Approach to the Patient with Liver Disease

Approach to the Patient with Liver Disease

Diagnosis of liver disease Careful history taking Physical examination Laboratory tests Radiologic examination and imaging studies Liver biopsy

Liver diseases Inherited hyperbilirubinemia Gilbert disease 5% of the population Viral hepatitis A, B, C, D, E Immune and autoimmune liver diseases Primary biliary cirrhosis, Autoimmune hepatitis, Sclerosing cholangitis Genetic liver diseases Hemochromatosis, Wilson disease

Liver diseases 2 Alcoholic liver disease Acute fatty liver, Acute alcoholic hepatitis, Laennec cirrhosis Nonalcoholic fatty liver Steatosis, Steatohepatitis Liver involvement in systemic diseases Sarcoidosis, Tuberculosis Cholestatic syndromes Cholangitis and cholecystitis, Extrahepatic biliary obstruction (stone, stricture,cancer)

Liver diseases 3 Drug-induced liver disease Isoniazid, Acetaminophen, Methotrexate Vascular injury Venoocclusive disease, Budd-Chiary syndrome, Portal vein thrombosis Mass lesions Hepatocellular carcinoma, Cholangiocarcinoma, Adenoma, Metastatic tumors, Focal nodular hyperplasia, Abscess, Cysts, Hemangioma

Liver diseases Hepatocellular diseases Cholestatic diseases gall stone, malignant obstruction

Symptoms Jaundice scleral icterus Dark urine Light stools Nausea Fatigue Itching Right upper quadrant pain Abdominal bloating GI bleeding

Physical examination Icterus Hepatomegaly Hepatic tenderness Liver edge Irregularity of the surface Splenomegaly Spider angiomata Palmar erythema Ascites Edema Hepatic fetor Gynecomastia Hepatic encephalopahy

Laboratory Testing ALT = serum alanine aminotransferase AST = serum aspartate aminotransferase Alkaline phosphatase GGT = gamma-glutamyl transpeptidase Total and direct serum bilirubin Prothrombin time

Evaluation of Liver Function Serum Bilirubin (indirect, direct) normal: <17 μmol/l Urine Bilirubin liver disease Blood Ammonia hepatic encephalopathy, hepatic failure Serum albumin hypoalbuminemia Serum Globulins: gamma globulins

Diagnostic Tests Hepatitis A Anti-HAV IgM Hepatis B HBsAg, anti-hbc IgM, HBV DNA Hepatitis C Anti-HCV, HCV RNA Autoimmune hepatitis ANA, SMA Primary biliary cirrhosis AMA Primary sclerosing cholangitis P-ANCA Wilson disease serum ceruolplasmin,copper Hemochromatosis iron saturation,serum ferritin Hepatocellular cancer AFP

Ultrasound CT MRI Diagnostic Imaging ERCP (endoscopic retrograde cholangiopancreatography) sphincterotomy, stone extraction, placement of biliary stent Doppler ultrasound

Gold standard Liver Biopsy Hepatocellular disease of uncertain cause Unexplained hepatomegaly FUO (fever of unknown origin)

Gilbert s Syndrome Mild unconjugated indirect hyperbilirubinemia Normal values for standard hepatic biochemical tests Normal hepatic histology Serum bilirubin <51 μmol/l Provocation test 48 h of fasting Prevalence 8 % Males predominate over females

Gilbert s Syndrome 2 Autosomal dominant inheritance

Icterus Jaundice Yellowish discoloration deposition of bilirubin Sclerae scleral icterus Darkening of the urine conjugated bilirubin urine as tea or cola colored

Measurement of serum Bilirubin Van den Bergh reaction direct- and indirect-reacting bilirubin Normal: 17 μmol/l Unconjugated Hyperbilirubinemia hemolytic disorders spherocytosis, sickle cell anemia, thalassemia, hemolytic-uremic syndrome, PNH, immune hemolysis, Gilbert s syndrome

Elevation of serum Bilirubin with other liver test Conjugated hyperbilirubinemia Hepatocellular process Intra- or extrahepatic cholestasis

Hepatocellular conditions with jaundice Hepatitis A,B,C,D and E EBV, CMV, Herpes simplex Alcohol Drug toxicity Acetaminophen, Isoniazid Environmental toxins wild mushrooms Amanita phalloides Wilson s disease Autoimmune hepatitis

Cholestatic conditions with jaundice I. Intrahepatic II. Extrahepatic

Intrahepatic cholestatic conditions Viral hepatitis Alcoholic hepatitis Drug toxicity anabolic steroids, contraceptive pills, PBC Primary sclerosing cholangitis Infiltrative disease TB, lymphoma, amyloid

Extrahepatic cholestatic conditions Cholangiocarcinoma Pancreatic cancer Gallbladder cancer Malignant involvement of the porta hepatis lymph nodes Choledocholithiasis Chronic pancreatitis