Chronic liver disease is a major cause of death in the United States and around the world. We have come to understand that alcohol is not the only cause of cirrhosis. In fact, chronic hepatitis C virus infection is the leading cause of cirrhosis in this country. A substantial portion of the U.S. population has nonalcoholic steatohepatitis, a condition associated with diabetes, obesity and insulin resistance.1 In a two-part article published in American Family Physician, Riley and Bhatti2,3 provide guidance for family physicians who are caring for patients with liver disease.
Gastroenterologists and hepatologists are often involved in making the diagnosis of chronic liver disease and arranging for specific therapy. However, family physicians are usually responsible for the day-to-day care of patients with chronic liver disease. They are often called on to treat these patients for conditions unrelated to the liver disease and to counsel them on measures that may maximize quality of life and prevent further disease progression.
Riley and Bhatti2,3 provide valuable guidance to family physicians. Much of their advice is evidence-based, while some is empiric, based on circumstantial evidence and reasonable assumptions. They emphasize that patients with chronic liver disease must abstain from alcohol use, even if their liver disease is not associated with alcohol. There is clear evidence that consuming even a few drinks a day exacerbates the progression of hepatic fibrosis in patients with chronic hepatitis C virus infection.4 Patients with chronic liver disease should also be vaccinated against hepatitis A and B if they are not immune or already infected with these viral agents.5
The use of drugs, minerals, herbs and vitamins is much more problematic. Many patients insist on taking herbal supplements or remedies. Most of these remedies are benign, although it is not clear that they offer any real benefit.6 Patients must be informed that some herbal medicines can cause liver disease, and Riley and Bhatti2 list various potential hepatotoxins.
Many prescription medicines are also potentially hepatotoxic, but evidence that their use in patients with chronic liver disease increases the risk of toxicity or the need for increased monitoring is lacking. Similarly, we cannot make recommendations regarding iron use. Iron overload may lead to liver disease and, in patients with chronic hepatitis C virus infection, iron depletion by phlebotomy results in transient improvement of liver injury.7 Beyond these observations, however, we currently have no evidence to recommend that patients with chronic liver disease restrict iron intake.
Riley and Bhatti's recommendations for patients with advanced liver disease are firmly grounded.3 All patients with cirrhosis should undergo endoscopy to determine if they have varices; noncardioselective beta blockers have been clearly proved to decrease the risk of bleeding from esophageal varices.8 Patients with cirrhosis should also be screened for hepatocellular carcinoma on a regular basis and should avoid excessive salt in their diet.
In patients with chronic liver disease, nonsteroidal anti-inflammatory drugs should be used with caution, if at all, because these drugs may worsen sodium retention or precipitate renal failure. Patients who have had spontaneous bacterial peritonitis are at great risk for further infections and should receive prophylactic antibiotics.9 Riley and Bhatti3 also provide sound recommendations on referral for liver transplantation.
When patients with chronic liver disease ask what they can do to improve their condition, family physicians now have some useful suggestions that may make all the difference.