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

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Presentation on theme: "Chronic liver disease and substance misuse Kapil Kapur Department of gastroenterology BDGH NFT."— Presentation transcript:

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 Wilsons 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 100% 85% 7-9 B 80% 60% C 45% 35%


26 Prognostic impact of SBP Survival in months ProbabilityProbability

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 clinicHep 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, AntiviralsLamivudine, 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

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