For final year medical students 2014 Dr Rosalind Pool GPST1 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?

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

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

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

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

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

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

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

Investigations Bedside tests Bloods More complex biochemistry Radiology Endoscopy

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

Complications of CLD

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

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

What is this and why? Gynaecomastia… from spironolactone

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

What are your main differential diagnoses for this gentleman 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?

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)?

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

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