length of alcohol use Alcohol withdrawal? Recent travel, risk factors for BBV? Bruising/bleeding? PMH of IBD, autoimmune disease etc? Drug history FH of liver disease Other features of chronic liver disease O/E

Investigations Bedside tests: § Blood glucose Blood tests: § FBC, clotting, U&E, LFTs, iron studies (ferritin, iron), viral serology § Others: § Alfa-1 antitrypsin, caeruloplasmin, antimitochondiral antibodies, antinuclear antibodies (ANA) and SMA, paracetamol levels Imaging: § Liver USS § MRCP § CT head Invasive tests: § Liver biopsy § Ascitic tap § ERCP § OGD

Interpreting LFTs ‘Liver function tests’ misleading ‘Liver biochemistry’ better term: Bilirubin Aminotransferases (liver cell damage) Alkaline phosphatase ALP (cannalicular and sinuosoidal membranes of liver) Gamma GT – liver microsomal enzyme induced by alcohol or drugs Think hepatitic or cholestatic picture? Synthetic function best measured by albumin and clotting

Management of decompensated liver disease • • • Resuscitation Treat the cause if possible Encephalopathy prevention/treatment Hypoglycaemia treatment Coagulopathy treatment Ascitic drainage Gastric mucosa protection Manage alcohol withdrawal Antibiotic prophylaxis Nutrition

Alcoholic liver disease Alcoholic fatty liver Usually asymptomatic Gamma GT/MCV elevated Reversible if stop drinking Alcoholic hepatitis Necrosis of liver cells Asymptomatic to very ill with hepatic failure Elevated bilirubin and transaminases Low albumin and deranged clotting Alcoholic cirrhosis End stage disease Destruction and fibrosis of liver Management directed at complications

Complications of chronic liver disease • • Hepatic encephalopathy Acute variceal bleeding Spontaneous bacterial peritonitis (SBP) Hepatorenal syndrome

Hepato-renal syndrome

Key points • • Causes of chronic liver disease Investigations in liver disease Management of decompensated liver failure How to manage an acute variceal bleed

Thank you Any Questions?