Chronic liver disease

Chronic liver disease is the progressive deterioration of liver function over a period of more than 6 months (Sharma and Nagalli, 2022). It is characterised by a continuous process of inflammation, destruction and regeneration of the parenchyma of the liver, which gives rise to fibrosis and cirrhosis (scarring of liver from long-term damage) (Office for Health Improvement and Disparities, 2022).

In 2022, there were 82 290 hospital admission with chronic liver disease in England (Office for Health Improvement and Disparities, 2023); chronic liver disease is estimated to affect around 1.5 billion people worldwide (Moon et al, 2020). There has been a steady reduction in the infective causes of chronic liver disease (hepatitis B and C) as a result of vaccination and other preventative strategies. However, there has been an increase in cases of chronic liver disease resulting from alcohol and drug use and metabolic syndrome (often related to obesity) in

The early signs and symptoms of chronic liver disease are general and may be mistaken for a number of other illnesses. These include:

• general fatigue
• feeling unwell
• anorexia
• nausea and vomiting
• disturbed sleep
• spider angiomas (vascular lesion above waist level) (Newton and Jones, 2012)

Many patients with chronic liver disease will also develop portal hypertension, which is the result of increased intrahepatic vascular resistance and hyperdynamic circulatory state (abnormal increase in circulatory volume) (Gunarathne et al, 2020). This can cause ascites, and gastro-oesophageal varices, which often bleed (Berzigotti, 2017), as well as hepatic encephalopathy and, in some cases, can prove fatal (Geraghty, 2023).  

Further signs and symptoms of chronic liver disease emerge if the underlying disease progresses. These include:

• jaundice
• malnutrition
• sepsis (Shingina and Larson, 2021; Office for Health Improvement and Disparities, 2022)

In end-stage liver disease, people with chronic liver disease can present with a variety of other

There are over 100 different known causes of chronic liver disease.  In Europe, the primary cause of chronic liver disease and cirrhosis is alcohol consumption (Blachier et al, 2013). European countries with low levels of alcohol consumption have seen dramatic increases in chronic liver disease associated with obesity (Pimpin et al, 2018).

In the UK, lifestyle accounts for about 90% of liver disease-related deaths, with the vast majority of these being caused by alcohol consumption (Office for Health Improvement and Disparities, 2022).

The most common causes of liver disease include:

• alcohol-related liver disease – a spectrum of disease including fatty liver, hepatitis and cirrhosis. The major cause of which is chronic excessive alcohol use
• non-alcoholic fatty liver disease (NAFLD) – caused by a metabolic syndrome including obesity, hyperlipidaemia and diabetes
• viral hepatitis – including hepatitis B, C and D
• genetic diseases, including:
  • alpha-1 antitrypsin deficiency – a rare genetic condition which

The National Institute for Health and Care Excellence (NICE, 2023) identify that the prevalence of liver disease is high among people who:

• have hepatitis B and/or C virus infection
• consume excess alcohol
• have obesity (with a body mass index of 30 kg/m² or higher)
• have type 2 diabetes

The suspicion of liver disease should be higher in these groups than it might be for other members of the general population.

The diagnostic tests used to detect chronic liver disease and identify its causes are:

• Blood tests for liver function, as well as a full blood count, including:
  • Alanine aminotransferase and aspartate aminotransferase - leak out of damaged liver cells into the bloodstream. Alanine aminotransferase is liver specific, although raised levels of both indicate inflammation
  • Alkaline phosphatase and gamma-glutamyl transferase - simultaneous increase in levels suggest that the disease is obstructing the bile duct. Raised gamma-glutamyl transferase is also suggestive of the

The management of chronic liver disease depends on the cause and severity of the disease. When a person living with chronic liver disease is at a high risk of complications, their care should be managed in a specialist centre (NICE, 2023). Complications of chronic liver disease include:

• ascites
• oedema
• gastrointestinal bleeding
• encephalopathy
• infections
• pruritis
• osteoporosis (Fabrellas et al, 2020)

The latter two are common in people living with primary biliary cholangitis (Hirschfield et al, 2018).

As with many disease states, removing the cause is the best course of action for management. This could involve, for example, referring people to alcohol services and for the patient to stop drinking alcohol entirely (Newsome et al, 2018). 

People with compensated cirrhosis (ie without major complications) should have a model for end‑stage liver disease (MELD) score calculated every 6 months (NICE, 2023). This is an objective score used to predict mortality among people with

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