Clinical

Chronic management

Management of patients with Chronic Liver Diseases

Background

  • Liver disease is now the 5th commonest cause of death in the UK and one of the few developed nations with an upward trend in mortality from liver disease
  • Admissions to hospital and liver deaths are both rising at between 8 – 10% per year.
  • Patients are presenting and dying from liver disease at an earlier age, the average age of death from liver disease is 59 years of age, compared to 82 – 84 years for heart and lung disease or stroke
  • Patients with liver disease are presenting at an earlier age. Over the last 10 years there has been a 5 – fold increase in the development of cirrhosis in 35 to 55 year olds
  • And yet liver disease morbidity and mortality is largely preventable
  • At present liver disease accounts for 60% of inpatient gastroenterology activity and 25 – 30% of new outpatient referrals are related to liver disease, and yet only 15% of the total gastroenterology workforce are Hepatologists. Of this subgroup of consultants one third are concentrated in the 7 liver transplant units in the UK

Patient View

  • There is a stigma attached to liver disease
  • A general view that all liver disease is self induced and alcohol related
  • A lack of awareness and understanding within healthcare workers and healthcare professionals of liver disease

Current Practice

  • Care for chronic liver disease and the complications of cirrhosis is completely within hospital care
  • This includes ascites and monitoring of electrolytes, hepatic encephalopathy, variceal bleeding and hepatocellular carcinoma
  • Surveillance in patients with cirrhosis for hepatocellular carcinoma, portal hypertension and osteoporosis is within hospital care
  • Terminal care for patients with end – stage liver disease remains within hospital care with little palliative care available in hospice or community settings

Recommended Practice and Opportunities for Integrated Working

  • Commissioners should require that all new patients registered at a general practice should undergo health screening for liver disease. This should include;
    • Assess alcohol intake (AUDIT, an alcohol questionnaire)
    • Assess risk of viral hepatitis (race, travel, intravenous drug use, blood transfusion, family history)
    • Assess BMI, and presence of diabetes as risk factors for fatty liver disease
    • Measure liver function tests (ideally ALT and AST, gamma – GT) as part of screening
  • Commissioners should require that all patients with decompensated liver disease are seen by a specialist trained in the management of liver disease within 24 hours if not responding to outpatient treatment
  • Patients with stable, compensated cirrhosis can have their surveillance (Hepatocellular carcinoma, portal hypertension, enemas for hepatic encephalopathy, monitoring of electrolytes and LFTs) performed within primary care if the requisite expertise is present. In this setting there should be ready access to a specialist in secondary care trained in liver disease
  • Virtual clinics under guidance of liver specialist
  • Palliative care for patients with end stage liver disease not suitable for liver transplantation

Desirable changes in practice:

  • Patient held record and development of shared specialist records

Opportunities for Savings

  • Clear delineation of responsibilities between primary and secondary care to reduce duplication of activity (and improve care)
  • Reduced admissions to hospital
  • Reduced length of stay in hospital
  • Direction of care to specialist trained in liver disease who can assess patient, determine levels of care ie Appropriate use of ITU and renal replacement
  • Streamline referrals to outpatients
  • Reduce duplication of investigations

Quality Indicators (Outcomes)

  • Hospital admissions
  • Length of stay
  • 30 day and 90 day survival
  • Detection rate hepatocellular carcinoma
  • Screening for portal hypertension and institution of primary & secondary prophylaxis
  • Patients referred for liver transplant assessment

Social Policy & Understanding

  • Increased education and awareness about liver disease, its aetiologies and available treatments with health care professionals
  • Public health education by approved sources (government / charities) to advise patients and the general public about;
    • The nature of liver disease
    • Alcohol, the risks
    • Obesity
    • When to see their doctor
    • Lifestyle issues, benefit of diet and exercise
    • Viral hepatitis, who is at risk

Alcoholic liver disease

Alcohol is the main driver of the enormous rise in liver disease. Reducing Under 75 mortality from liver disease is identified as a key Improvement Area with regard to the Overarching Indicator of “Potential Years of Life Lost from causes considered amenable to healthcare”. Although liver disease is the most obvious pathological consequence of alcohol dependence, it is primarily a behavioural disorder and has impacts on multiple areas of health. In view of its broad and pre-eminent importance and the need for multidisciplinary team care the whole topic is dealt with in Section xxx. Important issues specific to alcoholic liver disease are:

  • Management of associated nutritional deficiencies, principally thiamine deficiency. NICE quality standards on the prevention of Wernicke’s encephalopathy and Korsakoff’s psychosis should be adopted
  • Management of alcoholic hepatitis: this specific clinical syndrome has a high mortality. Specific treatments are corticosteroids or pentoxyphylline. Whether they are effective and which treatment is best is not known and commissioners should encourage management within the STOPAH clinical trial

References