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Chronic Liver Disease

Chronic Liver Disease. For final year medical students 2014 Dr Rosalind Pool GPST1. Objectives. List signs and symptoms of CLD List causes of CLD Understand LFTs How to investigate CLD Management of CLD Apply knowledge to a case study. Why might you suspect liver failure?.

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Chronic Liver Disease

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  1. Chronic Liver Disease For final year medical students 2014 Dr Rosalind Pool GPST1

  2. Objectives • List signs and symptoms of CLD • List causes of CLD • Understand LFTs • How to investigate CLD • Management of CLD • Apply knowledge to a case study.

  3. Why might you suspect liver failure?

  4. Why might you suspect liver failure? Drowsiness / Encephalopathy Jaundice Ascites / Oedema Excess alcohol Drugs Liver flap (use imagination!)

  5. Causes of CLD • Write down causes • Try to structure your list.

  6. Causes of liver disease • Toxins • Alcohol • Drugs e.g. paracetamol overdose, co-amoxiclav etc • Infections • Viral hepatitis, EBV, CMV • Metabolic • Wilson’s, Haemochromatosis, Alpha 1 antitrypsin deficiency • Neoplastic • Hepatocellular carcinoma, liver secondaries • Autoimmune • Autoimmune hepatitis • PBC, PSC • Vascular • Budd chiari

  7. ‘Liver screen’ • What is included in a liver screen? • Think about your differential diagnoses.

  8. Liver screen • LFTs • FBC, U&E, clotting • Hepatitis serology • EBV, CMV • Immunoglobulins • Glucose • Ceruloplasmin • ANA, AMA, alpha-1 antitripsin antibodies • AFP • Ferritin

  9. Interpreting LFTs • Buzz groups List LFTs in the following categories • Hepatic • Cholestatic • Synthetic

  10. LFTs • Hepatic • Transaminase enzymes (ALT, AST, GGT) • Cholestatic • ALP, Bilirubin • Synthetic • Albumin, INR

  11. Investigations • Bedside tests • Bloods • More complex biochemistry • Radiology • Endoscopy

  12. Investigations • Daily weights • Liver screen • USS doppler liver • portal blood flow and masses, hepatic vein patency • Ascitic tap • Microscopy and culture • Cell count • Biochemistry • Cytology • OGD • urgent if suspected UGIB otherwise surveillance. • Liver biopsy

  13. Complications of CLD

  14. Complications of CLD • Infection: • Spontaneous bacterial peritonitis • Sepsis • Ascites • Dehydration • respiratory distress • AKI • Encephalopathy • Bleeding • Oesophageal varices • Clotting abnormalities • Renal failure • AKI • Hepato-renal syndrome • Malnutrition • High risk of refeeding syndrome

  15. Management • Conservative • Low salt, high protein diet, avoid alcohol • Medical • Diuretics • Human albumin solution • Paracentesis • Vitamins • Surgical • TIPS (Transjugular intrahepatic portosystemic shunt) • Transplant

  16. What is this and why? Gynaecomastia… from spironolactone

  17. Case study • 54 year old gentleman presents to his GP with: • 2/12 Hx increasing swelling of his abdomen and feet • Tired over this time and feels nauseous and is off his food. • His wife has commented that his eye have turned yellow over the last few days. • He works in a warehouse and smokes 10 cigarettes a day. • He admits to drinking 4 cans of lager a night. His wife says he drinks at least 8 cans a night and a bottle of whiskey a week. • 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

  18. What are your main differential diagnoses for this gentleman? (include all important differentials that must be ruled out) • How would you investigate this gentleman? • What would your management plan be for this gentleman?

  19. What are the features of hepatic encephalopathy? • How do you manage hepatic encephalopathy? • What are the complications of CLD? • What is Spontaneous Bacterial Peritonitis? • How would you manage an acute GI bleed (in the context of CLD)?

  20. Summary • Signs, symptoms, causes, investigations and management of CLD • Understanding LFTs • Case study to apply your knowledge. Any questions?

  21. Many thanks • Please fill in an evaluation form!

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