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Dr Andrew Yeoman (Chair), Consultant Hepatologist, Gwent Liver Unit, Royal Gwent Hospital, Newport

Why does this matter?

Liver disease is increasing in incidence and severity, such that deaths related to liver disease have risen more than four-fold in the last 50 years, in contrast to many other disease areas, where mortality is falling.1 The reason for this sharp rise is due to increases in the lifestyle risk factors for liver disease in the population, namely excess alcohol consumption, obesity, and acquisition of blood borne viruses.1 Importantly these risk factors are not just modifiable, such that the majority of liver disease is preventable, these same risk factors predispose to other, more high-profile disease states such as diabetes and heart disease.1 As such, the acknowledgement and management of these risk factors in primary care is essential to improving population liver health. The vast majority of morbidity and mortality in relation to liver disease is mitigated through the development of cirrhosis and its complications, which include hepatic encephalopathy (HE).1

Currently, the majority of patients with cirrhosis are diagnosed late, often as a result of an admission to hospital with decompensation.1 This is typically due to a lack of symptoms in early liver disease coupled with historic misconceptions that minor abnormalities of liver blood tests are unlikely to be associated with significant disease. 

Once again, the early recognition of serious liver disease is something that can only be tackled in the primary care arena through the understanding that an assessment of liver fibrosis is essential. This approach is now supported by NICE in its guideline on the recognition and management of cirrhosis2 and the British Society of Gastroenterology guideline on the Management of Abnormal Liver Blood Tests.3 Several different approaches to a more assertive approach to the earlier recognition of significant liver disease in the general population have now been published and shown to be more efficient than traditional models of care.4,5

What makes HE so important?

HE is common in patients with cirrhosis, occurring in approximately 44% of patients during follow up of 5 years or more.6 Despite it affecting almost 1 in 2 people with cirrhosis during their lifetime, HE remains under recognised because it may be extremely subtle, it may fluctuate without treatment, and finally, there is no gold standard diagnostic test for it. Therefore, a high index of suspicion is required to look for, and diagnose, HE.6

Despite these challenges it remains critical to detect HE as it represents a severe manifestation of liver disease and is associated with poor outcomes.6 The development of persistent HE should, therefore, lead to the consideration of referral for liver transplantation, such are its negative associations. Recognition of all forms of HE, including low grade, remains extremely important as therapies exist that can improve cognitive and physical function, and prevent hospital admissions.7

References

  1. Williams R et al. Addressing liver disease in the UK: A blueprint for attaining excellence in healthcare and reducing premature mortality from lifestyle issues of excess consumption of alcohol, obesity and viral hepatitis. Lancet 2014; 384 (9958): 1953–1997.
  2. NICE. Cirrhosis in over 16s: assessment and management. NICE Guideline 50. NICE, July 2016. Available at: www.nice.org.uk/ng50
  3. Newsome P et al. Guidelines on the management of abnormal liver blood tests. Gut 2018; 67 (1): 6–19.
  4. Srivastava A et al. Prospective evaluation of a primary care referral pathway for patients with non-alcoholic fatty liver disease. J Hepatol 2019; 71 (2): 371–378.
  5. Dillon J et al. Intelligent Liver Function Testing (iLFT): A trial of automated diagnosis and staging of liver disease in primary care. J Hepatol 2019; 71 (4): 699–706.
  6. Tapper E et al. A risk score to predict the development of hepatic encephalopathy in a population-based cohort of patients with cirrhosis. Hepatology 2018; 68 (4): 1498–1507.
  7. Clayton M, Aspinall R, Merriman H, O’Malley J. Management of hepatic encephalopathy in primary care. Chesham: MGP Ltd; August 2016 (last updated 2020).

 

 

This short article has been commissioned and funded by Norgine Pharmaceuticals Ltd and developed in partnership with Guidelines in Practice. Norgine Pharmaceuticals Ltd suggested the topic and author, and carried out full medical approval on all materials to ensure compliance with regulations. The sponsorship fee included an honorarium for the author. The views and opinions of the author/s are not necessarily those of Norgine Pharmaceuticals Ltd, or of Guidelines in Practice, its publisher, advisers, or advertisers. No part of this publication may be reproduced in any form without the permission of the publisher.

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Date of preparation: February 2020