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Chronic Liver Disease (Examination (Peripheral Inspection (General…

- - - - Jaundice
      - Cachexia
      - Tattoos and track marks
      - Pigmentation
      - Ascites
    - - Leukonychia
        
        Terry’s nails (white proximally, red distally)
        
        Palmer erythema
        
        Dupuytren’s contracture
        
        Clubbing (esp. in PBC)
    - - Pallor: ACD
      - Xanthelasma: PBC
      - Keiser-Fleischer rings
      - Parotid enlargement (esp. w/ EtOH)
    - - Spider naevi
      - Gynaecomastia
      - Loss of secondary sexual hair
    - - Peripheral oedema
  - - - Distension ± Para- / umbilical hernia
      - Dilated veins
      - Drain scars
    - - ± hepatomegaly
      - ± splenomegaly
      - Shifting dullness
  - - - Jaundice
      - Encephalopathy: asterixis, confusion
      - Foetor hepaticus: ammonia and ketones
      - Hypoalbuminaemia: oedema and ascites
      - Coagulopathy: bruising
- - - - MDT: GP, hepatologist, dietician, palliative care, family
      - EtOH abstinence
      - Good nutrition
      - Cholestyramine for pruritus
      - Screening
        
        HCC: US + AFP
        
        Varices: OGD
    - - HCV: interferon-α + ribavarin
      - PBC: ursodeoxycholic acid
      - Wilson’s: penicillamine
      - HH: venesection, desferrioxamine
    - - Varices: β-B, banding
      - Ascites: fluid and salt restrict, spiro, fruse, tap, daily wt
      - Coagulopathy: Vit K, FFP, platelets
      - Encephalopathy: avoid sedatives, lactulose, rifaximin
      - Sepsis / SBP: tazocin or cefotaxime
      - Avoid gent: nephrotoxicity
      - Hypoglycaemia: dextrose
      - Hepatorenal syndrome: IV albumin + terlipressin
  - - - EtOH
      - Sexual Hx, IVDU, transfusions
      - FH
      - Other AI disease: e.g. DM, thyroid
      - DH
  - - - Urine: dip ± MC+S (? UTI)
      - Bloods: FBC, U+E, LFTs, INR, glucose
      - Ascitic tap: chemistry, cytology, MC+S, SAAG
        PMN >250mm3 indicates SBP
      - US + PV duplex
        
        Liver size and texture
        Focal lesions
        Ascites
        Portal vein flow
    - - EtOH: MCV, GGT, AST:ALT >2
      - Viral: Hep B and C serology
      - NASH: lipids
      - AutoAbs: SMA, AMA, pANCA, ANA
      - Ig: ↑IgG – AIH, ↑IgM – PBC
      - Genetic: caeruloplasmin, Ferritin, α1-AT
      - Ca: AFP, Ca 19-9
    - - Liver biopsy
        MRCP: PSC
- - - - ↓ nitrogen-forming bowel bacteria
      - 2-4 soft stools/d
- - - - Mortality 0
      - Tx Mortality 10
    - - 1yr Mortality 20
      - Tx Mortality 30
    - - 1yr Mortality 50
      - Tx Mortality 80