LIVER DISEASES. Anatomy

Transcription

1 LIVER DISEASES Anatomy

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5 PHYSIOLOGY

6 Bilirubin metabolism: mg/d SER Bile UDPG-A B. diglucuronide Unc. B B. monoglucuronide Albumin Glucuronyltransferase mg/d Bacteria 4mg In urine urobilinogen urobilin Stercobilinogen O 2 O 2 Stercobilin

7 Bile acids Cholic acid Chenodeoxycholic acid glycine taurine Jejunum Colon (small amount) Cholic Deoxycholic acid ] feces Chenodeoxycholic Lithocholic acid

8 Investigations: Bilirubin Enzymes- ALT (SGPT) AST(SGOT) ALP ᴕ-gt 5 -nucleotidase enzyme combinations Plasma proteins Immunoglobulins Coagulation factors α-feto protein copper ceruloplasmin ferretin Fe & IBC Serology- ANA ALKMA ASMA SLP-PA AMA

9 Imaging: U/S Radiography CT + MRI + MRCP Radionucleotide imaging TC 99 ERCP Cholangiography Arteriography Venography -Portal venography (Portal pressure = free hepatic vein pressure- wedged hepatic vein pressure = 3-5 mmhg) Endoscopy Ascitic fluid studies Liver biopsy & FNA Laproscopy

10 Jaundice > 3 mg/dl 1. Hemolytic 2. Hepatocellular 3. Obstructive [Cholestatic] - Intrahepatic- canalicular (hepatocyte) - Biliary Obstruction - Extra hepatic Clinical features Cholestasis of pregnancy Benign recurrent intrahepatic cholestasis

11 Congenital Hperbilirubinemia Unconjugated- Gilbert s Syndrome (Dominant) Criggler-Najar- (I) recessive (II) dominant Conjugated- Dubin-Johnson (recessive) Rotor (dominant)

12 Portal hypertension Causes: (I) Pre-hepatic (II) Hepatic (III) Post-hepatic - Portal vein obstructions 50%? - splenic vein thrombosis - massive splenomegaly ( Banti s Syndrome) - Pre sinosoidal - Sinusoidal Cirrhosis Myoproliferative diseases Drugs Sarcoid - Post-sinosoidal - Budd-Chiari - Cardiac causes

13 Clinical features: - Splenomegally - Hypersplenisim - Collateral vessels - Fetor hepaticus Complications: - Bleeding - Hypersplenisim Contributary factor in: Ascites Encephalopathy Hepato renal syndrome Hepatopulmonary syndrome

14 VARICEAL BLEEDING Recurrent Risk factors Other sites Management: - Supportive - Confirm 1. reduction of portal pressure 2. Local measures 3. Prevention of recurrent bleeding Primary prophylaxis:

15 Ascites 1. Increased hydrostatic pressure 2. Decreased oncotic pressure 3. Increased portal pressure 4. Inflammation 5. Malignancy Causes: Investigations:

16 Ascites in chronic liver disease Poor prognostic sign Commonly with leg edema 10% right pleural effusion Ascites in CLD doesn t exclude other causes (HCCA or PUTH ) Exudative ascites infection, malignancy, H-V obstruction.

17 Cirrhosis Incremental resistance to portal flow Portal hypertension Increased splanchnic capillary pressure Splanchnic vasodilatation Ascites Arterial underfilling Activattion of vasoconstrictar + antinaturetic factors Na & water retention Impaired free water excretion Renal vasoconstriction Expansion of plasma volume Dilutional hyponatremia Hepatorenal syndrome

18 Management: - Decrease Na & water by restriction - Increase urine output - Removal of ascetic fluid if necessary - TIPSS

19 Spontanous bacterial peritonitis Recurrent Hepatorenal syndrome Hepatopulmonary syndrome

20 Hepatic encephalopathy - Definition - Causes- Liver cell failure - Features - Precipitating factors - Differential diagnosis - Management - P-S shunting

21 Fulminant hepatic failure - Definition Acute - absence of CLD - Causes - Pathology - Presentation - Investigations - Complications - Management - Prognosis

22 Acute Hepatitis - Pathology - Causes: - Viral - Non-viral infections - Drug - Immune Hepatitis - Post-viral - Metabolic- Wilson - α1-antitrypsin deficiency - Pregnancy -Ischemic- Shock - Tamponade- severe heart failures - Budd-Chiari syndrome - Clinical features Frequently anicteric or asymptomatic - Investigations - Management - Complications - Prognosis

23 HEPATITIS A VIRUS - Incubation 2-4 wks - Diagnosis - No chronic carrier - Vaccine - Immune serum globulin

24 HEPATITIS E VIRUS - Incubation 4-8 wks - Water borne epidemics fecal -oral - High mortality in pregnant woman - Incubation 4-20 wks - Not cultured - Only man-man - Carrier - Vaccine HEPATITIS B VIRUS hyperimmune serum globilin - HBsAg - HBe Ag - Anti HBs Ab - Anti-HBeAb - Anti- HBcAb IgM IgG

25 Chronic HBV infection Activity HBsAg HBeAg Anti HBeAb Viral load (PCR) HD virus Incubation 6-8 wks Increased enzymes Anti-HBcAb Incomplete RNA Infection Con-comitant Super infection of chronic causes of HBV

26 HC virus - Incubate 2-26 wks - Chronic carrier > 50% - Anti-HCV Ab? - PCR HCV-RNA in blood

27 CHRONIC HEPATIC + CIRRHOSIS - 6/12 - Causes Viral Drugs and alcohol Metabolic o Wilson o Hemochromatosis o α1 anti-trypsin deficiency Immune Nutritional (intestinal bypass) Biliary obstructiono Primary biliary cirrhosis o Sclerosing cholangitis o Secondary biliary cirrhosis Hepatic congestiono Budd-Chieri o Veno-occlusive disease o Cardiac failure NAFLD Cryptogenic

28 - Symptomatology

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36 - Assessment & investigations Is there active liver disease? Liver functions Staging of liver disease- clinical

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38 Histological grade of activity Stage of fibrosis

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40 - Decompensated liver disease Bleeding Ascites Encephalopathy - Complications Infections Portal hypertension Ascites Hepatic encephalopathy Hepatorenal syndrome Hepatopulmonary syndrome Hepatoma - Management

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45 - Presentation - Associated features Immune hepatitis - Investigations ANA AMA A-LKmA ASMA SLA

46 ATP7B gene Presentation Investigations Management Ch13 Wilson disease HFE gene Ch6 C282Y Hemochromatosis Presentation Investigation Management Secondary Hemochromatosis

47 PiM PiS PiZ α1-antitrypsin deficiency Primary biliary cirrhosis Pathology Presentation Associated auto immune disease Investigations Management Pruritis Malabsorption Lipids Secondary biliary cirrhosis

48 - Dose Duration - Genetics Sex - Mechanism Alcoholic liver disease - Pathology Fatty liver Alcoholic hepatitis Mallory s hyaline Central hyaline sclerosis CAH Cirrhosis Hepatoma - Clinical Asymptomatic Gradual Cholestasis and abdominal pain Alcoholic hepatitis

49 - Investigations Establish alcohol abuse Exclude other causes of liver disease Establish severity AST/ALT> 2/1 - Management

50 Drugs and the liver Liver metabolism Water soluble (polar) conversion of fat-soluble (non-polar) MFO (P450) on SER Genetics, nutritional, hepatic blood flow, plasma protein binding, combination of drugs Induction and inhibition of enzymes

51 Hepatotoxicity of drug: All forms of liver disease Acute hepatic injury - Dose dependent paracetamol, CCl4 - Idiosyncratic - Cholestasis - Fatty liver - Chronic hepatitis - Granulomas - Fibrosis - Vascular - Tumors - Toxins

52 Hepatic vein obstruction - Anywhere from the small central hepatic veins heart - Veno-occlusive disease - Heart failure, tamponade - Budd- Chiari syndrome- thrombogenic disease - Clinical features - Management SPEED PRV PNH AT III deficiency Anti-phospholipid syndrome Protein C & S deficiency Vena Caval obstruction Webs Tumors

53 Hepatic Tumors

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