Chronic Liver Disease – Diagnosis, Symptoms, and Treatment

What is Chronic Liver Disease?

Chronic liver disease is a medical condition characterized by long-term liver injury and inflammation that leads to progressive scarring of the liver (cirrhosis).  The liver is a vital organ that helps regulate glucose, assists with the absorption of nutrients from the intestines, stores important fats, metabolizes drugs, and helps remove various toxins from the body. Severe Injury to the liver will lead to impairment in all of these bodily functions.  Another important role of the liver is to produce coagulation factors in concert with vitamin K.  Patients with severe cases often have bleeding complications due to the lack of clotting factors.

What Causes Chronic Liver Disease?

Chronic liver disease has many causes, generally, more than one cause will be present and will lead to more severe disease. Infectious diseases, autoimmune conditions, and diet can all lead to liver injury and eventual chronic liver disease. 

Chronic liver disease is most commonly caused by the following factors:

• • Alcohol abuse

• Obesity

• • Viral hepatitis – hepatitis B and C
  • Wilson disease
  • Hemochromatosis
  • Autoimmune hepatitis

• Liver cancer

• Drug toxicity - acetaminophen, amiodarone

Repetitive injury and inflammation over multiple months to years results in the replacement of healthy and functioning liver tissue with scar and fibrosis - this condition is called liver cirrhosis and is what leads to the loss of function of the liver.

How Common is Chronic Liver Disease?

Chronic liver disease is relatively common due to the large number of conditions that can lead to cirrhosis which decreases liver function. The most common causes of severe liver failure are alcohol abuse, obesity, hepatitis B, and hepatitis C. The exact number of people living with chronic liver disease is difficult to estimate as many people do not seek treatment until severe disease develops. 

In 2008, liver disease caused approximately 66,000 deaths – about 18,000 of these deaths were related to hepatobiliary malignancy.  Chronic liver disease was the 8th leading cause of death in 2010 - responsible for about 50,000 deaths.  Approximately 20,000 of these deaths were caused by hepatic malignancy (liver cancer).

Signs and Symptoms

Chronic liver disease generally has few to no symptoms until it is severe. The liver is an extremely resilient organ that can remain functional despite significant damage. Eventually, the number of functioning liver cells that are not replaced with scar tissue will fall below the amount the body needs to survive and liver failure will begin. The most common signs and symptoms of liver failure are:

• Yellow discoloration of the skin – jaundice
• Caput medusa – dilated blood vessels on abdomen
• Lower limb swelling – due to low albumin levels
• Fatigue
• Abdominal fluid & distension
• Abdominal pain
• Confusion – due to buildup of ammonia
• Easy bleeding & bruising
• Black “tarry stool” – upper gastrointestinal bleeding

Beyond the above signs and symptoms there are several complications that can result from chronic liver disease that has become severe. The most common are as follows: 

• Spontaneous bacterial peritonitis (SBP)
• Bad breath – fetor hepaticus
• Increased risk for infection
• Gynecomastia and loss of pubic hair
• Upper gastrointestinal bleeding – esophageal varices
• Liver cancer
• Death

Diagnosis

The diagnosis of chronic liver disease is generally made based on the signs and symptoms above. The physician will take a comprehensive history to better understand what lead to liver failure and perform an examination prior to ordering tests.

Blood tests including a CMP (comprehensive metabolic panel), CBC (complete blood cell count), and coagulation studies (PT/INR, PTT) are generally performed.  Patients with chronic liver disease may have elevated AST, ALT, and alkaline phosphatase levels which are markers of liver cell injury.  Albumin, a protein made by the liver, is usually low and PT/INR levels, which represent the ability of the blood to clot, are generally high.  Patients commonly have elevated total and occasionally direct bilirubin levels, as the liver is a critical step in the removal of bilirubin from the body, this is what leads to the yellowing of the skin and eyes in liver failure.  The more severe the disease is the more abnormal the laboratory results typically are.

Your doctor will also obtain imaging of the liver with abdominal ultrasound or CT scan.  Occasionally, your doctor will order an MRI of the abdomen.  Sometimes, the cause of chronic liver disease is uncertain and your doctor may recommend a liver biopsy.

Patients with advanced liver disease may require routine upper endoscopies to screen for esophageal varices. Abnormal blood vessels in the throat that can bleed and lead to death from blood loss

Chronic Liver Disease Medication and Treatment

The treatment of chronic liver disease is complex and will vary significantly depending upon the severity of the disease and its underlying cause Generally, this condition is managed by a hepatologist, which is a doctor specialized in the treatment of liver diseases. 

Treatment begins with prevention. Stopping any processes that are leading to further liver damage can help slow the progression of the disease. Your physician will recommend that you stop all alcohol intake, stop smoking, and adopt a healthy diet. Immunization against hepatitis A and B and treatment of any heaptits infections is also critical. 

Regular screening is also critical, labs may be done yearly, weekly, or monthly and are intended to monitor the progression of the disease and alter any treatments. If esophageal varices are present, endoscopy may be performed regularly to ensure that they will not lead to severe bleeding. 

Patients with ascites can benefit from diuretic medications such as Lasix (furosemide) and Aldactone (spironolactone).  Those with more severe ascites may require therapeutic paracentesis – during this procedure, your doctor will insert an ultrasound-guided needle into your abdominal cavity and drain out the excess fluid.   Patients with ascites that is refractory to medical therapy may require a TIPS procedure – transjugular intrahepatic portosystemic shunt which allows blood to bypass the liver and reduces the formation of fluid in the stomach, this is a last resort as it may worsen other symptoms.

Patients with spontaneous bacterial peritonitis, an infection within the abdominal cavity due to large amounts of fluid, typically require antibiotics.  These vary depending on the exact organism that has been identified – patients are typically on long-term Cipro (ciprofloxacin) to both treat and prevent infections.

Patients with hepatic encephalopathy (confusion) often require treatment with Constulose (lactulose) and Xifaxan (rifaximin) which help the body to eliminate the toxins that build up in the setting of liver failure through the stool.

Patients with end-stage liver disease that meet certain criteria may be candidates for liver transplantation. A liver transplant is the only cure for cirrhosis as the liver cannot repair areas that have been so severely damaged. Liver transplants are major procedures that require a long period of recovery and lifelong treatment with medications that suppress the immune system. 

References:

1. Asrani SK, Larson JJ, Yawn B, et al. Underestimation of liver-related mortality in the United States. Gastroenterology 2013; 145:375. - https://www.ncbi.nlm.nih.gov/pubmed/23583430
2. Mumtaz K, Ahmed US, Abid S, et al. Precipitating factors and the outcome of hepatic encephalopathy in liver cirrhosis. J Coll Physicians Surg Pak 2010; 20:514. - https://www.ncbi.nlm.nih.gov/pubmed/20688015
3. D'Amico G, De Franchis R, Cooperative Study Group. Upper digestive bleeding in cirrhosis. Post-therapeutic outcome and prognostic indicators. Hepatology 2003; 38:599. - https://www.ncbi.nlm.nih.gov/pubmed/12939586