1. Chronic liver disease Cirrhosis hepatic Encephalopathy Dr. Yasir M Khayyat MBcHB,FRCPC,FACP,ABIM Assistant professor of Medicine Faculty of Medicine Umm AlQura University

2. Chronic Liver disease …? Does this means there is acute liver disease ? Yes,but its ” acute liver insult “ Viral Metabolic Alcohol Autoimmune Vascular Toxins Drugs Inherited disorders سمعوني ايش هي ؟

3. Chronic liver disease Cirrhosis hepatic Encephalopathy Dr. Yasir M Khayyat MBcHB,FRCPC,FACP,ABIM Assistant professor of Medicine Faculty of Medicine Umm AlQura University

4. Acute Liver insult Chronic Inflammation Or Chronic Hepatitis Healing with Fibrosis Or Liver Cirrhosis Development of Portal hypertension And Development of stigmata of Chronic Liver disease Resolution without Clinical or histological consequences Compensated State Compensated Cirrhosis Decompensated State Or Decompensated Cirrhosis End Stage liver disease HCC death

5. Natural history of Cirrhosis 50 % over 10 years Compensated Cirrhosis Decompensated Cirrhosis Which is …… Ascites 50 % die in 2 years Variceal hemorrhage Hepatic Encephalopathy

6. Varices develop in 50-60 % of cirrhotics Annual rate of development 2-5 % 30% of them develop UGIB Risk of rebleeding (2 nd bleeding ) 60-70% over 24 months Death in cirrhotics 1/5 – 1/3,due to variceal bleeding

7. Stigmata of Chronic Liver disease Clubbing Leukonychia Palmar erythema Dupuytren's contracture Asterixis Spider angiomata Purpura Gynaecomastia or Feminizing Hair Re-distributionGynaecomastia Testicular atrophy Hepatomegaly Splenomegaly Ascites Distended abdominal veins in which flow is away from the umbilicus (caput medusae)caput medusae

8. Clinical features Symptoms Complications: Portal hypertension Hepatic encephalopathy GI bleeding Ascites Lower limbs edema Incidental abnormality of LFT

9. Clinical features Symptoms Complications: Portal hypertension Hepatic encephalopathy GI bleeding Ascites Lower limbs edema Incidental abnormality of LFT

10. Gynecomastia due to hypersestogenemia state Also noted in spironolactone use Flapping tremor due to False neurotransmitters Causing imbalance at the cerebellar function

11. Caput medusa due to portal hypertension with collateral formation between paraumbilical veins that arise from the umbilical portion of the left portal vein that connect to the epigastric and and internal mammry veins through the round ligament

13. Causes of Chronic Liver diseases

14. Causes of chronic liver disease Autoimmune VascularMetabolicViral Autoimmune hepatitis Portal Vein thrombosis Hemochromatosis Alcohol Primary biliary cirrhosis Hepatic Vein thrombosis Wilson’s disease Inherited Primary sclerosing cholangitis Non Alcoholic Fatty Liver Disease α1antitrypsin deficiency Toxins CCl 4 Aflatoxin

17. Laboratory markers for HBV infection and its interpretation InterpretationMarker Exposure to Hepatitis B virus. Present in acute or chronic infection HBsAg Immunity acquired via natural infection or immunisation Anti-HBs antibody Marker of infectivity. It correlates with high level of viral replication HBeAg It correlates with low level of viral replication Anti-HBe antibody Infection in previous 6 months Anti-HBc IgM antibody Distant HBV infection or chronic HBV infection Anti-HBc IgG antibody Rapid viral replication Hep B DNA >105 copies /mL

19. Diagnosis of HCV infection