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Chapter 5: Disorders of the liver 195

Inflammation of the portal tracts with spotty inflam- disease, galactosaemia, cystic fibrosis, Wilson’s disease
mation in the parenchyma of the lobules, but there is and drugs.
no liver cell necrosis.
Pathophysiology
Complications All the liver functions are impaired (bilirubin meta-
Cirrhosis is the most common complication. There is bolism, bile salt synthesis, specialised protein synthesis,
increased risk of hepatocellular carcinoma in patients detoxification of hormones, drugs and toxins). Impaired
with chronic viral hepatitis especially in hepatitis B. blood flow through sinusoids leads to an exacerbation of
the functional deficit and portal hypertension. Femini-
Investigations sation in males and amenorrhea in females are common
Chronic hepatitis is diagnosed by a combination of per- in alcoholic liver disease and haemochromatosis due to
sistently abnormal liver function tests and the findings alterations in the hypothalamic–pituitary–gonadal axis.
on liver biopsy. Other investigations are aimed at diag- Reduced immune competence and increased suscepti-
nosing the underlying cause and providing a prediction bility to infection also occur.
of prognosis including serum viral markers and autoan-
tibodies (e.g. antimitochondrial antibodies suggest pri- Clinical features
mary biliary cirrhosis). Patients may present with complications such as bleed-
ingfromoesophagealvaricesorencephalopathy.Patients
Management withactivechronichepatitismaypresentwithfeaturesof
Symptomatic management includes adequate nutri-
chronic liver disease before cirrhosis is established. Signs
tion and hydration. of chronic liver disease:
Specific treatments depend on the underlying cause,
1 General appearance: Jaundice, pigmented (haemo-
e.g. anti-viral treatment. chromatosis), pallor (anaemia), bruises (clotting ab-
Liver transplantation may be indicated.
normalities), petechiae (thrombocytopenia), scratch
marks (pruritus), spider naevi on trunk, muscle wast-
ing (malnutrition).
Cirrhosis 2 Hands: Leuconychia (if hypoalbuminaemic), club-
bing,palmarerythema,Dupuytren’scontracture,hep-
Definition
Cirrhosis is an irreversible change of the liver architec- atic flap (asterixis, sign of hepatic encephalopathy),
tremor may occur in alcoholism and Wilson’s disease.
ture,characterisedbynodulesofregeneratedlivercells
3 Abdomen: Dilated veins around the umbilicus, striae
separated by bands of fibrous scar tissue.
may result from abdominal distension. The liver is
usually enlarged, firm and irregular, but is shrunken
Aetiology
in late disease. The spleen may be enlarged due to
Cirrhosis results from continued hepatocellular necro-
portal hypertension. Ascites may be present.
sis and chronic inflammation. Fibrous scarring causes
disruption of the normal architecture, although regen-
eration of hepatocytes occurs between the fibrous tracts, Macroscopy
their function, which depends on intact architecture, is The liver is often enlarged and nodular, with a bosselated
impaired. surface. The cut surface shows nodules of liver tissue,
Alcohol accounts for more than 80% of cirrhosis in
separatedbyfineorcoarsefibrousstrands.Micronodular
the United Kingdom. cirrhosis consists of nodules less than 3 mm, if larger
Viralhepatitis due to hepatitis B and C is the most
nodules are seen it is termed macronodular cirrhosis.
common cause worldwide.
Other conditions include primary biliary cirrhosis Complications

(PBC), autoimmune hepatitis, nonalcoholic steato- Bleeding oesophageal varices secondary to portal hyper-
hepatitis (NASH), haemachromatosis, α 1 antitrypsin tension, hepatocellular carcinoma.