NME2.4: case 8 launch session22/01/08

Learning Outcomes

Appreciate the causes and clinical consequences of cirrhosis

Clinical Features of Chronic Liver Disease
  • Jaundice[TG1]–yellowing of the skin due to excess serum bilirubin exceeding 50μmol (NR 3-17)
  • Ascites – accumulation of serous fluid in the peritoneum causing abdominal distension
  • Spider naevi – branched growths of dilated capillaries on the skin
  • Asterixis– coarse flapping tremor of the hands, indicative of portosystemic encephalopathy
  • Hepato-/splenomegaly – enlargement of the liver / spleen (former causing right hypochondrial pain)
  • Leuco-/thrombocytopenia–reduced white blood cells / platelets (degraded by enlarged spleen)
  • Macrocytosis – often due to alcohol: direct toxic effect on bone marrow / folate deficiency
  • Liver function tests may show:
  • Lowserum albumin(NR 35-50) – produced in liver; bad prognostic sign
  • Prolonged prothrombin time[TG2](NR 12-16s) –due to thrombocytopenia?
  • Liver biochemistry may show:
  • Elevated alkaline phosphatase (ALP) (NR 39-117)–cholestasis[TG3], cirrhosis, metastatic cancer
  • Elevated transaminases (AST, ALT[TG4]) (NR 5-40) – found in hepatocytes, leak in cell damage
  • Elevated gamma-glutamyl transpeptidase (GGT) (NR 10-55) –guide to alcohol intake
Case 8 preliminary diagnoses
  • Alcoholic hepatitis – Inflammation of the liver due to excessive alcohol consumption; hepatocytes swell and undergo necrosis (maximal in zone 3) and are replaced with fatty deposits
  • Portosytemic encephalopathy –chronic neuropsychiatric syndrome due to chronic liver disease; toxic substances in the blood bypass the damaged liver and damage braincells
Management
  • Nutritional support with low salt (would exacerbate ascites), low proteinand multivitamins
  • Spironolactone – anti-aldosterone[TG5] diuretic
  • Monitored for renal failure (hyponatraemia[TG6], elevated creatine)
  • Gut cleansing – enema, purgatives, lactulose
Liver biopsy
  • Only performed when contraindications have been resolved (elevated PT, low platelet count, ascites)
  • Cirrhosis –necrosis of hepatocytes, fibrosis and formation of nodules; causes portal hypertension
  • Micronodular –Nodules < 3mm, uniform across liver; common in alcoholic liver disease
  • Steatohepatitis – accumulation of fat in cytoplasm of hepatocytes
Complications
  • Oesophageal varices –permanent dilation of veins, develop in 90% of cirrhosis sufferers, can further cause variceal haemorrhage – 25-50% fatal depending on severity of underlying liver damage
  • Haematemesis – vomiting of blood, often as a result of variceal haemorrhage
  • Child’s grades:
  • A –82% survival 1 year; 25% survival 10 years
  • B – 62% survival 1 year; 7% survival 10 years
  • C – 42% survival 1 year; 0% survival 10 years

[TG1]Icterus; of or relating to jaundice is icteric

[TG2]Clotting time of recalcified plasma

[TG3]Obstruction of normal bile flow

[TG4]Specific to the liver; rise definitively indicates liver disease

[TG5]Steroid hormone that controls renal salt and water balance

[TG6]Low sodium