Liver disease NOS

Chronic liver disease and cirrhosis refer to the long-term damage to the liver and the loss of liver cells, often leading to scarring (fibrosis) and reduced liver function. The progression of liver damage to cirrhosis can have numerous causes and presents significant health challenges.

Causes of Chronic Liver Disease/Cirrhosis

  • Alcohol Abuse: A leading cause of liver disease.
  • Chronic Viral Hepatitis: Particularly hepatitis B and C.
  • Non-Alcoholic Fatty Liver Disease (NAFLD): Linked with obesity, diabetes, and metabolic syndrome.
  • Autoimmune Hepatitis: The body’s immune system attacks liver cells.
  • Genetic Conditions: Such as hemochromatosis (excess iron storage) and Wilson’s disease (excess copper storage).
  • Biliary Cirrhosis: Including primary biliary cholangitis and primary sclerosing cholangitis.
  • Medications and Toxins: Certain drugs and toxins can cause liver damage.

Diagnosis

  • History
    • Symptoms: Fatigue, weakness, weight loss, jaundice, abdominal swelling, easy bruising or bleeding, spider angiomas, confusion or drowsiness.
    • Alcohol and Drug Use: History of alcohol consumption, medication use, or exposure to hepatotoxins.
    • Risk Factors: Family history of liver disease, personal history of hepatitis or other liver diseases.
  • Physical Examination
    • Jaundice: Yellowing of skin and eyes.
    • Hepatomegaly: Enlarged liver.
    • Ascites: Fluid accumulation in the abdomen.
    • Spider Angiomas: Spider-like blood vessels on the skin.
    • Palmar Erythema: Reddening of palms.
    • Caput Medusae: Enlarged veins around the navel.
  • Investigations
    • Liver Function Tests: To assess liver damage and function.
    • Imaging: Ultrasound, CT, or MRI to evaluate liver structure.
    • Viral Hepatitis Serologies: To check for hepatitis B and C.
    • Autoimmune Markers: ANA, SMA, and AMA for autoimmune hepatitis.
    • Genetic Testing: For conditions like hemochromatosis and Wilson’s disease.
    • Fibrosis Assessment: Using non-invasive methods like FibroScan
    • Liver Biopsy: To confirm diagnosis and assess the degree of liver damage.

Differential Diagnosis (DDx)

  • Congestive Heart Failure: Can cause liver congestion mimicking cirrhosis.
  • Chronic Pancreatitis: Abdominal pain and malabsorption symptoms.
  • Hepatic Cancer: Especially hepatocellular carcinoma in a cirrhotic liver.
  • Other Causes of Ascites: Including peritoneal carcinomatosis or tuberculosis.
  • Budd-Chiari Syndrome: Thrombosis of the hepatic veins.

Management of Chronic Liver Disease/Cirrhosis

  • Lifestyle Modification:
    • Alcohol Abstinence: Crucial in alcohol-related liver disease.
    • Weight Loss and Diet: Particularly in NAFLD.
    • Regular Exercise: Helps manage NAFLD.
  • Medical Management:
    • Vaccinations: Against hepatitis A and B.
    • Management of Complications: Like ascites, encephalopathy, and variceal bleeding.
    • Medications: Such as diuretics for ascites, lactulose for encephalopathy, beta-blockers for varices.
    • Antiviral Therapy: For viral hepatitis.
  • Monitoring for Liver Cancer:
    • Regular Ultrasound: With or without alpha-fetoprotein (AFP) blood test every 6 months.
  • End-Stage Disease Management:
    • Consideration for Liver Transplantation: In selected patients.
  • Management of Co-Morbid Conditions:
    • Control of Diabetes, Hyperlipidemia: Especially important in NAFLD.

Conclusion

Chronic liver disease and cirrhosis require careful, long-term management to slow disease progression, manage complications, and maintain quality of life. Multidisciplinary care involving hepatologists, dietitians, and other specialists is often necessary. Early intervention, particularly in the stages of liver disease before cirrhosis, can be crucial in preventing progression to end-stage liver disease.

Management of Cirrhosis/Ascites in more detail

  • Diagnosis and Assessment:
    • Cirrhosis: Diagnosed based on a combination of history, physical examination, laboratory tests, imaging, fibroscan and sometimes liver biopsy.
    • Ascites: Diagnosed through physical examination and confirmed with imaging like ultrasound. Paracentesis (removal of fluid from the abdomen) may be performed to analyze ascitic fluid.
  • Lifestyle Modifications:
    • Diet: Sodium restriction is crucial in the management of ascites. A limit of 2,000 mg of sodium per day is often recommended.
    • Fluid Restriction: In cases with severe hyponatremia (low sodium levels), fluid intake may need to be restricted.
    • Alcohol Cessation: Vital for patients with alcohol-related liver disease.
  • Medications:
    • Diuretics: The mainstay of ascites treatment.
      • Spironolactone and Furosemide are commonly used, often in combination.
    • Antibiotics: Used in cases of spontaneous bacterial peritonitis (SBP)
    • Beta-blockers: May be used for the prevention of variceal bleeding in cirrhosis.
      • Propranolol is often the first choice due to its non selective profile
      • It reduces portal pressure by decreasing cardiac output and producing splanchnic vasoconstriction.
  • Management of Complications:
    • Paracentesis: Therapeutic paracentesis can be performed in patients with tense ascites to relieve discomfort.
    • Transjugular Intrahepatic Portosystemic Shunt (TIPS): Considered in refractory cases where diuretics are not effective.
  • Prevention and Treatment of SBP:
    • Routine use of prophylactic antibiotics (Rifaximin) in high-risk patients.
  • Monitoring:
    • Regular follow-up for monitoring the response to therapy and the development of any complications.
    • Routine blood tests, including liver function tests, renal function tests, and electrolytes.
    • 6 monthly AFP and Ultrasound to check for development of HCC (Hepatocellular Carcinoma)
  • Managing Underlying Liver Disease:
    • Addressing the underlying cause of cirrhosis, such as viral hepatitis or alcohol use, is crucial.
  • Nutritional Support:
    • Nutritional assessment and support, considering the risk of malnutrition in cirrhotic patients.
  • Liver Transplantation:
    • Evaluation for liver transplantation in cases of decompensated cirrhosis.
  • Patient Education:
    • Educating the patient about the importance of adhering to the treatment plan, recognizing signs of complications, and when to seek medical help.
  • Multidisciplinary Approach:
    • Involvement of a multidisciplinary team including hepatologists, gastroenterologists, dietitians, and other healthcare professionals is essential for optimal management.

Management of cirrhosis and ascites requires careful consideration of the severity of the liver disease, the presence of complications, and the overall health status of the patient. The approach is highly individualized and should be regularly adjusted based on the patient’s response to treatment and changing clinical status.

Hepatitis A

Hepatitis A is an acute infectious liver disease caused by the hepatitis A virus (HAV). It’s usually self-limiting and does not lead to chronic infection.

Causes of Hepatitis A

  • Viral Infection: Caused by the hepatitis A virus.
  • Fecal-Oral Transmission: Usually from eating food or drinking water contaminated with feces from an infected person. Also common in areas with inadequate sanitation.
  • Close Personal Contact: With an infected person, including sexual contact.
  • Travel: Particularly to areas with high HAV prevalence and poor sanitary conditions.

Diagnosis

  • History
    • Symptoms: Often begins with sudden onset of fever, malaise, nausea, anorexia, and abdominal discomfort, followed by jaundice.
    • Recent Travel History: To areas with high incidence of HAV.
    • Exposure History: Ingestion of contaminated food or water, close contact with a known HAV case.
    • Vaccination History: Previous hepatitis A vaccination.
  • Physical Examination
    • Jaundice: Yellowing of the skin and eyes.
    • Hepatomegaly: Enlarged liver with tenderness.
    • General Assessment: For signs of dehydration or complications.
  • Investigations
    • Liver Function Tests: Elevated bilirubin, ALT, and AST levels.
    • Serological Testing: Detection of IgM anti-HAV antibodies indicates acute hepatitis A infection. IgG anti-HAV antibodies indicate past infection or vaccination.
    • Ultrasound: If there’s suspicion of other hepatic pathology.

Diferential Diagnosis

  • Other Hepatitides: Hepatitis B, C, D, and E.
  • Biliary Tract Disease: Like cholecystitis or choledocholithiasis.
  • Alcoholic Hepatitis: In patients with significant alcohol use.
  • Drug-Induced Hepatitis: From hepatotoxic drugs.
  • Autoimmune Hepatitis: Especially if there are signs of other autoimmune disorders.

Management of Hepatitis A

  • Supportive Care: Most cases resolve spontaneously without specific treatment.
    • Rest: Encourage adequate rest during the acute phase.
    • Hydration: Ensure sufficient fluid intake.
    • Nutrition: Balanced diet as tolerated; avoid alcohol and hepatotoxic medications.
    • Pain Management: As needed for abdominal discomfort.
  • Monitoring:
    • Regular Follow-Up: To monitor resolution of symptoms and normalization of liver function tests.
    • Observation for Complications: Rare, but can include fulminant hepatitis.
  • Prevention:
    • Vaccination: Highly effective and recommended, especially for travelers to endemic areas, individuals with chronic liver disease, and certain high-risk groups.
    • Hand Hygiene: Proper sanitation and personal hygiene practices.
    • Food and Water Safety: Especially in endemic areas.
  • Public Health Measures:
    • Reporting Cases: To health authorities for surveillance and prevention of outbreaks.
    • Education: About transmission and prevention.
  • Post-Exposure Prophylaxis:
    • Hepatitis A Vaccine or Immune Globulin (IG): For close contacts of a confirmed case, preferably within 2 weeks of exposure.

Conclusion

Management of hepatitis A is primarily supportive, as the infection is self-limiting and does not lead to chronic liver disease. Prevention through vaccination and maintaining good hygiene practices is key. Public health measures play an important role in preventing outbreaks, especially in settings where the virus is more common.

Hepatitis B

Hepatitis B is a potentially serious liver infection caused by the hepatitis B virus (HBV). It can become chronic in some people, leading to long-term liver problems.

Causes of Hepatitis B

  • Viral Infection: Caused by the hepatitis B virus (HBV).
  • Transmission Modes:
    • Parenteral: Through contaminated needles, syringes, or medical instruments.
    • Sexual Contact: Especially unprotected sex with an infected partner.
    • Perinatal Transmission: From an infected mother to her baby during childbirth.
    • Blood Transfusions or Organ Transplants: Less common due to rigorous screening.

Diagnosis

  • History
    • Symptoms: Many are asymptomatic, but symptoms can include fatigue, jaundice, dark urine, fever, and abdominal pain.
    • Risk Factors: Consider sexual history, drug use, occupational exposure (healthcare workers), travel history, and family history of hepatitis B.
    • Vaccination History: Previous hepatitis B vaccinations.
  • Physical Examination
    • Jaundice: Yellowing of the skin and eyes.
    • Hepatomegaly: Enlarged liver.
    • Signs of Chronic Liver Disease: Spider angiomas, palmar erythema, ascites, and splenomegaly in advanced cases.
  • Investigations
    • Serologic Tests: To identify HBV antigens and antibodies. Includes
      • HBsAg (surface antigen),
      • anti-HBs (surface antibody),
      • anti-HBc (core antibody),
      • HBeAg (e antigen), and
      • anti-HBe (e antibody).
    • Liver Function Tests: Elevated ALT and AST levels.
    • Viral Load Test (HBV DNA): To measure the amount of virus in the blood.
    • Liver Ultrasound: For evaluating liver status in chronic HBV.
    • Liver Biopsy: In selected cases for assessing the degree of liver damage.

Differential Diagnosis (DDx)

  • Other Hepatitis Forms: Hepatitis A, C, D, and E.
  • Alcoholic Liver Disease: History of alcohol abuse with similar symptoms.
  • Non-Alcoholic Fatty Liver Disease (NAFLD): Especially in obese or diabetic patients.
  • Autoimmune Hepatitis: Especially if other autoimmune markers are present.
  • Drug-Induced Liver Injury: Use of hepatotoxic drugs.

Management of Hepatitis B

  • Acute Hepatitis B:
    • Supportive Care: Rest, adequate nutrition, and hydration.
    • Monitoring: Regular follow-up to ensure resolution of infection and monitor for liver function.
    • Avoidance of Alcohol and Hepatotoxic Medications: To reduce liver strain.
  • Chronic Hepatitis B:
    • Antiviral Therapy: Nucleos(t)ide analogues like tenofovir and entecavir to reduce viral replication and prevent liver damage.
    • Regular Monitoring: For liver function, viral load, and signs of liver cirrhosis or cancer.
    • Liver Biopsy or Non-Invasive Imaging: In certain cases to assess liver damage.
  • Prevention:
    • Vaccination: Universal vaccination is recommended.
    • Screening of Pregnant Women: And treatment to prevent perinatal transmission.
    • Safe Sexual Practices and Safe Injection Practices.
  • Management of Complications:
    • Cirrhosis: Diuretics for ascites, beta-blockers for varices, surveillance for hepatocellular carcinoma.
    • Hepatocellular Carcinoma: Regular screening and appropriate oncological treatments.

Conclusion

Management of hepatitis B requires a combination of regular medical monitoring, antiviral therapy for chronic cases, and supportive care. Public health measures including vaccination and safe practices are key in preventing HBV transmission. The goal of treatment in chronic cases is to prevent progression to cirrhosis and hepatocellular carcinoma.

Hepatitis C

Hepatitis C is a liver infection caused by the Hepatitis C virus (HCV). It can cause both acute and chronic infection, with the latter leading to serious, long-term health problems such as liver cirrhosis and liver cancer.

Causes of Hepatitis C

  • Blood Transmission: The primary mode of HCV transmission is through exposure to small quantities of blood. This can happen through:
    • Intravenous drug use with shared needles.
    • Healthcare exposure (needlestick injuries).
    • Blood transfusions and organ transplants (especially before 1992 in the U.S. when widespread screening of the blood supply was implemented).
    • Hemodialysis.
    • Tattooing and piercing with non-sterile instruments.
  • Sexual Transmission: Less common, but possible, particularly among men who have sex with men.
  • Mother-to-Child Transmission: Can occur during childbirth.

Diagnosis

  • History
    • Risk Factors: A detailed history of potential exposure risks, including drug use, sexual history, blood transfusions, and occupational exposure.
    • Symptoms: Many individuals are asymptomatic. Symptoms, when present, may include fatigue, nausea, abdominal pain, jaundice, and dark urine.
  • Physical Examination
    • Jaundice: Yellowing of the skin and eyes.
    • Hepatomegaly: Enlarged liver.
    • Signs of Chronic Liver Disease: Spider angiomas, ascites, splenomegaly, and palmar erythema in advanced cases.
  • Investigations
    • Anti-HCV Antibody Test: Initial screening test for HCV antibodies.
    • HCV RNA PCR Test: To confirm active infection.
    • Liver Function Tests: Elevated ALT and AST levels.
    • Genotype Testing: To determine the specific HCV genotype, which can guide treatment decisions.
    • Ultrasound: For chronic HCV to assess liver health.
    • Fibrosis Assessment: Using non-invasive methods like FibroScan or liver biopsy.

Differential Diagnosis (DDx)

  • Other Viral Hepatitides: Such as hepatitis A, B, and E.
  • Alcoholic Liver Disease: In patients with a history of significant alcohol use.
  • Non-Alcoholic Fatty Liver Disease (NAFLD): Especially in obese or diabetic patients.
  • Autoimmune Hepatitis: If there are signs of other autoimmune disorders.
  • Drug-Induced Liver Injury: History of using hepatotoxic medications.

Management of Hepatitis C

  • Antiviral Therapy:
    • Direct-acting Antivirals (DAAs): Highly effective in curing HCV in most cases.
    • Treatment Regimen: Selected based on genotype, presence of cirrhosis, treatment history, and potential drug interactions.
  • Supportive Care:
    • Alcohol and Drug Cessation: To reduce liver damage.
    • Nutrition and Exercise: To maintain liver health and overall well-being.
  • Monitoring:
    • Regular Liver Function Tests: To monitor liver health.
    • Assessment for Cirrhosis: In chronic cases, surveillance for liver cancer (hepatocellular carcinoma) and esophageal varices.
  • Prevention and Public Health Measures:
    • Education on Risk Factors: Preventing HCV transmission.
    • Screening and Treatment: Particularly in high-risk populations.
  • Management of Complications:
    • Cirrhosis: Management of complications like ascites, varices, and hepatic encephalopathy.
    • Hepatocellular Carcinoma: Regular screening and appropriate oncological treatment.

Conclusion

Effective management of Hepatitis C involves a combination of antiviral therapy, which can cure the infection in most cases, along with regular monitoring for liver health and managing complications. Public health measures to prevent transmission are also crucial. With advances in treatment, the prognosis for patients with Hepatitis C has significantly improved.

Vaccines

  • Hepatitis B Vaccines:
    • Engerix-B Adult
    • Engerix-B Paediatric
    • H-B-Vax II
    • H-B-Vax II Paediatric
    • Infranrix Hexa (given at 2/4/6 months) Diptheria, Tetanus, Pertussis, Hep B, Hib, Polio
  • Combined Hepatitis A and Hepatitis B Vaccines:
    • Twinrix (720/20) – A combination vaccine that provides protection against both Hepatitis A and Hepatitis B.
    • Twinrix Junior (360/10) – A formulation specifically for children.
  • Combined Hepatitis A and Typhoid Vaccines:
    • Vivaxim. This vaccine is contained in a dual chamber syringe, with one chamber holding the hepatitis A vaccine and the other containing the typhoid vaccine​​.
  • No vaccine for Hepatitis C