Makindo Medical Notes

Related Subjects: |Chronic liver disease |Cirrhosis |Alkaline phosphatase (ALP) |Liver Function Tests |Ascites Assessment and Management |Budd-Chiari syndrome |Autoimmune Hepatitis |Primary Biliary Cirrhosis |Primary Sclerosing Cholangitis |Wilson disease |Hereditary Haemochromatosis |Alpha-1 Antitrypsin (AAT) deficiency |Non alcoholic steatohepatitis (NASH) |Spontaneous Bacterial Peritonitis |Alcoholism and Alcoholic Liver Disease |Hepatitis C

History and Risk Factors

• Symptoms: Assess for fatigue, jaundice, abdominal discomfort, pruritus, dark urine, and pale stools.
• Duration: Ask how long symptoms have been present. Chronic hepatitis is defined as inflammation lasting for 6 months or more.
• Risk Factors:
  • History of blood transfusions before 1992 (risk of hepatitis C).
  • Intravenous drug use or unsafe injection practices.
  • History of unsafe sexual practices.
  • Occupational exposure (e.g., healthcare workers, needle-stick injuries).
  • Alcohol use, particularly heavy drinking over time.
  • Family history of liver disease or autoimmune conditions.
  • Use of hepatotoxic medications (e.g., acetaminophen, methotrexate, amiodarone).
  • Travel history to areas endemic with hepatitis B or C.

Physical Examination

• General appearance: Evaluate for jaundice, cachexia, or lethargy.
• Abdominal examination:
  • Palpate for hepatomegaly or tenderness in the right upper quadrant.
  • Check for splenomegaly, ascites, or abdominal distension.
• Skin signs:
  • Spider angiomas, palmar erythema, or caput medusae (signs of liver cirrhosis).
  • Check for bruising or petechiae due to coagulopathy.

Causes

Laboratory Investigations

• Liver function tests (LFTs):
  • Assess for elevated alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP), and bilirubin.
  • Evaluate albumin and prothrombin time (PT) for liver synthetic function.
• Viral markers:
  • Test for hepatitis B surface antigen (HBsAg) and hepatitis C antibodies (anti-HCV).
  • HBV DNA and HCV RNA testing for viral replication.
• Autoimmune markers: Screen for autoimmune hepatitis with antinuclear antibodies (ANA), anti-smooth muscle antibodies (SMA), and liver/kidney microsomal antibodies (LKM).
• Metabolic tests: Consider iron studies for hemochromatosis, and ceruloplasmin levels for Wilson’s disease.

Imaging and Non-Invasive Tests

• Ultrasound: Assess liver size, texture, presence of cirrhosis, and rule out focal lesions.
• Elastography: Non-invasive test to measure liver stiffness and assess for fibrosis or cirrhosis.
• CT/MRI: For detailed imaging if there is suspicion of liver masses or complications like hepatocellular carcinoma (HCC).

Liver Biopsy (if indicated)

• Biopsy may be considered for unclear diagnoses, to assess the extent of fibrosis, or to confirm autoimmune hepatitis or other metabolic liver diseases.

Management

• Viral hepatitis: Antiviral therapy for chronic hepatitis B (e.g., entecavir, tenofovir) or hepatitis C (direct-acting antivirals).
• Autoimmune hepatitis: Corticosteroids and/or azathioprine for immune suppression.
• Alcoholic hepatitis: Abstinence from alcohol, nutritional support, and possibly corticosteroids in severe cases.
• Monitoring: Regular follow-up with liver function tests, viral load monitoring (if applicable), and screening for complications like cirrhosis or liver cancer.
• Lifestyle changes: Advise on healthy diet, weight management, and avoiding hepatotoxic substances (e.g., alcohol, NSAIDs).

Screening for Complications

• Patients with chronic hepatitis should be monitored for complications, including:
  • Cirrhosis and liver failure.
  • Portal hypertension (varices, ascites).
  • Hepatocellular carcinoma (HCC) - Screening with alpha-fetoprotein (AFP) and liver ultrasound every 6-12 months.