Chronic liver disease and substance misuse

1. Chronic liver disease and substance misuse Kapil Kapur Department of gastroenterology BDGH NFT

2. Introduction • Definition • Aetiology of chronic liver disease • Symptoms and signs of chronic liver disease • Complications in chronic liver disease • Investigations in chronic liver disease • Chronic liver disease and substance misuse • Alcoholic liver disease • Hepatitis C • Hepatitis B

4. Liver cirrhosis • Cirrhosis represents a late stage of progressive liver fibrosis and disease and results in a distortion of liver architecture • Usually changes are irreversible • Liver transplantation may be the only option

5. Aetiology • Alcoholic liver disease • Fatty liver disease (NAFLD) • Hepatitis B and C • Auto-immune liver disease • Primary biliary cirrhosis • Metabolic conditions • Hemochromatosis • Alpha 1 AT deficiency • Wilson’s disease

6. Symptoms of chronic liver disease • Asymptomatic • General symptoms • fatigue, wt loss, poor nutrition, general ill-health, non-specific symptoms • Abnormal LFTs • Symptomatic • asymptomatic • Symptoms of liver failure • Jaundice • Ascites (swelling in the abdomen) • Encephalopathy

7. Symptoms of chronic liver disease • Symptoms of complications • Variceal bleeding • Portal hypertension • Spontaneous bacterial peritonitis (SBP) • Hepato-cellular cancer • Hepato-renal syndrome

8. Signs of chronic liver disease • No signs in early stages • Stigmata of compensated chronic liver disease • Spider naevi, clubbing, liver palms, poor nutrition, • Gynaecomastia and poor secondary sexual characteritics • Oedema (swelling) feet

9. Spider naevi

11. Signs in chronic liver disease • Signs of decompensation / complications • Jaundice • Ascites and oedema feet • Encephalopathy • Confusion to coma • Upper GI bleeding • Haematemesis and or melaena • collapse

13. Signs of Liver Disease

14. Signs of liver disease

16. Complications of chronic liver disease • Upper gastrointestinal bleeding • Oesophageal varices • Gastric varices • Jaundice • Ascites, bacterial peritonitis and oedema • Encephalopathy • Hepatorenal syndrome • Liver cancer

20. Oesophageal varices after application of rubber bands

21. Gastric varices

22. Gastric varix after injection of histoacryl glue

23. Assessing severity

24. Child-Pugh Classification 1 yr survival 2 yr survival • 5/6  A 100% 85% • 7-9  B 80% 60% • 10-15  C 45% 35%

26. Prognostic impact of SBP Probability Survival in months

27. Investigations in chronic liver disease • Ultrasound abdomen • Non invasive liver screen (NILS) • LFTS and Prothrombin time • Hepatitis B and C serology • Autoimmune profile and immunoglobulins • Ferritin • Alpha 1 AT, Caeruloplasmin • Alpha feto protein

28. Investigations in chronic liver disease • Liver biopsy • Needle biopsy • Under X-ray control • Risks of bleeding and organ injuries

29. A general approach to management in chronic disease • Establish the diagnosis • Treatment of acute symptoms and complications • Addressing the underlying cause • Alcohol, Hep B, Hep C • Explore role for transplantation • Surveillance for hepato-cellular cancer

30. Substance misuse and liver disease • Alcohol • Hepatitis C • Hepatitis B

31. Acute alcoholic hepatitis • Acute alcoholic hepatitis • Abstinence • Supportive therapy • Steroids • Pentoxifylline

32. Chronic alcoholic liver disease • Abstinence • Detox • Alcohol liaison services and support • Nutrition and vitamins • Symptom management • ? Transplantation if abstinent for 6 months

33. The course of alcoholic cirrhosis • Compensated cirrhosis N = 122 Decompensated disease, with ascites in 58% at 10 years 5 year survival abstainers: 50 - 75% 5 year survival recalcitrants:10 - 30%

34. Hepatitis C • IVDU, contaminated needles, transfusion related • Confirm the diagnosis • RNA PCR • Viral load and genotype • Address risk factors • Antiviral therapy • Ribavirin • Pegylated interferon

35. Hep C treatment in Barnsley • We currently offer antiviral treatment and accept direct referrals • Expensive and prolonged and demanding • Difficult population to treat • Finite duration of treatment • Risk of re-infection • Nurse led clinic—Hep C Nurse

36. Current figures for Barnsley • 94 patients given treatment • 17 patients discontinued treatment • 52 patients have completed treatment • 39 patients had 6 month post Rx PCR • 33/39 sustained viral response (SVR) • 6/39 relapsed

37. Hepatitis B • IVDU, Infected sexual contacts, transfusion related • Vast majority need follow up rather than treatment • Business case for treatment in BDGH • Treatment is suppressive rather than curative • Prolonged antiviral therapy • Interferon, • Antivirals—Lamivudine, Tenofovir

38. Summary • Chronic liver disease comprises a big burden for health care • Alcohol, Hepatitis C and Hepatitis B are important public health care issues • Important to recognise and treat chronic liver disease