1. Week 3: Gastroenterology Chronic Liver Disease

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 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

3. 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

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

5. Functions of the liver Storage -Glucose (in form of glycogen) -Vitamins (A, D, K and B12) -Iron and copper Synthesis -Gluconeogenesis -Glycogenesis -Amino acid and protein synthesis -Lipogenesis, cholesterol synthesis -Coagulation factors -Bile -Growth factors e.g IGF-1 Breakdown -Drug and toxin metabolism (glucuronidation, methylation) -Ammonia (urea cycle) -Bilirubin metabolism -Glycogenolysis Immunological effects -Immunologically active cells, antigens carried to it through reticuloendothelial system

6. Aetiology of chronic liver disease COMMON AlcoholHistory of excess alcohol Chronic hepatitis BHBsAg +/- HBeAg in serum Chronic hepatitis CHCV antibodies and HCV RNA in serum OTHERS Autoimmune Primary biliary cirrhosisSerum antimitochondrial antibodies Autoimmune hepatitisCirculating autoantibodies Inflammatory Sclerosing cholangitisSerum pANCA, IBD Metabolic Wilson’s diseaseLow serum caeruloplasmin and copper Alpha 1-antitrypsin deficiencyLow alpha 1-antitrypsin, emphysema

7. Aetiology of chronic liver disease OTHERS DrugsMethotrexate, paracetamol Hereditary haemochromatosisFamily history, increased ferritin Non-alcoholic fatty liver diseaseMetabolic syndrome, hyperechoic liver Budd-Chiari syndromeRisk factors, liver USS

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

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

10. Presentation – symptoms and signs 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) Digestive Problems Immune Dysfunction Abnormal Metabolism of Fats Blood Sugar Problems Hormonal Imbalance Symptoms of chronic liver disease: Varied and vague! Symptoms of chronic liver disease: Varied and vague!

11. Case based discussion 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 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.

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

13. 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

14. Investigations Invasive tests:  Liver biopsy  Ascitic tap  ERCP  OGD 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

15. Interpreting LFTs ‘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 ‘Liver function tests’ misleading Think hepatitic or cholestatic picture? Synthetic function best measured by albumin and clotting

16. 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

17. 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

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

19. Hepato-renal syndrome

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

21. Thank you Any Questions?