A 64-year-old woman presents with complaints of itchy skin and fatigue. She is noted on physical examination to have scleral icterus and jaundice (Figure 61-1). Laboratory testing revealed elevated liver enzymes, particularly the serum alkaline phosphatase and γ-glutamyltranspeptidase, and positive antinuclear and antimitochondrial antibodies. A liver biopsy confirmed primary biliary cirrhosis. Two months later, she vomited up some blood and on endoscopy was found to have esophageal varices from her portal hypertension (Figure 61-2).
Scleral icterus in a 64-year-old Hispanic woman with primary biliary cirrhosis. (Courtesy of Javid Ghandehari, MD.)
Esophageal varices in the patient in Figure 61-1 secondary to her cirrhosis and portal hypertension. (Courtesy of Javid Ghandehari, MD.)
Liver disease can be caused by any number of metabolic, toxic, microbial, circulatory, or neoplastic insults resulting in direct liver injury or from obstruction of bile flow or both. Liver injury falls anywhere on the spectrum from transient abnormalities in biomarkers to life-threatening multiorgan failure.
The following terms refer to various types of liver diseases: hepatic failure, hepatic dysfunction, alcoholic hepatitis, viral hepatitis, cirrhosis, hepatocellular disease, cholestatic disease, liver fibrosis.
Common causes of liver disease include:
- Nonalcoholic fatty liver disease (NAFLD)—Present in 10% to 30% of adults in the general population; now the most common cause of chronic liver disease in Western countries.1 NAFLD is believed responsible for 90% of cases of elevated liver enzymes without an identifiable cause (e.g., viral hepatitis, alcohol, genetic, medications).2
- Alcohol, excessive use—Approximately 5% of the population are at risk; this includes women who drink more than two drinks per day and men who drink more than three drinks per day.3
- Drug-induced liver disease:4
- Drugs causing hepatitis include phenytoin, captopril, enalapril, isoniazid, amitriptyline, and ibuprofen.
- Drugs causing cholestasis include oral contraceptives, erythromycin, and nitrofurantoin.
- Drugs causing both of the above include azathioprine, carbamazepine, statins, nifedipine, verapamil, amoxicillin/clavulanic acid, and trimethoprim-sulfamethoxazole.
- Infectious disease—Viral hepatitis, infectious mononucleosis, Cytomegalovirus, and coxsackievirus are most common. Viral hepatitis infections include:
- Hepatitis A—Twenty-nine percent to 33% of patients have ever been infected with hepatitis A; there are no chronic infections.5 Incidence rates in recent years have declined with approximately 1987 cases reported and 9000 estimated in 2009.6
- Hepatitis B—Five percent to 10% of volunteer blood donors in the United States have evidence of prior infection, with 1% to 10% of those infected progressing to chronic hepatitis B virus (HBV) infection.5 Up to 1.4 million people have chronic hepatitis B.6
- Hepatitis C—In the United States, 1.8% of the general population have had hepatitis C, with 50% to 70% developing chronic hepatitis and 80% to 90% chronic infection.5 Nearly 3.9 million have chronic hepatitis C.6...