Liver disease: Early signs you may be missing

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Applied Evidence

Liver disease: Early signs you may be missing

J Fam Pract. 2009 October;58(10):514-521

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References

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Portal hypertension/esophageal varices. The main aim of treating portal hypertension is to prevent esophageal variceal bleeding. The appearance of varices should be checked by endoscopy every 2 to 3 years, or yearly for patients at high risk of bleeding. Patients with varices can be managed with nonselective beta-blockers at doses that are sufficient to elicit a 25% reduction in resting heart rate. Those at high risk for bleeding and patients who have already had esophageal bleeding may require endoscopic band ligation.³² TIPS is an alternative for those whose previous treatments have failed.³³

FAST TRACK

Without transplantation, patients with decompensated cirrhosis have an 85% mortality rate over 5 years.

Hepatic encephalopathy. This potentially reversible decrease in neuropsychiatric function mainly affects patients with portal hypertension. Caused by reduced hepatic clearance of gut-deriving neurotoxins, hepatic encephalopathy is associated with a range of signs and symptoms—from subtle personality changes to coma, with flapping tremor as a frequent initial finding. Acid-base and electrolyte disturbances, constipation, infections, gastrointestinal bleeding, and sedatives can precipitate encephalopathy. Hepatic encephalopathy is a diagnosis of exclusion, however, requiring the exclusion of all other etiologies of altered mental status.

Treatment consists of identifying and correcting the precipitating factors, and includes electrolyte correction, colon cleansing, and acidification with lactulose. Dietary protein restriction is no longer advocated, because it may facilitate malnutrition and complications. Oral rifaximine is useful and well tolerated for suppression of intestinal bacterial flora. Venous infusion of branched-chain amino acids or flumazenil may be effective in case of coma.

FAST TRACK

Patients with cirrhosis may not develop the typical signs and symptoms of infection; leukocytosis may be absent, for example, and they may be afebrile.

Fever and sepsis. Infection is a high-risk factor for mortality in patients with cirrhosis, as it can lead to renal and liver failure, variceal bleeding, and hepatic encephalopathy. However, individuals with cirrhosis often do not develop the typical signs and symptoms of infection; leukocytosis may be absent because of severe leukopenia, for instance, and patients may be afebrile.

Thus, the general appearance of systemic illness is an indication for antibiotics, with quinolones and cephalosporins as first-line agents. Infections most commonly involve the urinary tract (25%-55%) or the respiratory tract (20%), or are related to SBP (10%-30%).³³ Hospitalization is suggested in case of poor general health status or the appearance of organ dysfunction.

When medical therapy and other interventions fail to control complications, transplantation is the only alternative. Primary care physicians can play a role here, too, in referring potential candidates for liver transplants to specialists for further consideration.

CASE 1: Resolution

As we’ve already seen, John M.’s ultrasound revealed an enlarged liver. The results led to a probable diagnosis of an advanced form of NASH. Other lab tests indicated that he had poorly controlled diabetes, high triglyceride levels, and—for the first time—a low platelet count. His physician stressed the importance of following a low-calorie, low-carbohydrate diet and exercising regularly, prescribed insulin, and referred the patient to a hepatologist for further noninvasive evaluation of fibrosis and to determine whether liver biopsy was needed.

CASE 2: Resolution

Blood tests revealed that Anna B. had a low platelet count (64,000/mm³), elevated liver enzymes (AST 2× upper limit of normal [ULN], ALT 1.5× ULN, GGT 2.5× ULN), and high gamma-globulins (33.6%) with no monoclonal bands. Ultrasound revealed an enlarged liver with diffuse echostructural dyshomogeneity, portal vein dilatation, and moderate ascites. She also tested positive for HCV and had an HCV-RNA reading of 15×10⁶ IU/mL. No other cause of chronic liver disease emerged. Ms. B.’s physician told her that she had an osteoporotic vertebral fracture—a frequent comorbidity in patients with liver cirrhosis—and decompensated liver cirrhosis from an old HCV infection. He added that her abdomen was distended because of fluid retention. The physician recommended bed rest, prescribed paracetamol (1 g tid) and spironolactone (100 mg/d), and referred the patient to an orthopedist for treatment of the fracture and to a hepatologist to be evaluated for transplantation.

CORRESPONDENCE
Ignazio Grattagliano, MD, Department of Internal Medicine, University Medical School of Bari, P.zza G. Cesare, 11 – 70124, Bari, Italy; i.grattagliano@semeiotica.uniba.it