APPROACH TO
PATIENT WITH LIVER DISEASE
The many causes of liver disease present clinically in a few distinct patterns either
a)
Hepatocellular
diseases-Features of injury, inflammation and necrosis.
b)
Cholestatic
(obstructive)-Feature of obstruction of bile flow predominate.
-Typical presenting
symptoms of liver disease include
-Jaundice
-Generalized Fatigue
-Itching
-Right upper quadrant pain,
-Abdominal distention
-Intestinal bleeding.
-However, some patients
with liver disease are found to have abnormalities
in biochemical liver tests as
a part of a routine biochemical tests.
Evaluation of patients
with liver disease should be directed at
(1) Establishing the
etiologic diagnosis
Hepatocellular versus
cholestatic injury, as well as on the specific etiologic diagnosis
(2) Estimating the disease severity (grading)
Assessing the severity or
activity of disease-active or inactive, and mild, moderate, or severe.
(3) Establishing the disease stage (staging).
Estimating the place in
the course of the natural history of the disease, whether acute or chronic;
early or late; pre-cirrhotic, cirrhotic, or end-stage.
CLINICAL
HISTORY
-Follow
symptoms of liver disease
ü Their nature
ü pattern of onset
ü progression
- Liver-specific symptoms of jaundice, dark urine, light stools,
itching, abdominal pain, and bloating.
-Itching occur
early in obstructive jaundice (from biliary obstruction or drug-induced
cholestasis)
Itching also
occurs in chronic liver diseases, typically the cholestatic forms such as primary
biliary cirrhosis and sclerosing cholangitis where it is often the presenting
symptom, occurring before the onset of jaundice.
-RUQ pain or ache ("liver pain") occurs in many liver diseases and is usually marked
by tenderness over the liver
area.
-The pain arises from
stretching or irritation of Glisson's capsule, which surrounds the liver.
-Severe pain is most
typical of gall bladder disease,
liver abscess, and severe
venoocclusive disease but is
an occasional accompaniment of acute hepatitis.
-Jaundice is
the hallmark symptom of liver disease.
Patients
usually report darkening of the urine before they notice scleral icterus.
Rarely
detectable with a bilirubin level less than 51 umol/L. With severe
cholestasis there will also be lightening of the color of the stools and
steatorrhea. Jaundice without dark urine usually indicates indirect
(unconjugated) hyperbilirubinemia and is typical of hemolytic anemia eg
malaria and sickle cell and the genetic disorders of bilirubin conjugation eg
Gilbert's syndrome, Crigler-Najjar syndrome..
Symptoms
suggestive of complications of stage of liver disease:
ü Haematemesis-varices or portal HTN
ü Hemoptysis-chronic heart failure and
cardiac cirrhosis.
ü Any other bleeding diasthesis-liver
failure.
ü Swelling of legs-low albumin.
ü Abnormal behaviour, confusion or
drowsiness
PHYSICAL EXAMINATION
-In many
patients, the physical examination is normal unless the disease is acute or severe and
advanced.
-The physical
examination can reveal signs that point to a specific diagnosis, either in
risk factors or in associated diseases.
-Typical
physical findings in liver disease
-General
condition
-The
patient may be wasted because of chronic illness, confused-encephalopathy,
dehydrated etc
Hands-6 items
-Leuconychia-chronic liver disease
with hypoalbuminaemia
-Finger clubbing
-Asterexis
-Dupytrens contracture
-Palmar erythema
-Palmar parlor
Others
general exam
-Spider
angiomata
-Excoriations
-Jaundice
-Gynecomastia, scrotal
atrophy, parotid enlargement
-Edema
-Hepatic fetor
Per Abdomen
-Prominent veins over the
abdomen, and caput medusa
-Ascites
-Hepatomegaly-
Careful assessment of the liver edge may also demonstrate unusual firmness,
irregularity of the surface, or frank nodules.
-Hepatic tenderness
-Splenomegaly
-Pulsatile liver-Chronic CCF with Tricuspid
regurgitation.
-Hepatic bruit-hepatoma,
hepatic hemangioma
Signs of advanced disease include
-Dilated
abdominal veins
-Asterixis
-Mental
confusion
-Stupor or Coma.
A helpful measure of
hepatic encephalopathy is a careful mental status examination and use of the
trail-making test, which consists of a series of 25 numbered circles that the
patient is asked to connect as rapidly as possible using a pencil. The normal
range for the connect-the-dot test is 15 to 30 s; it is considerably delayed
in patients with early hepatic encephalopathy.
INVESTIAGTIONS
1. FHG- Anaemia
of chronic illness may be seen.
Lymphocytosis-Viral
hepatitis.
2. LFT
-Liver parenchyma- ALT and
AST)
-Cholestasis-alkaline
phosphatase, γ-glutamyl transpeptidase (GGT) to define whether alkaline
phosphatase elevations are due to liver disease
-Direct and total serum
bilirubin
-Synthetic Function of the
liver-albumin and prothrombin time.
3.Viral hepatitis serology to define the type of viral
hepatitis-Commonly HBV and HBV plus
HIV ELISA
Hepatitis B
Acute- HBsAg and anti-HBc IgM
Chronic- HBsAg and HBeAg
and/or HBV DNA
Hepatitis C
Anti-HCV IgG
HCV RNA
Other hepatitis
HAV- Anti HAV IgM
HDV- HBsAg and anti-HDV
HEV-Anti-HEV IgM
4.RFT’s esp those presenting with ascitis
5.Autoimmune markers –If indicated
-Primary biliary cirrhosis
(antimitochondrial antibody; AMA, elevated IgM levels, and compatible
histology
-Sclerosing cholangitis
(peripheral antineutrophil cytoplasmic antibody; P-ANCA), cholangiography
-Autoimmune hepatitis –
ANA-antinuclear antibodies; SMA-smooth-muscle antibody, elevated IgG levels,
and compatible histology
6.Familial liver diseases
i)α1
Antitrypsin disease- Reduced α1 antitrypsin levels, phenotypes
PiZZ or PiSZ
ii)
iii)
Haemachromatosis-Elevated iron saturation and serum ferritin; genetic testing
for HFE gene mutations
7.Tumour markers
Elevated α-fetoprotein
level >500; ultrasound or CT image of mass
Staging of Liver disease
Reliable staging system is
the modified Child-Pugh classification with a scoring system of 5 to 15:
§ scores of 5 and 6 being Child-Pugh class A
(consistent with “compensated cirrhosis”),
§ scores of 7 to 9 indicating class B
§ 10 to 15 class C
-This scoring system was
initially devised to stratify patients into risk groups prior to undergoing
portal decompressive surgery.
-The Child-Pugh score is a
reasonably reliable predictor of survival in many liver diseases and predicts
the likelihood of major complications of cirrhosis such as bleeding from
varices and spontaneous bacterial peritonitis.
-It was used to assess
prognosis in cirrhosis and to provide the standard criteria for listing for liver
transplantation (Child-Pugh class B).
Child Pugh Classification
Long term follow up for liver disease patients
1.Abstinence from alcohol
should be encouraged for all patients with alcohol-related liver disease and
in patients with cirrhosis and those receiving interferon-based therapy for
hepatitis B or C.
2.Regarding vaccinations,
all patients with liver disease should receive hepatitis A vaccine and those
with risk factors should receive hepatitis B vaccination as well. Influenza
and pneumococcal vaccination should also be encouraged.
3. Patients with liver
disease should be careful in use of any medications, other than the most
necessary. Drug-induced hepatotoxicity can mimic many forms of liver disease
and can cause exacerbations of chronic hepatitis and cirrhosis; drugs should
be suspected in any situation where the cause of exacerbation is unknown.
4. Surveillance for
complications of chronic liver disease such as variceal hemorrhage and
hepatocellular carcinoma.
Upper endoscopy to assess
the presence of varices and should be given chronic therapy with beta
blockers if large varices are found.
Patients with cirrhosis
also screening and long-term surveillance for development of hepatocellular
carcinoma. Eg US of the liver at 6- to
12-month intervals
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Constitutional
symptoms such as fatigue, weakness, nausea, poor appetite, and malaise.
Nausea - may accompany fatigue or be provoked by odors of
food or eating fatty foods.
Vomiting -rarely
persistent or prominent.
Anorexia with weight loss
occurs commonly in acute liver
diseases but is rare in chronic
disease, except when cirrhosis
is present and advanced.
Diarrhea -uncommon in liver disease, except with severe jaundice, with malabsorption leading
to steatorrhea.
-Major risk
factors for liver disease
ü Detailed history of alcohol use- more than two drinks (22 to 30 g) per day in women
and three drinks (33 to 45 g) in men. Increased risk. Most patients with
alcoholic cirrhosis have a much higher daily intake and have drunk
excessively for 10 years or more before onset of liver disease.
ü Previous
history of yellowness of
eyes-viral hepatitis, aflatoxicosis.
ü Medications (including herbal compounds, birth control pills, and
over-the-counter medications).
ü History of pulmonary TB treatment or chronic cough-Dessimnated TB .Also
adverse effects of anti-TB.
ü Sexual
History- For assessing
the risk of viral hepatitis should include life-time number of sexual
partners. Sexual exposure is a common mode of spread of hepatitis B but is
rare for hepatitis C
ü Methods of grain storage and history of other family members having similar
symptoms.
ü Exposure to jaundiced or other high-risk
persons
ü A history of injection drug use, even in the remote past, is of great
importance in assessing the risk for hepatitis B and C. Injection drug use is
now the single most common risk factor for hepatitis C.
ü Recent
surgery
ü Remote
or recent transfusion with
blood and blood products .Transfusion with blood or blood products is no
longer an important risk factor for acute viral hepatitis. However, blood
transfusions received before the introduction of sensitive enzyme
immunoassays for antibody to hepatitis C virus (anti-HCV) in 1992 is an
important risk factor for chronic
hepatitis C. Blood transfusion before 1986, when screening for antibody to
hepatitis B core antigen (anti-HBc) was introduced, is also a risk factor for
hepatitis B
ü Occupation-schistosomiasis, chemical exposure
ü Accidental exposure to blood or
needlestick
ü familial history of liver disease -Wilson's disease; hemochromatosis and a1-antitrypsin (a1AT)
deficiency
ü Suggestive
of heart failure-orthopnea ,
paroxysmal nocturnal dysnea-Cardiac cirrhosis
-Spider
angiomata and palmar erythema occur in both acute and chronic liver disease
and may be especially prominent in persons with
cirrhosis, during pregnancy.
-Spider
angiomata are superficial, tortuous arterioles and, unlike simple
telangiectases, typically fill from the center outwards.
-Occur arms,
face, and upper torso; they can be pulsatile and may be difficult to detect
in dark-skinned individuals.
-Hepatic
failure is defined as the occurrence of signs or symptoms of hepatic
encephalopathy in a person with severe acute or chronic liver disease.
-The first
signs of hepatic encephalopathy can be subtle and nonspecific-change in sleep
patterns, change in personality, irritability, and mental dullness.
Thereafter, confusion, disorientation, stupor, and eventually coma supervene.
Physical findings include asterixis and flapping tremors of the body and
tongue.
-Fetor
hepaticus refers to the slightly sweet, ammoniacal odor that is common in
patients with liver failure, particularly if there is portal-venous shunting
of blood around the liver.
-Other causes
of coma and confusion should be excluded, mainly electrolyte imbalances, sedative
use, and renal or respiratory failure.
-Widened pulse pressure
and signs of a hyper dynamic circulation can occur in patients with cirrhosis
as a result of fluid and sodium retention, increased cardiac output, and
reduced peripheral resistance.
-Patients with
long-standing cirrhosis are prone to develop the hepatopulmonary syndrome
with hypoxemia due to pulmonary arteriovenous shunting, characterized by
hypoxia that worsens when lying flat.
Several skin disorders and
changes occur commonly in liver disease.
-Hyper pigmentation -chronic cholestatic diseases such as
primary biliary cirrhosis and sclerosing cholangitis.
-Xanthelasma and tendon
xanthomata occur as a result of retention and high serum levels of lipids and
cholesterol. A slate-gray pigmentation to the skin also occurs with
hemochromatosis if iron levels are high for a prolonged period.
-Mucocutaneous vasculitis
with palpable purpura, especially on the lower extremities, is typical of
cryoglobulinemia of chronic
hepatitis C but can also occur in chronic
hepatitis B.
-Some physical signs point
to specific liver diseases. Kayser-Fleischer rings occur in Wilson's disease and consist of a
golden-brown copper pigment deposited at the periphery of the cornea; they
are best seen by slit-lamp examination.
DIAGNOSTIC IMAGING
1. Ultrasonography-have a high sensitivity for detecting biliary duct dilatation and are
the first-line options for investigating the patient with suspected
obstructive jaundice.
2. (CT-scan)
3. (MRI)
CT and MRI are indicated for
the identification and evaluation of hepatic masses, staging of liver tumors,
and preoperative assessment.
4.. Magnetic resonance cholangiopancreatography (MRCP
5.ERCP
-(MRCP) and (ERCP) are the
procedures of choice for visualization of the biliary tree.
-MRCP offers several
advantages over ERCP; there is no need for contrast media or ionizing
radiation, images can be acquired faster, it is less operator dependent, and
it carries no risk of pancreatitis.
-MRCP is superior to US and
CT for detecting choledocholithiasis but less specific.
-It is useful in the
diagnosis of bile duct obstruction and congenital biliary abnormalities, but
ERCP is more valuable in evaluating ampullary lesions and primary sclerosing
cholangitis.
-ERCP allows for biopsy,
direct visualization of the ampulla and common bile duct, and intraductal
ultrasonography.
-It also provides several
therapeutic options in patients with obstructive jaundice, such as
sphincterotomy, stone extraction, and placement of nasobiliary catheters and
biliary stents.
-Doppler US and MRI are used
to assess hepatic vasculature and hemodynamics and to monitor surgically or
radiologically placed vascular shunts such as transjugular intrahepatic
portosystemic shunts (TIPS).
- Finally, interventional
radiologic techniques allow the biopsy of solitary lesions, insertion of
drains into hepatic abscesses, and creation of vascular shunts in patients
with portal hypertension.
Liver
biopsy
Check preparation and the
performance of liver biopsy
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