Chronic Liver Disease
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 as it regulates glucose metabolism, stores important fats, metabolizes drugs, and helps synthesize bile. Injury to the liver can lead to impairment in any 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 their coagulopathy.
What Causes Chronic Liver Disease?
Chronic liver disease is most commonly caused by the following factors:
- Alcohol abuse
- Viral hepatitis – hepatitis B and C
- Wilson disease
- Autoimmune hepatitis
- Drug toxicity - acetaminophen, amiodarone
Repetitive injury and inflammation progressively result in the replacement of parenchymal liver tissue with scar and fibrosis - this condition is called liver cirrhosis. The liver may eventually become shrunken.
Complications of chronic liver disease include:
- Confusion – hepatic encephalopathy
- Easy bleeding & bruising – coagulopathy
- Jaundice – yellow discoloration of skin
- Swelling in the legs – lower extremity edema
- Ascites – increased abdominal fluid
- 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
How Common is Chronic Liver Disease?
Chronic liver disease is exceedingly common in the United States and responsible for frequent primary care visits. The most common causes include alcohol abuse and hepatitis B and C infection. The condition often requires referral to a gastroenterology or hepatology specialist.
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
Symptoms & signs of chronic liver disease often include:
- Yellow discoloration of the skin – jaundice
- Caput medusa – dilated blood vessels on abdomen
- Lower limb swelling – due to low albumin levels
- Abdominal fluid & distension
- Abdominal pain
- Confusion – due to buildup of ammonia
- Easy bleeding & bruising
- Black “tarry stool” – upper gastrointestinal bleeding
The diagnosis of chronic liver disease is suggested based on symptoms and physical examination but typically confirmed with laboratory and imaging studies. Your doctor will typically order blood tests including a CMP (comprehensive metabolic panel), CBC (complete blood cell count), and coagulation studies (PT/INR, PTT). Patients with chronic liver disease may have elevated AST, ALT, and alkaline phosphatase levels. Albumin is usually low and PT/INR levels are generally high. Patients commonly have elevated total and occasionally direct bilirubin levels. 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.
Chronic Liver Disease Medication and Treatment
The treatment of chronic liver disease depends on its severity. Patients typically require proper immunization against hepatitis A and B – if not already immune. If they have evidence of esophageal varices on upper endoscopy screening, they may benefit from a medication called propranolol – this has been shown to reduce the risk of variceal hemorrhage.
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 fluid. Sometimes they need to administer intravenous albumin if they are planning on removing a significant amount of fluid (≥ 4 liters). Patients with ascites that is refractory to medical therapy may require a TIPS procedure – transjugular intrahepatic portosystemic shunt.
Patients with spontaneous bacterial peritonitis typically require antibiotics. These vary depending on the exact organism that has been identified – patients are typically on long-term Cipro (ciprofloxacin).
Patients with hepatic encephalopathy (confusion) often require treatment with Constulose (lactulose) and Xifaxan (rifaximin).
Patients with end-stage liver disease that meet certain criteria may be candidates for liver transplantation.
- 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
- 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
- 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
The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.