Chronic Liver Disease

Introduction 
Chronic liver disease refers to the disease progression that persists for more than six months. The disease begins when your liver gets affected due to an infection, alcohol intake, or other causes. If those factors persist, they continue to damage your liver tissues, leading to scarring or fibrosis. This stage is called cirrhosis, and it is irreversible in most cases. Cirrhosis may further progress towards liver cancer or liver failure if treatment measures are not utilised. Some cases can progress toward liver failure without going through the stage of cirrhosis. 
Viruses, parasites, chemicals, drugs, metabolic products, toxins, autoimmune diseases, and malformations are some of the agents and events that cause chronic liver disease. Correcting the underlying disorder, preventing further damage, giving symptomatic relief, and providing palliative care and support are all part of managing chronic liver disease.
 

Causes
Chronic liver disease can happen due to different causes. One of the common causes is hepatitis B and C viruses. If the virus stays for more than 6 months, it can lead to a chronic infection of the liver. Alcohol is another major cause of chronic liver disease. People who are alcohol addicts or have frequently been drinking for a long time can develop this chronic condition. In severe cases, it can also cause alcoholic fatty liver disease, which may progress to cirrhosis. Some people may develop fatty liver disease even though they do not drink alcohol. It is known as non-alcoholic fatty liver disease, and it is thought to occur due to obesity, diabetes, high level of triglycerides in the blood, or metabolic syndrome. 
Certain medications may also contribute to chronic liver disease, including amiodarone, tamoxifen, nitrofurantoin, methotrexate, etc. Damage or blockage of the bile ducts (tubes that deliver bile from the liver to the digestive tract) can also cause chronic liver disease. This can occur due to primary biliary cholangitis, primary sclerosing cholangitis, biliary atresia, or direct bile duct blockage. Some other causes of chronic liver disease include Wilson’s disease, hemochromatosis, autoimmune hepatitis, and congestive heart failure. 
 

Risk Factors and Epidemiology
The risk of chronic liver disease is high in those who get infected by hepatitis B or C virus. Adults can contract this virus if they have unprotected sex with an infected person. A man having intercourse with other men or having sex with multiple partners also increases the risk. Sharing contaminated needles or blades, especially among drug abusers, is another risk factor.
Long-term alcoholics also have a high risk of developing chronic liver disease. Obesity and diabetes are among other risk factors because they can contribute to the development of non-alcoholic fatty liver disease. Those with a family history of genetic disorders that cause chronic liver disease are also at high risk of developing this condition.
In Pakistan, the incidence of chronic liver disease is high due to hepatitis B, C, and non-alcoholic fatty liver disease. It can affect people of any age, but elders over the age of 50 are more commonly affected. Based on the underlying causes, chronic liver disease is more predominant among males than females.
 

Signs and Symptoms
The signs and symptoms of chronic liver disease progress in certain stages. Some people may remain asymptomatic throughout its course until extensive damage has been done. The symptoms may also vary depending on the cause. In majority of the cases, you may experience mild symptoms in the early stages, including nausea/vomiting, loss of appetite, fatigue, fever, generalized weakness, or unexplained weight loss. As the disease continues to progress, the normal functioning of your liver declines. This can lead to severe signs and symptoms, which may include abdominal pain, jaundice, persistent itching, light-colored stools, dark urine, fluid buildup in your feet and around the abdomen, breast enlargement in males, change in hair distribution patterns, spider-like vessels on your skin, redness in palms, confusion, memory loss or difficulty in performing cognitive tasks. 
 

Diagnosis
Chronic liver disease may remain undiagnosed for a long time as it does not present with any signs or symptoms in the early years. If you do develop symptoms, your doctor will require a detailed history followed by a physical examination. Both history and physical examination can help understand the possible cause of the disease. 
The conformational diagnosis of chronic liver disease is made based on multiple tests. These can include complete blood count (CBC), liver function tests (LFTs), INR, hepatitis tests, renal function tests (RFTs), and other suitable tests according to the suspected cause. Imaging tests are also done to visualize the extent of this disease. These can include CT scans, abdominal ultrasounds, and MRI. Transient elastography can be done to measure the stiffness of the liver. Endoscopic tests are required if damage to the bile duct or portal hypertension is suspected. A liver biopsy can be done if there is a risk of liver cancer. 
 

Differential Diagnosis    
Chronic liver disease can occur due to many different underlying causes, making it difficult to differentiate the original cause. Differentiation should be done on the basis of history, physical examination, and diagnostic tests. Some other diseases can have symptoms that are similar to chronic liver disease such as:
•    Cystic diseases of the liver
•    Glycogen Storage diseases
•    Tuberculosis of liver
•    Tropical liver
•    Bacterial or amoebic liver abscess
•    Trematode or other parasitic diseases.
 

Treatment 
Treatment of chronic liver disease depends on the cause and severity of your condition. Chronic alcoholics are recommended for the treatment of alcohol addiction. Those with hepatitis B or C are given medications and suitable guidelines to limit the extent of liver damage. People with fatty liver disease are suggested to lose weight and maintain a healthy diet to reduce the stress on their liver. Those with genetic conditions are treated based on the underlying cause. If the liver damage has exceeded beyond compensation and cannot function on its own, a liver transplant will be the last option for this condition.
 

Medication 
Medications are given according to the underlying cause of chronic liver disease. Those with hepatitis B or C are given antivirals and interferon, which can halt the disease progression to some extent. In many cases, supportive medications are given to reduce symptoms such as pain, swelling, itching etc.
Complications 
•    Ascites (Fluid accumulation in the abdomen)
•    Portal Hypertension (increased pressure in liver blood supply)
•    Coagulopathy (Bleeding and clotting problems)
•    Hepatorenal syndrome (Kidney damage)
•    Hepatic Encephalpathy  (Brain damage) 
•    Hepatocellular Carcinoma (Liver Cancer)

Prognosis
The prognosis of a patient with chronic liver disease depends on the underlying cause and severity of the disease. Chronic liver disease due to chronic alcoholism has a worse prognosis than hepatitis and other causes. Lack of proper treatment can increase the risk of future complications and mortality.
 

Prevention
Prevention can be achieved by avoiding its common causes to the best possible extent. Get hepatitis vaccinations and avoid unprotected sex or sharing needles with other people. Reduce alcohol consumption, especially if you are at high risk of liver disease. Eat a balanced diet, exercise regularly, and maintain a healthy weight to reduce the stress on your liver.