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Chronic liver disease

Clinical Discipline(s)/Organ System(s)
Digestive System, Gastroenterology & Hepatology, Anaesthesiology, General Surgery
Progress Test Topic(s)
Digestive
Description
A 45 year old NZ European man presents to the General Medical Clinic after being told he has abnormal blood tests. He has been feeling 'run-down' for some time. He thinks he has lost some weight and his friends remark that he is 'yellow'. Recently his legs and abdomen have become swollen and he seems to bruise easily.
Applied Science for Medicine 
   - Anatomy of the liver and biliary tree; include microscopic detail of lobules
   - Production and excretion of bilirubin
   - Pathophysiology of ascites and portal hypertension
   - Histopathology of hepatitis and cirrhosis
   - Mode of action and metabolism of ethanol
   - Microbiology of the hepatitis viruses, especially hepatitis B and C viruses
   - Mechanisms controlling haemostasis: platelets and coagulation factors
Clinical and Communication Skills 
   - History from a jaundiced patient, including information relevant to risk factors and complications of liver disease
   - Elicit a detailed drug and alcohol history in a sensitive and non-judgemental manner
   - Apply criteria for assessing withdrawal from alcohol e.g. CIWA-Ar (Clinical Institute Withdrawal Assessement for Alcohol)
   - Perform examination the abdomen; examine for shifting dullness and recognise signs of chronic liver disease
   - Perform ascitic tap
   - Differential diagnosis of chronic liver disease
   - Indications for abdominal ultrasound, CT abdomen, endoscopy, fibroscan, liver biopsy
   - Interpret liver function tests, albumin, coagulation screen, hepatitis serology, ascitic fluid pathology report
   - Grade the severity of chronic liver disease using recognised scoring systems
   - Complications of acute and chronic liver disease
   - Management of reversible liver disease, non-alcoholic fatty liver disease
   - Indications for referral for liver transplantation if required
   - Prognosis of chronic liver disease
   - Prescribing for patients with impaired liver function
   - Roles of liver disease specialist nurse, dietitian, alcohol cessation counsellor
   - Provide lifestyle advice including alcohol cessation
Personal and Professional Skills 
   - Self-care: ensure relevant vaccinations are up-to-date and demonstrate personal safety regarding prevention of needle-stick injury
Hauora Māori 
   - Cater for differential health literacy needs of Māori patients and whānau
   - Appropriate engagement and consultation with whānau
   - Awareness of differing risk profiles for Māori (and other disadvantaged populations) compared with non-Māori in New Zealand with regard to viral and cancer causes for jaundice
   - Understanding of inequities in liver-related health outcomes for Māori compared with non-Māori, and application of this to clinical decision making and management
Population Health 
   - Epidemiology of liver disease
   - New Zealand hepatitis B vaccination guidelines
   - Prevention of the spread of infectious diseases
   - Screening for hepatocellular carcinoma
Conditions to be considered relating to this scenario
Common
alcoholic liver disease, non-alcoholic fatty liver disease, chronic hepatitis B and C, drugs (including non-prescription medications), hepatic congestion, acute hepatitis virus A-E, cytomegalovirus, Epstein-Barr virus (EBV)
Less common but 'important not to miss'
hepatocellular carcinoma
Uncommon
Wilson's disease, alpha-1-antitrypsin deficiency, haemochromatosis, primary biliary cirrhosis, primary sclerosing cholangitis, autoimmune hepatitis, hepatotoxins including aspergillus flavum