1. Chronic liver disease and substance misuse
Kapil Kapur
Department of gastroenterology
BDGH NFT

2. Introduction Definition Aetiology of chronic liver disease
Symptoms and signs of chronic liver disease
Complications in chronic liver disease
Investigations in chronic liver disease
Chronic liver disease and substance misuse
Alcoholic liver disease
Hepatitis C
Hepatitis B

4. Liver cirrhosis
Cirrhosis represents a late stage of progressive liver fibrosis and disease and results in a distortion of liver architecture
Usually changes are irreversible
Liver transplantation may be the only option

5. Aetiology Alcoholic liver disease Fatty liver disease (NAFLD)
Hepatitis B and C
Auto-immune liver disease
Primary biliary cirrhosis
Metabolic conditions
Hemochromatosis
Alpha 1 AT deficiency
Wilson’s disease

6. Symptoms of chronic liver disease
Asymptomatic
General symptoms
fatigue, wt loss, poor nutrition, general ill-health, non-specific symptoms
Abnormal LFTs
Symptomatic
asymptomatic
Symptoms of liver failure
Jaundice
Ascites (swelling in the abdomen)
Encephalopathy

7. Symptoms of chronic liver disease
Symptoms of complications
Variceal bleeding
Portal hypertension
Spontaneous bacterial peritonitis (SBP)
Hepato-cellular cancer
Hepato-renal syndrome

8. Signs of chronic liver disease
No signs in early stages
Stigmata of compensated chronic liver disease
Spider naevi, clubbing, liver palms, poor nutrition,
Gynaecomastia and poor secondary sexual characteritics
Oedema (swelling) feet

9. Spider naevi

11. Signs in chronic liver disease
Signs of decompensation / complications
Jaundice
Ascites and oedema feet
Encephalopathy
Confusion to coma
Upper GI bleeding
Haematemesis and or melaena
collapse

13. Signs of Liver Disease

14. Signs of liver disease

16. Complications of chronic liver disease
Upper gastrointestinal bleeding
Oesophageal varices
Gastric varices
Jaundice
Ascites, bacterial peritonitis and oedema
Encephalopathy
Hepatorenal syndrome
Liver cancer

20. Oesophageal varices after application of rubber bands

21. Gastric varices

22. Gastric varix after injection of histoacryl glue

23. Assessing severity

24. Child-Pugh Classification
1 yr survival 2 yr survival
5/6  A % %
7-9  B % %
 C % %

26. Prognostic impact of SBP
Probability
Survival in months

27. Investigations in chronic liver disease
Ultrasound abdomen
Non invasive liver screen (NILS)
LFTS and Prothrombin time
Hepatitis B and C serology
Autoimmune profile and immunoglobulins
Ferritin
Alpha 1 AT, Caeruloplasmin
Alpha feto protein

28. Investigations in chronic liver disease
Liver biopsy
Needle biopsy
Under X-ray control
Risks of bleeding and organ injuries

29. A general approach to management in chronic disease
Establish the diagnosis
Treatment of acute symptoms and complications
Addressing the underlying cause
Alcohol, Hep B, Hep C
Explore role for transplantation
Surveillance for hepato-cellular cancer

30. Substance misuse and liver disease
Alcohol
Hepatitis C
Hepatitis B

31. Acute alcoholic hepatitis
Abstinence
Supportive therapy
Steroids
Pentoxifylline

32. Chronic alcoholic liver disease
Abstinence
Detox
Alcohol liaison services and support
Nutrition and vitamins
Symptom management
? Transplantation if abstinent for 6 months

33. The course of alcoholic cirrhosis
Compensated cirrhosis
N = 122
Decompensated disease, with ascites
in 58% at 10 years
5 year survival abstainers: %
5 year survival recalcitrants: %

34. Hepatitis C IVDU, contaminated needles, transfusion related
Confirm the diagnosis
RNA PCR
Viral load and genotype
Address risk factors
Antiviral therapy
Ribavirin
Pegylated interferon

35. Hep C treatment in Barnsley
We currently offer antiviral treatment and accept direct referrals
Expensive and prolonged and demanding
Difficult population to treat
Finite duration of treatment
Risk of re-infection
Nurse led clinic—Hep C Nurse

36. Current figures for Barnsley
94 patients given treatment
17 patients discontinued treatment
52 patients have completed treatment
39 patients had 6 month post Rx PCR
33/39 sustained viral response (SVR)
6/39 relapsed

37. Hepatitis B IVDU, Infected sexual contacts, transfusion related
Vast majority need follow up rather than treatment
Business case for treatment in BDGH
Treatment is suppressive rather than curative
Prolonged antiviral therapy
Interferon,
Antivirals—Lamivudine, Tenofovir

38. Summary Chronic liver disease comprises a big burden for health care
Alcohol, Hepatitis C and Hepatitis B are important public health care issues
Important to recognise and treat chronic liver disease