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Chronic Liver Failure

Chronic Liver Failure (CLF) is a disease process of the liver that involves progressive destruction and regeneration of the liver parenchyma leading to fibrosis and cirrhosis. Venous flow into the liver decreases due to this, leading to elevated portal pressures. Portal hypertension then leads to splenomegaly, causing anaemia and thrombocytopenia. Ascites, hepatorenal syndrome, hepatopulmonary syndrome, variceal bleeding and hepatic encephalopathy are all recognised complications.

Cirrhotic patients may have stable liver functions for long periods of time, and an acute insult in the presence of advanced fibrosis and decreased functional reserve may lead to development of hepatic decompensation. These patients may develop decompensation in two ways:

  • The most common is a progressive decompensation resulting in a clinical course of end-stage liver disease.

  • Acute liver decompensation resulting from a precipitating event such as variceal bleeding or sepsis.

You may also want to view the Acute Liver Failure clinical tool.

Aetiology

  • Alcohol

  • Hepatitis B/C

  • NASH (non alcoholic steatosis)

  • Autoimmune hepatitis, Primary sclerosing cholangitis, Primary biliary cirrhosis

  • Right heart failure, CCF

  • Drugs e.g. Amiodarone

  • Metabolic / genetic e.g. Wilsons, Haemachromatosis.

History – remember to ask about

  • Medications patient taking and degree of compliance

  • Previous endoscopy and presence of varices

  • Anorexia, weight loss, pruritus, fever, abdo pain, shortness of breath etc.

Examination – Signs

  • Vital signs – pulse may be low due to B blockers (for varices), BP may be low due to bleeding / dehydration / sepsis, sats may be low due to pleural effusions / splinting of diaphragm / encephalopathy and drowsiness

  • Encephalopathy

  • Jaundice

  • Hepatomegaly – may be tender

  • Splenomegaly

  • Ascites

  • Peripheral oedema

  • Spider naevi

  • Bruising

  • Liver flap

  • Gynaecomastia.

Further References and Resources

1. Galvin R. et al. (2010) EFNS guidelines for diagnosis, therapy and prevention of Wernicke encephalopathy, European Journal of Neurology, vol 17, no. 12, pp. 1408-1418.

2. Moore, KP. and Aithul, GP. (2006) Guidelines on the Management of ascites in cirrhosis, Gut Journal, vol. 55, suppl 6, vi1-vi12.3. 

3. Mandorfer M et al. (2014) Nonselective B blockers increase risk for hepatorenal syndrome and death in patients with cirrhosis and spontaneous bacterial peritonitis, Gastroenterology Journal, vol. 146, no. 7, pp. 1680-1689. 

4. O’Shea, R., Darasathy, S., McCullough, A. (2010) AASLD Practice Guidelines: Alcoholic Liver Disease, Hepatology Journal, vol. 51, no. 1, pp. 307-328.

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