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Drugs / toxins Methotrexate, amiodarone, chronic toxins Pathophysiology Chronic injury inflammation fibrosis regenerative nodules Portal hypertension develops due to increased resistance to portal blood flow Hepatic insufficiency leads to coagulopathy, hypoalbuminemia, jaundice, and endocrine changes Clinical Features General Fatigue, weakness, anorexia, weight loss Skin & mucosa Jaundice Spider angiomas Palmar erythema Purpura / easy bruising Abdomen Hepatomegaly (early), shrunken liver (late) Ascites Caput medusae Neurologic Hepatic encephalopathy: confusion, asterixis, sleep disturbances Others Splenomegaly Gynecomastia, testicular atrophy (men) Menstrual irregularities (women) Complications Portal hypertension: esophageal/gastric varices, splenomegaly Ascites, spontaneous bacterial peritonitis Hepatorenal syndrome Hepatocellular carcinoma Coagulopathy, hypoglycemia, hypoalbuminemia Hepatic encephalopathy Investigations Laboratory LFTs: bilirubin, ALT/AST (variable), albumin, ALP Coagulation: prolonged PT/INR CBC: anemia, thrombocytopenia (from hypersplenism) Imaging Ultrasound: nodular liver, ascites, splenomegaly CT/MRI: nodules, hepatocellular carcinoma screening Other Liver biopsy (sometimes needed for diagnosis / etiology) Management 1