LIVER DISEASE

HEPATITIS

The hepatitis viruses (HPV) A, B, C, D and E cause acute hepatitis. HPVB and, particularly, HPVC, can cause chronic infection that can lead to cirrhosis, liver failure, and liver cancer. All types of viral hepatitis are notifiable diseases in UK. Practices will have a policy for vaccinations against hepatitis A and B. Acute infection may present with:

• nausea and vomiting
• myalgia
• fatigue/malaise
• right upper quadrant pain
• change in sense of smell or taste
• coryza
• photophobia
• headache.

Diarrhoea (with pale stools) and dark urine may also be present. However, often no signs unless jaundice develops, when hepatomegaly, splenomegaly and lymphadenopathy may occur. Hepatitis A Previously a common childhood infection in the UK but now unusual. May occur in outbreaks in institutions, and is common in travellers. Infection confers immunity. Spread normally by the faecal-oral route (ingestion of food or drink contaminated by infected stool) but occasionally through blood. Usually self-limiting (rarely fulminant); there is no carrier state, and chronic liver disease does not occur. HPVA vaccine can protect people at high risk, eg, those who have been in contact with an infected person, travellers to countries where the infection is common, and injecting drug users. Hepatitis B Early symptoms flu-like; infection can lead to liver disease and liver cancer. HPVB is 10-100 times more infectious than HIV. Transmitted by contact with infected blood or body fluids, e.g. by:

• sharing or use of contaminated equipment during injecting drug use
• vertical transmission (mother to baby) from an infectious mother to her unborn child
• sexual transmission
• receipt of infectious blood (via transfusion) or infectious blood products (e.g. clotting factors)
• needlestick or other sharps injuries (in particular those sustained by healthcare workers)
• tattooing and body piercing.

HPVB vaccination:

• should be given to all individuals at risk, including health professionals.
• is usually provided free (on the NHS) to people in a high-risk group.
• is not free if requested for travel abroad.

GPs are not obliged to offer HPVB vaccine free for occupational purposes; if it is required, many employers will offer to pay. Hepatitis C Often asymptomatic initially; 15-20% clear their infection within 2-6 months. Of those with chronic infection, some remain well but many develop mild to moderate liver damage (with or without symptoms); of these, 20% progress to cirrhosis over 20–30 years. Excessive alcohol consumption increases risk of severe liver complications. HPVC blood borne and most often acquired through injecting drug use; also by sharing razors or toothbrushes or during body piercing (eg, tattooing, acupuncture) with non-sterile needles. Was also spread by blood transfusions before September 1992, when screening for hepatitis C was brought in. There is no vaccine. Increasingly effective drug treatment (not suitable for everyone, lasts 6 or 12 months) can clear the virus in c. 50%. Around 100,000 people in England are thought to have undiagnosed HPVC; DH runs awareness campaigns to promote diagnosis and treatment. Hepatitis D An important cause of acute and severe chronic liver damage in some parts of the world (Mediterranean, parts of Eastern Europe, Middle East, Africa, and South America). Occurs only in people infected with HPVB. Hepatitis E Uncommon in the UK, but common in Asia, Africa and Central America, particularly where sanitation is poor. Disease is usually mild but rarely can be fatal, particularly in pregnant women. Transmission and clinical features similar to HPVA. See also Travel health, Sexual health

ALCOHOL-RELATED LIVER DISEASE (ARLD)

Liver damage caused by prolonged alcohol misuse. Does not usually cause symptoms until the liver has been severely damaged, and diagnosis is often incidental. ARLD is widespread in the UK and the number of people diagnosed with the condition has increased over recent years because of increasing levels of alcohol misuse. There are three stages of disease:

Alcoholic fatty liver. Drinking large amounts of alcohol, even in the short term, can lead to a build up of fat in the liver. Reversible by abstaining from alcohol, often for as little as two weeks.

Alcoholic hepatitis not related to infectious hepatitis, inflammation of the liver as a result of longer term alcohol misuse; less commonly, from binge drinking.

Cirrhosis is the final stage of ARLD, when the liver becomes significantly scarred. Not usually reversible, but stopping drinking can prevent further deterioration.

Complications include variceal bleeding, encephalopathy, ascites, kidney failure and liver cancer.

NICE CG100. Alcohol-use disorders: diagnosis and management of physical complications; 2010 (Updated 2017. Update in development) https://www.nice.org.uk/guidance/cg100  

NON-ALCOHOLIC FATTY LIVER DISEASE (NAFLD)

Accumulation in the liver of triglycerides, the most common fats in the body, associated with obesity. Often noted incidentally on ultrasound examination. Patients usually asymptomatic, and NAFLD usually causes no harm. But for increasing numbers, NAFLD over a long period leads to inflammation (hepatitis) and scarring (fibrosis), which may progress to life-threatening cirrhosis.