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
