Chronic Liver Disease

Relevant Physical Signs

• Hands and arms
  • Clubbing
  • Leukonychia (hypoalbuminaemia)
  • Dupuytren’s contracture
  • Palmar erythema
  • Asterixis (hepatic encephalopathy)
  • Pulse (sinus bradycardia indicates propranolol use for oesophageal varices)
  • Tattoos (risk factors for viral hepatitis)
• Head and neck
  • Conjunctival pallor (anaemia)
  • Scleral icterus (decompensated liver disease)
  • Jugular venous pulsation (elevated in cardiac cirrhosis)
• Chest
  • Spider naevi (central arterioles which blanch and fill from the centre out)
  • Gynaecomastia
  • Loss of axillary hair
• Abdomen
  • Inspection
    • Scars
      • Liver biopsy
      • Previous abdominal drainage
      • Mercedes Benz scar indicating previous liver transplantation
    • Distension (ascites)
    • Bruising (coagulopathy)
    • Distended umbilical veins (veins fill away from umbilicus, towards in IVC thrombosis)
  • Palpation
    • Liver is usually small in cirrhosis, but may be large in alcoholic disease or NASH
    • Spleen may be enlarged because of portal hypertension with hypersplenism
  • Percussion
    • Shifting dullness for ascites
  • Legs: peripheral oedema and assessment of volume status

Differential Diagnosis

• Alcoholic liver disease
• Non-alcoholic steatohepatitis
• Viral liver disease
  • Chronic hepatitis B
  • Chronic hepatitis C
• Autoimmune
  • Autoimmune hepatitis
  • Primary biliary cirrhosis
  • Primary sclerosing cholangitis
• Neoplastic disease
  • Primary hepatocellular carcinoma
  • Secondary metastatic disease from breast, lung or gastrointestinal tract
• Degenerative: Wilson’s disease
• Drugs
  • Isoniazid, methotrexate
  • Diet pills
• Metabolic
  • Haemochromatosis
  • Alpha-1 antitrypsin deficiency
  • Cystic fibrosis

Investigations

• Confirm diagnosis: ultrasound scan of the hepatobiliary system
  • May proceed to triphasic computed tomography scan of the liver
• Grade the severity of the disease (Child-Pugh score or MELD score)
  • Synthetic function of the liver
    • Prothrombin time / international normalized ratio
    • Albumin
  • Renal function
  • Bilirubin
  • Look for evidence of encephalopathy / albumin
• Look for complications
  • Full blood count: anaemia, thrombocytopaenia (hypersplenism)
  • Surveillance ultrasound scan and alphafetoprotein (hepatocellular carcinoma)
  • Oesophagogastroduodenoscopy (oesophageal varices)
• Look for an underlying cause
  • Alcohol and drug history
  • Hepatitis serology
  • Liver biopsy (NASH, PBC, PSC)
  • Serology
    • Anti-mitochondrial antibody (PBC)
    • Anti-neutrophil cytoplasmic antibody (PSC)
    • Anti-smooth muscle antibody (AIH)
    • Elevated immunoglobulin G (AIH)
    • Anti-liver kidney microsomal antibody (AIH)
  • Age-appropriate malignancy screening
  • Serum caeruplasmin (low) and urinary copper (high) for Wilson’s disease
  • Serum ferritin for haemochromatosis

Management

• Multidisciplinary team approach with patient education
• Treat underlying cause
  • Alcohol: abstinence
  • Viral hepatitis
    • Hepatitis B: telbivudine, entecavir, lamivudine
    • Hepatitis C: ribavirin and interferon, simeprevir and sofosbuvir
  • PBC: ursodeoxycholic acid, immunosuppression (methotrexate, steroids, cyclophosphamide)
    • Antihistamines or cholestyramine for itch
  • Haemochromatosis: venesection, iron chelation (desferasirox / Exjade)
• Treat complications
  • Variceal bleed
    • Resuscitation, transfusion of blood products
    • Oesophagogastroduodenoscopy for variceal banding and / or adrenaline injection
    • Sengstaken-Blakemore tube if resistant to banding
    • Propranolol for prophylaxis
  • Hepatic encephalopathy
    • Treat precipitants (infection, constipation, variceal bleed)
    • Consider rifaximin (reduces bacterial translocation)
  • Ascites
    • Diuretics: spironolactone and furosemide
    • Consider therapeutic paracentesis
  • Spontaneous bacterial peritonitis
    • Drainage of ascitic fluid
    • Empirical antibiotic therapy with ceftriaxone
    • Targeted therapy based on blood and peritoneal fluid culture
  • Hepatorenal syndrome
    • Volume expansion with intravenous albumin
    • Terlipressin
  • Hepatocellular carcinoma
    • Transplant if meeting criteria
    • Surgical resection
    • Transcatheter arterial chemoembolization (curative or debulking)
    • Radioembolisation (Y90)
    • Sorafenib (anti-angiogenic, raf-kinase inhibitor and pro-apoptotic novel agent)
• Definitive: liver transplant

Summary

Sir, this patient has cirrhosis. There are stigmata of chronic liver disease, including clubbing, palmar erythema, spider naevi, gynaecomastia and loss of axillary hair. In addition, there is bruising over the abdomen and limbs, indicating a synthetic defect in coagulation factors. There is no jaundice to suggest decompensated liver disease. On examination of the abdomen, the spleen is palpable four finger breadths below the costal margin. The liver is not enlarged. The abdomen is not distended, and there is no clinical evidence of ascites. The patient is currently euvolaemic, as the jugular venous pulsation is not elevated and there is no pedal oedema.

The differential diagnosis for chronic liver disease includes alcoholic liver disease, non-alcoholic steatohepatitis, chronic hepatitis B and C, right sided heart failure, inflammatory conditions such as autoimmune hepatitis, primary biliary cirrhosis and primary sclerosing cholangitis as well as mitotic disease such as infiltration of the liver by primary breast, lung or gastrointestinal malignancies. Other less common aetiologies include haemochromatosis, alpha-1 antitrypsin deficiency and Wilson’s disease.