Chronic liver disease

Chronic liver disease in the clinical context is a disease process of the

Signs of chronic liver disease detectable on clinical examination can be divided into those that are associated with the diagnosis of chronic liver disease, associated with decompensation, and associated with the cause.[2]

Chronic liver disease

• Nail clubbing
• Palmar erythema
• Spider nevi
  (angiomata)
• Gynaecomastia
• Feminising hair distribution
• Testicular atrophy
• Small irregular shrunken liver
• Anaemia
• Caput medusae

Decompensation

• Drowsiness
  (encephalopathy)
• Hyperventilation (encephalopathy)
• Metabolic flap/asterixis (encephalopathy)
• Jaundice (excretory dysfunction)
• Ascites (portal hypertension and hypoalbuminemia)
• Leukonychia (hypoalbuminaemia)
• Peripheral oedema
  (hypoalbuminaemia)
• Bruising
  (coagulopathy)
• Acid-base imbalance, most commonly respiratory alkalosis

• Dupuytren's contracture (alcohol)
• Parotid enlargement
  (alcohol)
• Peripheral neuropathy (alcohol and some drugs)
• Cerebellar signs (alcohol and Wilson's disease)
• Liver enlargement (alcohol, NAFLD, haemochromatosis)
• Kayser-Fleisher rings (Wilson's disease)
• Increased pigmentation of the skin (haemochromatosis)
• Signs of right heart failure

Note that other diseases can involve the liver and cause hepatomegaly but would not be considered part of the spectrum of chronic liver disease. Some examples of this would include chronic cancers with liver

• Portal hypertension
  • Ascites
  • Hypersplenism
    (with or without splenomegaly)
  • Lower
    oesophageal varices
    and rectal varices
• Synthetic dysfunction
  • Hypoalbuminaemia
  • Coagulopathy
• Hepatopulmonary syndrome
• Hepatorenal syndrome
• Encephalopathy
• Hepatocellular carcinoma

Causes

The list of conditions associated with chronic liver disease is extensive and can be categorised in the following way:^[3]

Viral causes

• Hepatitis B
• Hepatitis C

• Alcoholic liver disease
• Rarely
  drug induced liver disease from methotrexate, amiodarone, nitrofurantoin
  and others

Paracetamol (acetaminophen) causes acute liver damage.

Metabolic

• Non-alcoholic fatty liver disease
• Haemochromatosis
• Wilson's disease

Autoimmune response causes

• Primary biliary cholangitis (previously known as primary biliary cirrhosis)
• Primary sclerosing cholangitis
• Autoimmune Hepatitis

Other

• Right heart failure

Risk factors

These differ according to the type of chronic liver disease.^{[citation needed]}

• Excessive alcohol use
• Obesity
• Metabolic syndrome including raised blood lipids
• Health care professionals who are exposed to
  body fluids
  and infected blood
• Sharing infected needle and syringes
• Having unprotected sex and multiple sex partners
• Working with toxic chemicals without wearing safety clothes
• Certain prescription medications

Diagnosis

Chronic liver disease takes several years to develop and the condition may not be recognised unless there is clinical awareness of subtle signs and investigation of abnormal liver function tests.

Testing for chronic liver disease involves blood tests, imaging including ultrasound, and a biopsy of the liver. The liver biopsy is a simple procedure done with a fine thin needle under local anaesthesia. The tissue sample is sent to a laboratory where it is examined underneath a microscope.^[3]

Treatment

The treatment of chronic liver disease depends on the cause. Specific conditions may be treated with medications including

• MELD-Plus, a rating system used to assess the severity of chronic liver disease

References