What is the approach to a patient with liver disease?

Approach to the Patient with Liver Disease

The management of patients with liver disease requires a systematic approach that prioritizes early identification of disease etiology, assessment of disease severity, and implementation of appropriate therapeutic interventions to reduce morbidity and mortality.

Initial Assessment and Risk Stratification

History and Physical Examination Focus

• Risk factors: Alcohol use (quantify using AUDIT-C), viral hepatitis exposure, metabolic syndrome components, medications/supplements, family history
• Symptoms: Fatigue, jaundice, pruritus, abdominal distention, mental status changes, GI bleeding
• Physical findings: Spider nevi, palmar erythema, jaundice, ascites, hepatomegaly, splenomegaly, encephalopathy

Laboratory Evaluation

1. Basic liver panel:

   • Transaminases (AST, ALT)
   • Alkaline phosphatase, GGT
   • Bilirubin (total and direct)
   • Albumin
   • Prothrombin time/INR

2. Complete blood count:

   • Platelet count <160 × 10³/μL strongly suggests cirrhosis (LR 6.3) 1

3. Etiology-specific testing:

   • Viral hepatitis serologies (HBV, HCV)
   • Autoimmune markers (ANA, ASMA, immunoglobulins)
   • Iron studies, ceruloplasmin, alpha-1 antitrypsin
   • Drug and alcohol screening

Non-invasive Fibrosis Assessment

• Calculate fibrosis scores:
  • FIB-4 or NAFLD Fibrosis Score for NAFLD 2
  • MELD score for prognosis in advanced disease 2
  • Child-Turcotte-Pugh (CTP) score for cirrhosis severity 2

Diagnostic Approach Based on Pattern of Liver Test Abnormalities

Hepatocellular Pattern (↑↑ AST/ALT, ↑ ALP)

• Consider: Viral hepatitis, NAFLD, alcohol-related liver disease, autoimmune hepatitis, drug-induced liver injury
• Next steps: Viral serologies, autoimmune markers, ultrasound

Cholestatic Pattern (↑↑ ALP, ↑ AST/ALT)

• Consider: Biliary obstruction, primary biliary cholangitis, primary sclerosing cholangitis, drug-induced cholestasis
• Next steps: Ultrasound to assess for biliary dilatation, MRCP if intrahepatic cholestasis suspected

Mixed Pattern

• Consider: Drug-induced liver injury, alcoholic hepatitis with cholestasis, infiltrative diseases
• Next steps: Detailed medication review, ultrasound, consider liver biopsy

Liver Biopsy Indications

Liver biopsy should be considered when 2:

1. Diagnosis remains unclear after non-invasive testing
2. Multiple potential etiologies exist
3. Assessment of disease severity will guide treatment decisions
4. Suspected infiltrative or malignant disease

Management of Specific Complications

Hepatic Encephalopathy

1. Identify and treat precipitating factors: Infections, GI bleeding, electrolyte disturbances, medications, constipation 2, 3
2. First-line treatment: Lactulose 25-30 mL orally every 12 hours, adjusted to achieve 2-3 soft stools daily 3
3. Add-on therapy: Rifaximin 550 mg twice daily if lactulose alone fails 3
4. Nutritional support: Maintain protein intake 1.2-1.5 g/kg/day with small, frequent meals 3
5. Severe encephalopathy (Grade III-IV): ICU admission, airway protection if GCS <7 3

Ascites

1. First-line: Sodium restriction (<2 g/day) and combination diuretic therapy (spironolactone + furosemide) 4
2. Refractory ascites: Large volume paracentesis with albumin, consider TIPS evaluation
3. Spontaneous bacterial peritonitis prophylaxis: For patients with ascitic fluid protein <1.5 g/dL

Portal Hypertension and Variceal Bleeding

1. Primary prophylaxis: Non-selective beta-blockers (carvedilol or propranolol) for patients with high-risk varices 4
2. Acute bleeding: Vasoactive drugs (terlipressin, octreotide), endoscopic band ligation, antibiotics

Hepatorenal Syndrome

1. Type 1 HRS: Expedited referral for liver transplantation 2
2. Medical management: Terlipressin (improves reversal rate from 18% to 39%) 4
3. Supportive care: Albumin, careful fluid management, avoid nephrotoxins

Transplant Evaluation

Refer patients for transplant evaluation when 2:

• CTP score >7 or MELD score >10
• First major complication (ascites, variceal bleeding, encephalopathy)
• Type 1 hepatorenal syndrome

Transplant evaluation includes 2:

1. Cardiopulmonary assessment
2. Laboratory confirmation of etiology and severity
3. Creatinine clearance
4. Viral serologies (HBV, HCV, EBV, CMV, HIV)
5. Abdominal imaging for vascular anatomy and HCC screening

Surveillance in Chronic Liver Disease

1. Hepatocellular carcinoma screening:

   • Ultrasound ± AFP every 6 months in cirrhotic patients 2

2. Varices surveillance:

   • Endoscopy every 1-3 years based on initial findings and disease progression

3. Fibrosis reassessment:

   • Repeat non-invasive fibrosis assessment every 3 years in NAFLD patients 2
   • More frequent monitoring for those with risk factors for progression

Prevention Strategies

1. Disease-specific interventions:

   • HBV vaccination
   • Antiviral therapy for HBV/HCV
   • Weight loss and metabolic control for NAFLD
   • Alcohol cessation

2. General measures:

   • Avoid hepatotoxic medications
   • Cardiovascular risk reduction
   • Immunizations (HAV, HBV, pneumococcal, influenza)

By systematically addressing these aspects of liver disease management, clinicians can optimize outcomes and reduce complications in patients with liver disease.