approach to liver disease
TRANSCRIPT
APPROACH TO LIVER DISEASE
Dr Anoop R Prasad
ANATOMY
70%
30%
Glucose metabolism
• The liver performs several roles in carbohydrate metabolism:
• Gluconeogenesis • Glycogenolysis • Glycogenesis • Glucogenesis • Glucose buffer function
Protein• Amino acid synthesis • Protein metabolism,
(synthesis as well as degradation)
Lipids
• Cholesterol synthesis • Lipogenesis, the
production of triglycerides (fats).
• Lipoprotein synthesis• Beta oxidation
Synthesis of plasma proteins
Albumin
Acute phase proteins
Clotting factors
Steroid binding and other hormone binding proteins
HORMONES
Erythropoietin
IGF-1
Thrombopoietin
Angiotensinogen
25 hydrxoy choolecalciferol
Hematopoesis
Extramedullary hemopoiesis during first trimester of gestation
• STORAGE:
Vitamins
Glycogen
Iron
Copper• Immunity
Kupffer cells
Detoxification
toxins
steroids
other hormones
drugs
Bilirubin
Urea formation
CLINICAL FEATURES OF h DISEASE
• Fatigue• Nausea• Vomiting• Jaundice• Right upper quadrant pain• Bleeding manifestation(echymosis, easy
bruising,hematemesis,malena)• Colicky pain• Pruritus• Clay colored stools • Abdominal distension• Muscle wasting• Altered sensorium
Obstructive jaundice
Cholestatic disease
• fatigue, malaise• anorexia, nausea• Biliary colic• Deep jaundice• +++ pruritus• +++ abdominal pain and pancreatitis• +++ gray or clay-colored stools
CIRRHOSIS
• Fatigue• Muscle wasting• Hematemesis • Ascites • Easy bruising• Edema
Other points in history
• Fever, prodrome (anorexia,vomiting,nausea) –which disappears with onset of jaundice – acute viral hepatitis
• Joint pain, diabetes, pigmentation, jaundice –• Young individual with extrapyramidal symptoms,
neuropsychiatric manifestation, anemia• Colicky abd pain, jaundice, fever- gall stones• Rash, arthritis • Drug history
Acute onset jaundice
• Viral hepatitis• Alcoholic liver disease• Autoimmune hepatitis• Ischemic hepatitis• Medication-induced liver disease• Common bile duct stones• Pancreatic cancer• Primary Biliary Cirrhosis (PBC)• Primary Sclerosing Cholangitis (PSC)
Jaundiced Emergencies
• Acetaminophen Toxicity• Fulminant Hepatic Failure• Ascending Cholangitis
Jaundice Unrelated to Intrinsic Liver Disease
• Hemolysis (usually T. bili < 4)• Massive Transfusion• Resorption of Hematoma• Ineffective Erythropoesis• Disorders of Conjugation
• Gilbert’s syndrome• Intrahepatic Cholestasis
• Sepsis, TPN, Post-operation
Alcohol
• A standard drink is any drink that contains about 14 grams of pure alcohol (about 0.6 fluid ounces or 1.2 tablespoons)
• One "Standard Drink" equals = one 30ml nip of whisky or other basic spirit = 60ml fortified wine = 150ml table wine = 250ml beer = 425ml low alcohol beer
• Strength (ABV) x Volume (ml) ÷ 1000 = No. of units.
• 40–80 g/d of ethanol produces fatty liver; 160 g/d for 10–20 years causes hepatitis or cirrhosis. Only 15% of alcoholics develop alcoholic liver disease.
Signs
Alopecia
Pigmentation of face
Jaundice
KF ring
Parotid swelling
Gynaecomastia
Spider naevi
Palmar erythema
Dupyutren’s contracture
Half and half nail
Asterixis
Testicular atrophy
Scratch marks
Echymotic patches
Muscle wasting
Pallor
Clubbing
Edema
Leuconychia
Hepatomegaly …..
Splenomegaly
Ascites
• Dilated veins• Caput medusae
Biochemical tests in liver disease
• The true tests of liver function:• INR, PT, Albumin,Bilirubin
• Tests of hepatic injury/inflammation:• Aspartate aminotransferase (AST)• Alanine aminotransferase (ALT)• Alkaline phosphatase (ALP)• Gamma-glutamyl transpeptidase (GGT)
• Hepatocellular – AST/ALT elevation twice that of ALP
• Cholestatic – AST/ALT elevation less than twice ALP
INVESTIGATIONS
• AST-ALT-ALP• Bilirubin – total/indirect• Albumin• INR• Glucose• Na-K-PO4, acid-base • Acetaminophen level• CBC/plt
• Ammonia• Viral serologies• ANA-ASMA-
AMA• Quantitative Ig• Ceruloplasmin• Iron profile• Blood cultures
Hepatocellular • AST/ALT >> ALP• Unconjugated bil >>
conjugated• USG – BILE DUCTS
NORMAL
Cholestatic • ALP>>AST/ALT• Conjugated bil>>
unconjugated• ↑GGT, 5’nucleotidase• USG- Intrahepatic biliary
duct dilation
Non hepatic cause of elevated transaminases
• Muscle disease• Thyroid diseases• Bone disease - ALP
THANK YOU
QUESTIONS??