Biliary Stones. Biliary Stones. Biliary Stones. Chapter XI K00-K93 Digestive System. ำ จ ยทางค ก (Clinical Diagnosis)

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1 Biliary Stones Chapter XI K00-K93 Digestive System นพ.บ ก เจ ญ ล ก มงาน ลยกรรม รพ.สวรร ประชา ก นครสวรร 1 2 Biliary Stones Biliary Stones ำ จ ยทางค ก (Clinical Diagnosis) Gallbladder Common Bile Duct Intrahepatic Duct Gallstones Gallbladder stone Cholelithiasis CBD stones Choledocholithiasis IHD stones Choledocholithiasis Gallbladder Common Bile Duct Intrahepatic Duct Gallstones Gallbladder stone Cholelithiasis CBD stones Choledocholithiasis IHD stones Choledocholithiasis Summary Diagnosis With Infection No Infection K80.0 [acute] Gallstone K80.2 K80.1 [chronic] K80.3 [cholangitis] Common bile duct stone K80.5 K80.4 [cholecystitis] Intrahepatic duct stone K70.5 [liver abscess] K

2 Biliary Infections Biliary Infections ำ จ ยทางค ก (Clinical Diagnosis) Gallbladder Common Bile Duct Intrahepatic Duct Cholecystitis Cholangitis Acute cholecystitis Acute cholangitis Empyema gallbladder Ascending cholangitis Suppurative cholecystitis Toxic cholangitis Gangrenous cholecystitis Suppurative cholangitis Gangrenous gallbladder Recurrent cholangitis Chronic cholecystitis Post-ERCP cholangitis no stone with Gallstone with CBD stone no stone with CBD stone Cholangitic liver abscess with IHD stone Gallbladder Cholecystitis Acute cholecystitis Empyema gallbladder Suppurative cholecystitis Gangrenous cholecystitis Gangrenous gallbladder Chronic cholecystitis no stone with Gallstone with CBD stone ำ จ ยทางค ก (Clinical Diagnosis) 5 6 Biliary Infections Gallbladder Common Bile Duct Intrahepatic Duct Acute cholecystitis Chronic cholecystitis Cholecystitis Acute cholangitis Cholangitis Cholangitic liver abscess Summary Diagnosis With Stone No Stone Acute cholecystitis Chronic cholecystitis Cholecystitis Cholangitis Cholangitic liver abscess K80.0 K80.1 K80.1 K80.3 K K75.0 # CBD stone with cholecystitis ใ ร ส K80.4 [พบ อยในเวชป ] K81.0 K81.1 K81.9 K83.0 K75.0 Disease of Liver Alcoholic Liver Disease Toxic Liver Disease Hepatic Failure Chronic Hepatitis Fatty Liver exclude Infectious disease 7 8

3 Non-Infectious Hepatitis Alcoholic hepatitis, Toxic hepatitis Alcohol Drugs : acetaminophen, methotrexate, methyldopa, halothane, nacrotics, ketoconazole, chlorpromazine, methimazole, sulfonamide Other : Wilson s disease, herbs, carbon tetrachloride, chloroform 9 10 AST : Liver, Heart, Muscle, Kidney, Brain : Released into serum when any of those tissues damaged ALT : Liver Transaminases AST SGOT / ALT SGPT : Released into serum when liver injury, fairly specific indicator of liver NOT..Transminitis in Summary Discharge Alcoholic Liver Disease Normal liver : Not storage organ for fat, normal concentration ~5% Heavy alcohol drinking for 20 years: at risk for alcohol problems : Men >6 drinks/day : Women >2 drinks/day Alcohol Liver Disease [ALD] : Alcoholic fatty liver : Alcoholic hepatitis : Alcoholic cirrhosis Maximal metabolism of alcohol g/day 1 standard drink = 10 g alcohol 11 12

4 Acute Hepatic Injury Laboratory Test Disease Peak ALT (x URT) AST/ALT ratio Peak Bilirubin (mg%) PT prolong (sec) Viral hepatitis <1 <15 <3 Alcoholic hepatitis 2-8 >2 <5 1-3 Toxic hepatitis >40 >1 (early) <5 >5 (transient) Ischemic injury >40 >1 (early) <5 >5 (transient) Fatty Liver [Steatosis] Yellow, greasy, enlarged liver Fatty vacuoles displace hepatocellular nuclei peripherally Alcoholic Hepatitis [Steatohepatitis] Associated with extreme fatty change and sometimes with cirrhosis Swelling of hepatocytes, necrosis, cholestasis and beginning fibrosis Alcoholic Enlarged liver with micronodular formation End stage resembles post-necrotic cirrhosis Progression in ALD Alcoholic Fatty Liver Excessive deposition of triglycerides in liver cells Alcohol consumption AASLD Practice Guideline : >21 drinks/week in men; >14 drinks/week in women: >2-year Diagnosis : Elevated liver enzyme [ALT 2-4 times, AST/ALT <1] : Exclude viral hepatitis - serology : Imaging - fatty infiltrate [US, CT, MRI, LSM (fiboscan)] 15 16

5 Fatty Liver Hepatic steatosis Normal liver : Not storage organ for fat, normal concentration ~5% Nonalcoholic Fatty Liver Disease (NAFLD) : Metabolic syndrome : Malnutrition, Rapid weight loss, Weight reduction surgery : Medications - steroids, estrogen, amiodarine, tamoxifen, methotrexate Alcoholic Fatty Liver : Earliest stage of alcohol-related liver disease Acute Fatty Liver of Pregnancy : Symptoms begin in 3rd trimester : Improved after delivery and no lasting effects Alcoholic Hepatitis Steatohepatitis Alcohol consumption : >21 drinks/week in men; >14 drinks/week in women: >2-year : nonspecific - anorexia, weight loss, abdominal pain, N/V : severe - liver stigmata, fever, encephalopathy Diagnosis : Elevated liver enzyme [<500 IU/ml, AST/ALT >2] (viral hepatitis <1) : Elevated GGT (gamma-glutamyl-transpeptidase) : Macrocytic anemia : Hyperbilrubinemia [conjugated] Predictive Models Hepatic steatosis Maddrey s Discriminate Function [MDF] (1989) : 4.6 x [patient s PT - control PT] + total bilirubin : MDF >32 associated with a high short-term mortality Model for End-Stage Liver Disease [MELD] score (2001) : bilirubin, INR, creatinine : MELD >21 have 90-days mortality Glasgow Alcoholic Hepatitis Score (2005) : age, bilirubin, BUN, PT ratio, WBC : >9 have 28-days mortality Lille Model : age, creatinine, albumin, PT, bilirubin : 6-months survival 19 Non-Infectious Liver Disease Summary Diagnosis Alcoholic fatty liver [AFL] Non-alcoholic fatty liver disease [NAFLD] Fatty liver Alcoholic hepatitis Non-alcoholic hepatitis Non-alcoholic steatohepatitis [NASH] Non-alcoholic acute hepatitis Hepatitis Acute hepatitis 20 ICD-10 K70.0 K76.0 K76.0 K70.1 K71.6 K71.6 K71.2 K75.9 B71.9

6 Chronic Hepatitis Active, Persisting and Ongoing Inflammation >6 months Classification hy Etiology Chronic viral hepatitis Autoimmune hepatitis Drug induced hepatitis Cryptogenic hepatitis Classification hy Pathology Chronic persistant hepatitis - mild activity Chronic lobular hepatitis - mild to moderate fibrosis Chronic active hepatitis - moderate to severe fibrosis Autoimmune Hepatitis old name Lupoid hepatitis Common in young or middle-aged women Insidious onset, remission and relapsed Fatigue, malaise, anorexia, amennorrhea, acne, arthralgia, jaundice, arthritis, colitis, pericarditis, anemia, cirrhosis Laboratory features - serum AST units - serum bilirubin normal to 10 mg/dl - prothrombin time prolonged - hypergammaglobulinemia >2.5 g/dl - Antinuclear Ab, Smooth muscle Ab, Anti-LKM1 Ab Chronic Hepatitis [K73] based on histological distinction K73.0 Chronic persistent hepatitis, not elsewhere classified K73.1 Chronic lobular hepatitis, not elsewhere classified K73.2 Chronic active hepatitis, not elsewhere classified Lupoid hepatitis NEC K73.8 Other chronic hepatitis, not elsewhere classified K73.9 Chronic hepatitis, unspecified Old.. Classification Not Correlate with Prognosis Now Much Less Used 23 24

7 kirrhos = tawny the orange-yellow colour + osis = condition อาการและอาการแสดงของ บแ ง อ าง อย 3 อ Jaundice, Spider nevi, Palmar erythema, Gynecomastia or or Testicular atrophy or Decrease of libido, Enlarged parotid gland, Portal hypertension [caput medusa, hemorrhoids, esophageal varix, gastric varix], Small liver or Splenomegaly กร พบอาการและอาการแสดง อยก า 3 อ อง ผลการำงานของ บ ดปก [LFT, prolong PT] ผลตรวจทาง ง ทยา [U/S, CT, MRI, Fibroscan] ผลการ า ด ระ กษณะของ บแ ง ผลตรวจทางพยา ทยา kirrhos = tawny the orange-yellow colour + osis = condition Drugs and Toxins : Alcohol, Methotrexate, Isoniazid, Methyldopa Infections : Hepatits B, Hepatitis C, Schistosoma Autoimmune disorders : Primary biliary cirrhosis, Primary sclerosing cholangitis Metabolic disorders : Wilson s disease, Hemochromatosis, Porphyria Biliary obstruction : Biliary atresia, Cystic fibrosis, Gallstones Cardiovascular disorders : Chronic right heart failure, Budd Chiari syndrome kirrhos = tawny the orange-yellow colour + osis = condition Hepatitis C Virus Infection Alcoholic cirrhosis : ประ ม ราป มาณมากและเ อ งเ นเวลา 5-15 : กเ น micronodular cirrhosis (<3 mm) Hepatitis virus cirrhosis : กเ น macronodular cirrhosis (>3 mm) Cardiac cirrhosis : เ ดจากภาวะเ อด งเ อ ง บจาก วใจ องขวาวายเ อ ง : เ อ บขาดออก เจนและตาย Biliary cirrhosis : เ ดจากระบบ ม นำลาย อำ ใน บเ น Primary biliary cirrhosis : เ ดจากทางเ น ด นเ น Secondary biliary cirrhosis 27 28

8 Primary Biliary Alcoholic cirrhosis Toxic cirrhosis Hepatitis B cirrhosis Hepatitis C cirrhosis Cryptogenic cirrhosis Macromodular cirrhosis Micronodular cirrhosis Liver cirrhosis Summary Diagnosis ICD-10 K70.3 K71.7 B B Congenital cirrhosis Cardiac cirrhosis Cholestatic cirrhosis Biliary cirrhosis Primary biliary cirrhosis Secondary biliary cirrhosis Summary Diagnosis ICD-10 P78.8 K76.1 K74.3 K74.5 K74.3 K