1. For final year medical students 2014 Dr Rosalind Pool GPST1
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 Cholestatic Synthetic
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: 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

15. 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

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
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
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