PRESENTING PROBLEMS

IN
LIVER DISEASE
Liver injury may be either acute or chronic.

• Acute liver injury :- may present with non-specific

symptoms of fatigue and abnormal LFTs, or with
jaundice and acute liver failure.

• Chronic liver injury is defined as

hepatic injury, inflammation and/or fibrosis occurring in
the liver for more than 6 months.
In the early stages, patients can be asymptomatic with
fluctuating abnormal LFTs. With more severe liver
damage, the presentation can be with jaundice, portal
hypertension or other signs of cirrhosis and hepatic
decompensation
The main causes of liver disease are
Presentation of liver disease
LIVER CIRRHOSIS
It is an irreversible end result of
fibrous scarring and hepatocellular
regeneration , characterized by
diffuse hepatic fibrosis and nodule
formation, due to inflammatory,
toxic , metabolic and congestive
insults.
Liver cirrhosis is a histological
diagnosis can occur at any age and
is the most common cause of portal
Liver cirrhosis is

Chronic diffuse hepatic condition characterized by :

1.Degeneration
2.Regeneration
3.Fibrosis
4.Loss of architecture
 LIVER CIRRHOSIS
cause distortion of the normal liver architecture that distort the hepatic
vasculature bed , causing portal hypertension and portosystemic shunts
with impairment of liver function. It can be classified histologically into:
• Micronodular cirrhosis, characterised by small nodules about 1 mm in
diameter and typically seen in alcoholic cirrhosis.
• Macronodular cirrhosis, characterised by larger nodules of various sizes.
Macronodular cirrhosis
The causes of cirrhosis are
1• Chronic viral hepatitis (B or C)
2• Alcohol
3• Non-alcoholic fatty liver disease (NAFLD)
4• Immune
Primary sclerosing cholangitis
Autoimmune liver disease
5• Biliary
Primary biliary cirrhosis
Secondary biliary cirrhosis
Cystic fibrosis
6• Genetic
Haemochromatosis
Wilson’s disease
α1-antitrypsin deficiency
7• Cryptogenic (unknown – 15%)
8• Chronic venous outflow obstruction
9• Any chronic liver disease
 Clinical features
The clinical presentation is highly variable. The disease may be completely
asymptomatic and the diagnosis is made incidentally at ultrasound or at
surgery. Others present with isolated hepatomegaly, splenomegaly, signs
of portal Hypertension or hepatic insufficiency.
other non-specific symptoms include weakness, fatigue, muscle cramps,
weight loss , anorexia, nausea, vomiting and upper abdominal discomfort.
Cirrhosis may present with shortness of breath due to a large right pleural
effusion, or with hepatopulmonary syndrome
Hepatomegaly is common when the cirrhosis is
due to ALD, CHF or haemochromatosis.
Progressive hepatocyte destruction and fibrosis
gradually reduce liver size as the disease
progresses in other causes of cirrhosis. The liver
is often hard, irregular and non-tender.
Jaundice is mild when it first appears .
parotid enlargement are most common in
alcoholic cirrhosis. Pigmentation is most striking
in haemochromatosis and in any cirrhosis
associated with prolonged cholestasis.
Endocrine changes are noticed more readily
in men , who show loss of male hair distribution
and testicular atrophy
Spider telangiectasias occur and comprise a central arteriole (which
occasionally raises the skin surface), from which small vessels radiate.
They vary in size from 1 to 2 mm in diameter, and are usually found only
above the nipples. One or two small spider telangiectasias may be
present in about 2% of healthy people and may occur transiently in
greater numbers in the third trimester of pregnancy, but otherwise they
are a strong indicator of liver disease.
Gynaecomastia is common in liver cirrhosis and can be due to drugs such as
spironolactone.
Palmar erythema can be seen early in the disease,
Ascites also signifies advanced disease. Splenomegaly
and collateral vessel formation are features of portal
hypertension, which occurs in more advanced disease.
Evidence of hepatic encephalopathy also becomes common with
disease progression. Nonspecific features of chronic liver disease
include clubbing of the fingers and toes and Dupuytren’s contracture.
Chronic liver failure develops when the metabolic capacity of the liver
is exceeded. It is characterised by the presence of encephalopathy .
Easy bruising becomes more frequent as cirrhosis advances.

Other clinical and laboratory features may be present ; these include

peripheral oedema, renal failure, jaundice, and hypoalbuminaemia and
coagulation abnormalities due to defective protein synthesis.
 In Summary
Regarding Clinical
Features
Clinical Features of Liver Cirrhosis
Features of chronic liver
failure
 Worsening synthetic liver function
Prolonged PT and
Low albumin
• Jaundice
• Portal hypertension
• Variceal bleeding
• Hepatic encephalopathy
• Ascites
Spontaneous bacterial peritonitis and
Hepatorenal failure
 stigmata of chronic liver

disease
- Spider angiomata
 - Palmar erythema
 - Gynecomastia
 - Dupuytren's contracture
 - Parotid enlargement
 - Testicular atrophy
 - Paucity of axillary and pubic hair
 - Eye signs mimicking hyperthyroidism
 Management
This includes
 treatment of the underlying cause,
• Maintenance of nutrition and
• treatment of complications , including ascites , hepatic encephalopathy,
portal hypertension and varices . Once the diagnosis of cirrhosis is made,
endoscopy should be performed to screen for oesophageal varices and
repeated every 2 years. As cirrhosis is associated with an increased risk of
hepatocellular carcinoma (HCC), patients should be placed under regular
surveillance for it . Chronic liver failure due to cirrhosis can also be treated
by liver transplantation.
The overall prognosis in cirrhosis is poor. Many patients present with advanced
disease and/or serious complications that carry a high mortality.
 Overall, only 25% of patients survive 5 years
from diagnosis, but where liver function is good, 50% survive
for 5 years and 25% for up to 10 years. The prognosis is more
favourable when the underlying cause can be corrected, as in
alcohol misuse, haemochromatosis or Wilson’s disease.
Deteriorating liver function, as evidenced by jaundice, ascites
or encephalopathy, indicates a poor prognosis unless a
treatable cause such as infection is found. Increasing bilirubin,
falling albumin (or an albumin concentration of <30 g/L (3.0
g/dL)), marked hyponatraemia (<120 mmol/L) not due to
diuretic , and a prolonged PT are all bad prognostic features
renal function;if this is impaired, it is known to be a poor
prognostic feature in end-stage disease , the course of
cirrhosis can be unpredictable, as complications such as
variceal bleeding may occur
 Complications of Liver
cirrhosis
1- Portal hypertension and its complications
• Variceal bleeding:oesophageal,gastric,other (rare)
• Congestive gastropathy
• Hypersplenism
• Ascites
• Iron deficiency anaemia
• Renal failure
• Hepatic encephalopathy
2- Hepatocellular carcinoma
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