chronic liver disease

Chronic liver disease results from sustained hepatocyte injury causing chronic inflammation, stellate cell activation, and progressive fibrosis that can culminate in cirrhosis. Etiologies include: viral (Hepatitis B and C), alcoholic liver disease, non-alcoholic fatty liver disease/steatohepatitis (associated with metabolic syndrome), autoimmune hepatitis, primary biliary cholangitis, primary sclerosing cholangitis, hemochromatosis, Wilson disease, alpha-1 antitrypsin deficiency, and drug-induced liver injury. Pathophysiologically, repeated hepatocyte necrosis/apoptosis triggers activation of hepatic stellate cells, which transdifferentiate into myofibroblasts producing excess extracellular matrix (collagen), leading to fibrosis and eventually cirrhosis with nodular regeneration. This disrupts normal hepatic architecture, impairing synthetic function (albumin, clotting factors) and detoxification (ammonia, bilirubin metabolism) and causing portal hypertension. Clinical manifestations include jaundice, ascites, spider angiomata, palmar erythema, gynecomastia, testicular atrophy, caput medusae, asterixis, hepatic encephalopathy, coagulopathy (elevated INR due to decreased factor synthesis), and hypoalbuminemia. Complications include variceal bleeding (esophageal/gastric varices), spontaneous bacterial peritonitis, hepatorenal syndrome, hepatopulmonary syndrome, and hepatocellular carcinoma (especially with HBV, HCV, hemochromatosis, cirrhosis of any cause). Diagnostic workup includes liver function tests (AST, ALT, ALP, bilirubin), synthetic function tests (albumin, PT/INR), imaging (ultrasound with Doppler, FibroScan, CT/MRI), and liver biopsy for staging fibrosis. Child-Pugh and MELD scores are used to assess severity and prognosis, guiding transplant listing. Management focuses on treating the underlying cause (antivirals for hepatitis, alcohol cessation, weight loss for NAFLD), managing complications (diuretics/paracentesis for ascites, beta-blockers/banding for varices, lactulose/rifaximin for encephalopathy), and liver transplantation for end-stage disease.