This document discusses the identification, diagnosis, and management of chronic liver disease (CLD). It identifies the main etiologies and risk factors for CLD, including infections like hepatitis B and C, alcohol, drugs, and metabolic disorders. It outlines the approach to diagnosing CLD based on symptoms, signs, laboratory tests, and imaging. Factors are assessed to determine if the CLD is compensated or decompensated. Management involves treating complications like ascites, bacterial peritonitis, variceal bleeding, and hepatic encephalopathy. Treatment may also include procedures like paracentesis or transplantation.

1. Long Case Approach to Chronic Liver Disease Identify Complications of CLD (ABCDE + HP)
Albumin (hypo)
Identify the Aetiology & their Risk Factors Bilirubin - jaundice
1. Infections – Hepatitis B, C Coagulopathies
2. Alcohol / drugs (MTX, amiodarone) Distension (ascites)
3. Metabolic Encephalopathy
a. DO NOT mention haemochromatosis. Gene not found in local population HCC
b. Wilson’s disease Hepatorenal synd
c. Alpha1 antitrypsin deficiency Hepatopulm synd
4. Congenital / hereditary – biliary atresia Heart failure
5. Autoimmune – usually female Portal HTN – varices
6. Cryptogenic Portal vein thrombosis
Diagnosing CLD – based on:
1. Stigmata of CLD – jaundice, clubbing, leukonychia, palmar erythema, spider naevi, Common Presentations
gynaecomastia, testicular atrophy i. Swelling – ascites, pedal edema
2. Symptoms of CLD – jaundice, ascites, pedal edema, Cx of CLD, non-specific ii. Abdominal pain
symptoms (LOW, LOA, malaise) iii. Upper GI bleed – due to bleeding oesophageal varices or Mallory-Weiss tear after
3. Radiological/ Histological results alcoholic binge
4. LFT iv. Encephalopathy
v. CCF secondary to CLD
Assessing CLD vi. HCC – enlarged abdominal mass
Is the CLD
i. Compensated History
ii. Decompensated – presence of Cxs of CLD Common presenting complaints:
Child-Pugh score – for prognostication & assessment of CLD severity ♦ Jaundice
Criteria Points ♦ GI bleed – ddx: peptic ulcer, drugs, Mallory Weiss, CA
Total S. Bilirubin 1 <2 ♦ Petechiae – many present initially ITP-like
(mg/dl) 2 2-3 ♦ Ascites – ddx: cardiac, renal, malabsorption
3 >3 ♦ Encephalopathy – ask about ppt’g causes (hemorrhage/ hypoxia/ hypnotics/ hard stools/
S. Albumin 1 >3.5 infections/ CA – see below for complete list)
(g/dl) 2 2.8-3.5
3 <2.8 Symptoms of Jaundice Non-specific symptoms (LOW,
INR 1 <1.70 CLD pruritis LOA, malaise)
2 1.71-2.20 Abdominal pain If viral hepatitis – usually due to malignancy or SBP
3 >2.20 If EtOH hepatitis – usually due to stretching of liver capsule or pancreatitis
Ascites 1 No ascites (often after alcoholic binge).
2 Ascites controlled medically Complications of CLD (ABCDE+ portal HTN + CA)
3 Ascites poorly controlled hypoAlb Abdominal swelling LL swelling
Encephalopathy 1 No encephalopathy Bilirubin jaundice pruritis
2 Encephalopathy medically controlled Coagulopathy Bruising Menorrhagia
3 Encephalopathy poorly controlled Epistaxis Bleeding gums
Distension Ascites SBP
Child Class A (5-6 pts) B (7-9 pts) C(10-15 pts) Encephalopathy Lethargy / drowsiness / LOC Sleep-wake cycle reversal
Prognosis Life expectancy 15-20 Indicated for liver Life expectancy 1-3 yrs Limb rigidity & hyperreflexia Personality change
yrs transplant evaluation Abdo Sx peri-op Sensory neuropathy Seizures
Abdo Sx peri-op Abdo Sx peri-op mortality: 82% Asterixis
mortality: 10% mortality: 30% Portal HTN’s Hemetemesis – oeso variceal bld Symptoms of shock – dizziness,
varices Melaena – black, tarry formless LOC, SOB
stool

2. Cancer LOW/ LOA Investigations
Is regular f/u done? U/S, AFP To confirm dx
Causes of CLD To look for etiology
Alcohol CAGE questionnaire Occupation – esp bartender, To look for complications
Present drinking hx – no. of waiter, seamen, military FBC Hypersplenism – ↓HB, ↓ leucocytes, ↓pltlets
units/wk >14 male, >7 female Recent alcoholic binge Anaemia – megaloblastic (Vit B12 or folate deficiency), Fe
Past drinking hx deficiency
Hepatitis Hx of hepatitis & treatment IVDA/Tattoos/transfusions Infections – SBP
Hx of Hepatitis B vaccination CSW/ Homosexuality LFT Confirm dx
↑GGT suggests alcoholic liver disease
S. albumin and bilirubin for Child-Pugh classification
Signs to look for in CLD PT/aPTT INR for Child-Pugh classification
CLD & complications AFP HCC
Hands Clubbing Palmar erythema – EtOH liver dz U/S HBS HCC
Pallor Dupuytren’s contractures CXR Malignancies
Cyanosis Asterixis Liver biopsy Confirm dx
Leuconychia Postural tremors – EtOH liver dz HCC
Arms / chest Bruises / petechiae Spider naevi >5 in area of Paracentesis Microscopy, C/S, amylase
Gynaecomastia drainage of SVC Malignant cells, infections (SBP), pancreatitis
Head Jaundice Parotid enlargement – EtOH liver Hepatitis serology Cause of CLD
Pallor dz Other causes of Autoantibodies
Alopecia Fetor hepaticus CLD Urinary Cu (Wilson’s disease)
Abdomen / Ascites Caput medusae
pelvis ± tenderness – SBP, Hepatomegaly ± tenderness, note Management of CLD
pancreatitis, malignancy, liver especially if liver irregular, hard 1. Ascites / pedal oedema Non pharmacological
capsule stretch Splenomegaly Fluid & salt restriction
Testicular atrophy I/O charting, daily wt measurement
Legs Pedal oedema Pharmacological
Rectum Melaena Hard stools (encephalopathy) Diuretics – spironolactone +/- frusemide
Hepatic Test for orientation to TPP Procedural
Encephalopathy 4 stages of encephalopathy Paracentesis – diagnostic & therapeutic (SOB)
Stage I: sleep-wake reversal, slurred speech, slow mentation If leucocyte count >250cells/mm3, give fluoroquinolone
Stage II: irritability, asterixis, lethargy, disorientation, personality Δ 2. Spontaneous Bacterial Acute onset abdominal pain, rebound tenderness, absent
Stage III: confusion, sleepy by responds to pain & voice Peritonitis bowel sounds and fever in the presence of ascites &
Stage IV: coma, unresponsive to voice ± pain cirrhosis
Other cx of Cardiac Invx: paracentesis – cloudy fluid with neutrophils count
3
alcoholism displaced apex >250/mm
CCF Usually enteric organisms, esp E. Coli
Neuro/Psy Rx: cefuroxime + metronidazole
Neuro exam—Peripheral neuropathy, Prophylaxis with ciprofloxacin
--Wernicke’s encephalopathy (NOA+confusion) 3. Varices Acute variceal bleed
o Horizontal nystagmus Resuscitate, stabilize, optimize for endoscopy
o Ophthalmoplegia ABC
o Ataxia (test gait) Fluid resus – 2 large bores
MMSE – dementia Bloods – FBC/ PT/aPTT/ GXM/ UECr/ LFT
--Korsakoff’s psychosis Get ready FFP/VitK/pRBC
o Impaired recall & learning abilities IV omeprazole, also somatostatin (Ocreotide)/ terlipressin
o Confabulation if GI bleed suspected to be varices
o Intact consciousness Urgent endoscopy for banding/ligation
IV glypressin

3. 90% can be treated by endoscopy
5% need re-endoscopic tx
5% need surgical TIPS/ esophageal resection/ gastric
repair
4. Encephalopathy Identify precipitating factor and treat it – hemorrhage/
hypoxia/ hypercarbia/ hard stools/ hypnotics/ infections/
progression to CA
Low protein diet
Lactulose – aim to achieve at least 2-3 loose stools/day
MARS (Membrane Adsorbent Recirculating System) – for
acute liver failure. Able to restore liver function only to
pre-morbid state
5. HCC Sx resection preferred but only for
o Child A/B,
o unilobar CA with no portal vein
involvement
Therapeutic radiology only if Sx impossible
o Transarterial chemoembolism (TACE)
o Percutaneous ethanol injection
Liver transplant indications
o ESLD
o Fulminant
o HCC
o Metabolic disease
Contraindications
o Mets
o Severe comorbidities
o HIV
o Active HBV
o Alcohol dependence
6. Malnutrition Vit K injection
Vit D and Ca supplements
Extra information
Factors precipitating Hepatic encephalopathy
↓K
+
Uraemia – spontaneous or diuretic Digitally signed by DR WANA HLA
SHWE
induced Paracentesis (>3-5L) – leads to DN: cn=DR WANA HLA SHWE,
hypovolaemia and ↓K
+
Drugs – sedative/narcotics, c=MY, o=UCSI University, School of
Medicine, KT-Campus, Terengganu,
antidepressants, hypnotics Infections ou=Internal Medicine Group,
GI bleeding Trauma / Sx email=wunna.hlashwe@gmail.com
Excessive dietary protein Reason: This document is for UCSI
Portasystemic shunts year 4 students.
Constipation EtOH binge Date: 2009.02.22 15:17:48 +08'00'