Chronic Liver Disease:

Complication and Treatment

Syifa Mustika

A Patient Case
54 year old gentleman presents to internist with increasing swelling of his
abdomen and feet over the last 2 months. He has been increasing tired over
this time and feels nauseous and is off his food. His wife has commented that
his eyes have turned yellow over the last few days. He works in as a truck
driver and smokes 10 cigarettes a day. He admits to drinking 2 cans of beer
every weekend since young. His wife also says he sometimes drinks a bottle of
whisky.
On examination he is jaundiced but has no hepatic flap and is orientated in
time, place and person. His abdomen is distended but soft and non-tender.
There is no palpable organomegaly but there is shifting dullness.
What are your main differential diagnoses for this gentleman?

Differential Diagnosis

(Decompensated) Alcoholic liver disease

Viral liver disease

Hepatocellular Carcinoma

Pancreatic Cancer

Cryptogenic Liver Cirrhosis

Autoimmune liver disease

What further history would be needed?

What signs would you look for on examination?

Signs of CLD

How would you investigate this

patient?
Bedside

Observations, BM, fluid balance, weight

Blood tests

LFTs (pre/post) (including albumin), INR

CBC, RFT, CRP

Liver screen: viral hepatitis serology, autoantibodies, alpha-1 antitrypsin

Imaging

US abdomen + portal vein doppler

CXR, CT, MRI, MRCP

Special tests

Ascitic tap, Endoscopic examination (oesophageal varices), liver biopsy

What is your management plan?

Conservative
Alcohol abstinence, optimise nutrition, low salt diet, fluid restriction
Medical
Vitamin B supplementation
Diuretics
Beta-blocker
Paracentesis (give albumin)
NG feeding
Antibiotics (? SBP)
Lactulose (in hepatic encephalopathy)
Surgical
TIPS
Liver transplantation

What is possible complications and the

prognosis of this patient?

Portal hypertension: esophageal varices, ascites

SBP

Hepatic encephalopathy (constipation, GI bleed, infection, renal failure)

Hepatocellular carcinoma

Coagulopathy

Hepato-renal syndrome

Liver failure

Prognostic :

Calculates Child Pugh Score: bilirubin, INR, albumin, ascites, hepatic

encephalopathy

Outline
Epidemiology

Definition,

Etiologies and Classification

Clinical Presentation
Diagnostic Approach
Progostic Measurement
Management
Complications: Variceal Hemorrhage, HE, HRS

Epidemiology

Cirrhosis is the 12th leading cause of death in the

United States.

It accounted for 29,165 deaths in 2007, with a mortality

rate of 9.7 per 100,000 persons.

Cirrhosis is a major risk factor for the development of

hepatocellular carcinoma; the incidence of this
malignancy tripled from 1975 to 2005.

Definitions and Etiologies

The

word cirrhosis is derived from the Greek word

kirrhos, meaning orange or tawny, and osis, meaning
condition.

World

Health Organization definition of cirrhosis is a

diffuse process characterized by fibrosis and the
conversion of normal liver architecture into structurally
abnormal nodules that lack normal lobular
organization.

Classification
Morphologic classification is less useful because of considerable overlap.

Micronodular cirrhosis, with uniform nodules less than 3 mm in diameter:

causes include alcohol, hemochromatosis, biliary obstruction, hepatic
venous outflow obstruction, jejunoileal bypass, and Indian childhood
cirrhosis.

Macronodular cirrhosis, with nodular variation greater than 3 mm in

diameter: causes include chronic hepatitic C, chronic hepatitis B, alpha-1
antitrypsin deficiency, and primary biliary cirrhosis,

Mixed cirrhosis, a combination of micronodular and macronodular cirrhosis:

micronodular cirrhosis frequently evolves into macronodular cirrhosis

Clinical Presentation

Diagnostic Approach

Prognostic Measurement

Management

Management focuses on the treatment of complications

Surveillence for hepatocellular carcinoma with serial USG and

serum alpha fetoprotein measurements at frequent intervals
(e.g., every 6 months) Vaccination of cirrhotic patients against
hepatitis A and B is recommended if patients lack serologic
evidence of immunity.

Cirrhotic patients should be advised to avoid alcohol and

other hepatotoxins.

In end-stage cirrhosis, liver transplantation can be a lifesaving

procedure if the patient is an appropriate candidate

Complication
Ascites

Variceal

Hemmorhage
Hepatic Encephalopathy
Hepatorenal Syndrome
Spontaneus Bacterial Peritonitis
Malnutrition
Hepatocellular Carcinoma

Variceal Hemorrhage

ABC
- Protect airway
- High flow O2
- Haemodynamically stable?

- Bloods (Hb, Urea, Crossmatch 4-6 units), ABG

- Fluid resuscitation anything, blood is best

Correct clotting abnormalities (vitamin K, FFP)

Emergency endoscopy: banding, adrenaline injections
Somatostatin or Octreotide
IV omeprazole, antibiotics
Rockall Risk Score:
Age, Co-morbidities, Shock, Diagnosis, evidence of bleeding (OGD)

Hepatic Encephalopathy
Reversible decrease in neurological function
secondary to liver disease
Acute: seen with acute liver failure
Acute on chronic: established cirrhosis
Diagnosis :
Clinical (most important)
The drawing tests
EEG
CT/MRI may show cerebral atrophy

Hepatic Encephalopathy
West Haven Criteria for Hepatic Encephalopathy

Grade 1: shorted attention span, reversal of sleep-wake cycle, impaired

performance of addiction or substraction (anxiety, irritability)

Grade 2: lethargy, subtle personality change, disorientation minimal of

time and place. Asterixis.

Grade 3: stupor but responsive, severe confusion and disorientation,

abnormal behaviour, incomprehensible speech, confusion and gross
disorientation.

Grade 4: coma (unresponsive to verbal and stimuli)

Hepatic Encephalopathy - Treatment

Identify and treat precipitation factor

Treat underlying liver disease
Low to normal protein diet
Antibiotics (Neomycin, metronidazole)
Lactulose
BCAA
LOLA
Liver Transplantation

Hepatorenal Syndrome

Progressive renal failure

Type 1 : rapidly progressive, high mortality
Type 2: slower progression
R/O volume depletion secondary to diuretics
IV vasoconstrictors
Liver transplantation

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