1. Chronic Liver Disease Simon Lynes

2. Definition Progressive destruction and regeneration of the liver parenchyma leading to fibrosis and cirrhosis

3. Aetiology Vascular – Budd Chiari Infectious – viral hepatitis B and C T Autoimmune – PBC/PSC, autoimmune hepatitis Metabolic – Wilsons, Haemochromatosis, fatty liver Iatrogenic - meds Neoplasm C Drugs – e.g. ALCOHOL, antibiotics, methotrexate, amiodarone

4. Presentation – 2 types Compensated: Stigmata of chronic liver disease Gynaecomastia Spider Naevi Clubbing May have no symptoms or vague: RUQ pain Pruritis Fatigue Oedema Synthetic function tests e.g. PT, albumin may be NORMAL Some abnormalities of LFTs e.g. ALT Decompensated Encephalopathy Jaundice Ascites Asterisks

5. Investigations Bedside BM Bloods Serology Autoantibodies Ceruloplasmin, ferritin/transferrin/TIBC Alpha fetoprotein Imaging USS and doppler of portal vein Special Tests Biopsy OGD - ?varices Ascitic tap A LIVE CATCH Alpha fetoprotein LFTs Igs Viral hepatitis Ethanol Ceruloplasmin Autoantibodies Transferrin and Ferritin CMV/EBV HIV

6. Management Conservative Salt restriction Avoid alcohol Vaccinations Medication Diuretics Calcium/Vit D Surgical Paracentesis Transplant TIPSS *3-6 monthly screening for HCC*

7. Prognosis Child-Pugh classification PT Albumin Bilirubin Ascites Encephalopathy ‘Pour Another Beer At Eleven’

8. Interpreting LFTs Hepatic vs. post hepatic/obstructive ALT vs alk phos/gamma GT Synthetic function Albumin – chronic PT - acute Bilirubin Gamma GT – for alcohol (if alk phos normal)

9. Clinical scenario 54 year old gentleman presents to his GP with increasing swelling of his abdomen and feet over the last 2 months. He has been increasingly 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

10. Differential Diagnoses? Investigations? Management?

11. Complications Decompensation Encepalopathy Jaundice Hepatocellular carcinoma Increased portal pressure Varices/GI bleed – exacerbated by decreased clotting Ascites SBP Hepatorenal syndrome

12. Encephalopathy Key features: Reversal of sleep patterns Confusion/drowsiness Asterisks and positive babinski Due to ammonia Treat with lactulose

13. SBP Suspect in sudden deterioration/pyrexia in patient with ascites Therepeutic tap >250 neutrophils per microlitre Broad spectrum antibiotics Albumin

14. GI Bleed Signs and symptoms: Haematemesis/malaena Signs and symptoms of anaemia +/- abdominal pain +/- haemodynamic instability Blood tests: Low Hb – and raised urea Management A-E Rockall/Blatchford score Terlipressin, broad spectrum antibiotics for varices Endoscopy

15. Any questions?