Acute liver disease

Acute liver damage occurs for one of three reasons:

Investigation

Biochemical markers of liver disease such as AST and ALT will indicate hepatocyte damage. Elevated serum bilirubin and alkaline phosphatase levels show the presence of cholestasis. Disease progression or recovery can be followed by serial measurements of LFTs.

Outcome

Acute liver damage can progress in three ways:

Chronic liver disease

Three forms of chronic liver damage are:

All of these conditions may progress to cirrhosis, a disease characterized by extensive liver fibrosis. Fibrosis is the formation of scar tissue, resulting in the disorganization of liver architecture and its shrinkage. (Fig 30.3).

Aetiology

Cirrhosis is the terminal stage of chronic liver damage and only occasionally follows an acute course. The most common causes of cirrhosis are:

Cirrhosis is not reversible, although in alcoholics the preceding stage, that of chronic fatty liver, does respond to abstention from alcohol. For reasons that are not clear, only about 30% of alcoholics progress to cirrhosis.

Clinical features

There are no good biochemical indicators of cirrhosis in the early and stable period, which may last for many years. In the terminal stages the features include:

However, the cirrhotic liver has a reserve of function despite its macro- and microscopic appearance. The major complaint in cirrhosis may be difficulty in coping with food, especially fatty meals. Patients with cirrhosis have a reduced capacity to metabolize drugs. Some patients with cirrhosis suffer badly from itch, due to the disruption of the biliary architecture and subsequent failure to excrete bile acids, which accumulate in the skin. The immunological response of patients with cirrhosis may well be reduced, leading to increased susceptibility to infection.

Unusual causes of cirrhosis

Cirrhosis can develop in children as a result of α₁-antitrypsin deficiency or Wilson’s disease, and in adults due to haemochromatosis. α₁-antitrypsin deficiency can be detected in newborn infants in whom there may be a prolonged period of jaundice for several weeks. In some cases this progresses to juvenile cirrhosis. Haemochromatosis is a disorder of iron absorption, associated with deposition of iron in the hepatocytes and other tissues, which can lead to liver failure. The diagnosis is by measurement of serum iron, transferrin and ferritin (p. 115). Wilson’s disease is an inherited disorder of copper metabolism that leads to failure in copper excretion, low concentrations of caeruloplasmin, and deposition of copper in the liver and other tissues (p. 117). Cirrhosis may also occur following chronic ingestion of pyrrolizidine alkaloids, such as are found in some herbal teas.

Other liver problems

The liver is a common site of secondary metastases from a wide variety of primary tumours, and jaundice may be the first indication of the presence of cancer in some patients.

Primary hepatoma is associated with a number of conditions such as cirrhosis or hepatitis, although a number of causative carcinogens, such as aflatoxins generated by specific fungi infecting foodstuffs, have been identified. Alpha-fetoprotein is a useful marker of primary hepatic tumours (pp. 140–141).