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Flashcards in Liver and gall disease Deck (45)
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1

The normal liver

Right lobe
Left lobe

2

The portal circulation 'the third arm'

Portal vein
Umbilical vein
Pancreas
Spleen
Inferior mesenteric vein
Superior mesenteric vein
-nutrients from gut into liver

3

Bile flow

Produced in liver as primary bile acids --> bile salts
Helps to digest food
Primary and secondary bile acids

4

Functions of liver

Approx 500 different functions
Detoxification
-filters and cleans blood of waste products
-drugs, hormones
Immune functions
-fights infections and diseases
-RE system
Iinvolved in synthesis of clotting factors, proteins, enzymes, glycogen and fats
Production of bile and breakdown of bilirubin
Energy storage (glycogen and fats)
Regulation of fat metabolism
Ability to regenerate

5

Microanatomy

Organised in lobules with central (hepatic vein)
Hexagon - portal triads in the "corner"

6

Types of liver injury

Acute
-->viral (A,B, EBV), drugs, alcohol, vascular --> liver failure
--> recovery
Chronic
-->recovery
-->cirrhosis --> liver failure (varices, hepatoma)
--> alcohol, viral (B, C), autoimmune, metabolic (iron, copper) --> liver failure (varices, hepatoma)

7

Presentation of acute liver injury

Asymptomatic
abnormal LFTs
Malaise, nausea, anorexia
Jaundice
Confusion - think ALF
*rarer*:
Bleeding
Liver pain

8

Presentation of chronic liver injury

Ascites, oedema
Haematemesis (varices)
Malaise, anorexia, wasting
Easy bruising
Itching
Hepatomegaly,
Abnormal LFTs
*rarer*:
Jaundice
Confusion

9

Serum "liver function tests" (LFTs)

Albumin
ALP – Alkaline phosphatase
GGT – gamma GT
ALT – Alanine Aminotransferase
AST – Aspartate Aminotransferase
Bilirubin
Globulin

Prothrombin time (PT)/ INR
Platelet count
-normal LFTs and normal PT and platelet count do not exclude liver disease/ cirrhosis, but while normal the function is relatively preserved

10

Albumin
Bilirubin
Prothrombin time (PT)

Give some index of liver function
-if normal would suggest a "preserved" liver function

11

ALP – Alkaline phosphatase
GGT – gamma GT
AST – Alanine Aminotransferase
ALT – Aspartate Aminotransferase

Give no index of liver function

12

Jaundice causes

Pre-hepatic
-haemolysis
Hepatic
-cirrhosis
-acute hepatitis (viral, alcoholic, autoimmune, drug-induced)
-infiltration of the liver by tumours
Post-hepatic (obstruction of biliary outflow)
-gallstones
-external compression: pancreatitis, lymphadenopathy, pancreatic tumour, ampullary tumour

13

Bilirubin metabolism and excretion

Breakdown product of haemoglobin
Metabolised in liver
Excreted via intestine (and renally)
If bilirubin rises and is not excreted the motion turns pale
Bilirubin metabolism can be interrupted at various points

14

Cirrhosis of the liver

Scarring of the liver
Result of chronic longstanding damage to the liver
Scar tissue replaces healthy tissue (exceed healing capacity of liver) --> leading to disruption of liver architecture
> resistance to blood flow through the liver, leading to portal hypertension and its complication

15

Causes of chronic liver disease: most common

Alcohol
Non Alcoholic Steatohepatitis (NASH)
Viral hepatitis (B, C)

16

Jaundice

Mild can be difficult to spot (light; skin tone)
Scleral jaundice usually first noted
Due to > bilirubin

17

Less common causes of chronic liver disease

Immune
-autoimmune hepatitis
-primary biliary cirrhosis
-primary sclerosing cholangitis
Metabolic
-haemochromatosis
-Wilson’s
-alpha 1 antitrypsin deficiency…
Vascular
-Budd-Chiari
Drugs
-amiodarone

18

Alcoholic liver disease

Commonest cause of cirrhosis in the UK
Deaths from ALD rising dramatically

19

Weekly safe limits

14 units

20

Harmful drinking

15-28 units

21

Hazardous drinking (very heavy)

>28 units

22

Binge drinker

Men = >10 units in one session
Women = >7 units in one session

23

The burden of alcohol

9 million adults in the UK who are drinking over the recommended daily limits
People aged 16-24 are the heaviest drinkers
In inner city A&E departments approximately 75% of patients attending after midnight are drunk
20% of patients admitted to hospital for illnesses unrelated to alcohol, are drinking at hazardous levels

24

Taking an alcohol history

1 unit = 8g EtOH
= half pint normal beer/ lager
= small glass of wine
= pub measure of spirits

25

Hepatitis B

DNA virus
Reads in hepatocyte genome
Persists in liver even if no longer in blood
Can reactivate
Mainly transmitted via intercourse/ vertically
Early infection: chronicity
Vaccination available
Longterm treatment

26

Hepatitis C

RNA virus
Mainly transmitted through IVDA; needles blood products
Once cleared = cleared
Reinfection possible - no immunity
Time limited treatment - well tolerated, 90% cure
No vaccination

27

Non-alcoholic fatty liver disease

On the rise; often unrecognised
Risk factors
-diabetes
-obesity
-hypertension
-dyslipidaemia = metabolic syndrome
LFTs may be normal; even in advanced disease
Affecting 20% of Western population

28

Iceberg of fatty liver disease

HCC
NASH CirrhosisNASH
NAFLD with abnormal LFT
NAFLD normal LFT
Normal liver

29

UK HCV prevalence

<1%
2-400,000
IV drug use
Medical treatment abroad
Blood donation screening 1991

30

Complications of cirrhosis

Portal hypertension
-ascites
-varices ± haemorrhage
-hypersplenism → thrombocytopenia (↓ platelets)
Hepato-renal syndrome
Encephalopathy
Hepatocellular carcinoma

31

Portal hypertension

< platelets (thrombocytopenia)

32

Signs of chronic liver disease

Jaundice
-sign of decompensation in chronic liver disease
Leuconchia
-white nails fro hypoalbuminaemia (not liver disease specific)
Palmar erythema
Spider naevi
-sign of advanced liver disease but does not imply decompensation
Gynaecomastia
-sign of liver disease (related to low testosterone) but can also be drug related (spironolactone)
Finger clubbing
-not liver specific
Ascites
-advanced liver disease - decompensation

33

Dental considerations for pts with liver disease

Potential for increased bleeding in patients with liver disease
-coagulopathy
-thrombocytopenia
Potential for increased drug toxicity in patients with advanced liver disease
-caution should be used in prescribing medications metabolized in the liver
Infection risk, consider extra precautions if higher risk of injury (double gloves)
Hep B vaccination
HCV now very treatable

34

Dental considerations in practice in liver disease

Comprehensive medical and dental histories
Appropriate laboratory investigations
-full blood count (FBC)
-prothrombin Time (PT)
-LFTs
Consultation with and/or referral to treating physician(s) prior to dental treatment
Minimization of soft tissue trauma during dental procedures
Consideration of hospital setting for advanced surgical procedures or severely coagulopathic pts

35

Stages of (chronic) liver disease

NCPH = non-cirrhotic portal hypertension
-often due to vacular problems in liver
-tolerating bleeding well and clotting generally intact
-relatively rare (pts generally aware)
Pre-cirrhotic
-no effect on dental work
-may be asymptomatic
Liver cirrhosis

36

Dental considerations in liver disease - medications

Caution in prescribing meds metabolised in liver and/ or impair haemostasis
-anaesthetics: local (amides) and general (halothane)
-spot antiplatelet (aspirin) 7 days before
-increased DILI with flucoloxacillin and co-amoxylav
-sedatives
Potential for increased drug toxicity in pts with advanced liver disease
-avoid NSAIDs
-paracetamol is safest pain killer in liver disease
-opiates: slow and low

37

Spotting liver cirrhosis

Compensated
-invisible
-blood can be normal
-risk low
Decompensated
-visible
-abnormal blood tests
-risks high

38

Prognosis in cirrhosis (diagram)

Time (big to small)
Bilirubin (small to big)
Albumin (big to small)
-as it gets lower ascites develops
INR small to big
Encepalopathy over time

39

Complications of chronic liver disease: chronic

Malnutrition
Bone disease

40

Complications of chronic liver disease: acute

GI bleeding and ascites (due to portal hypertension)
Jaundice
Hepatic encepalopathy
Renal impairment
Coagulopathy
Infection

41

Treatment of liver disease: symptomatic

Diuretics
Nutrition support
Supplements
Propanolol

42

Treatment of liver disease: specific

Antiviral
Immunosuppression
Relieving obstruction
Venesection
Detox from alcohol

43

Hepatic encephalopathy

One of several features of decompensation
Difficult to spot if subtle
Can present as overt confusion in patient with CLD
Often more troublesome for other than pt, but can be disabling
Indicates underlying problem
-bleed
-infection
-compensation
-worsening chronic disease
Collateral history

44

Recognising hepatic encephalopathy

Confusion
Altered behaviour
Coma
Collateral history

45

How to test for hepatic encephalopathy

Serial 7s from 100
"baby hippopotamus"
5-star drawing
Number connection test
Ammonia level >50 (poor correlation)