GIT Dr.

Shaf3y

G.I.T. 2013 16 24

acute hepatitis inflammation of the liver less than 6 months acute hepatitis viruses A, B, C, D, E and G viruses pathology clinical pictures clinical pictures Icteric anicteric complications complications hepatic extra hepatic Hepatic acute chronic investigations investigations Liver functions Liver functions

acute hepatitis

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GIT Dr. Shaf3y

liver enzymes

albumin Normal globulins

bilirubin biphasic slightly enlarged << Liver sonar inflammation Edema spleen enlarged stool Clay color Clay color it is a stool stercobilinogen variable << urobilinogen Urine dark frothy

20 %

clay color

bile acute inflammation of the liver urine

RBCs cast in urine RBCs cast glomeurlonephritis

Kidney RBCs cast Leucopenia with relative lymphocytosis

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CBC

GIT Dr. Shaf3y

bone marrow Leucopenia It is a leucopenia with relative lymphocytosis

Liver inflammation B hepatitis A Inflammation Hepatitis markers

hepatitis D virus

Hepatitis markers hepatitis E virus Hepatitis A virus Ig G Ig M marker

hepatitis A , E and D viruses Ig G Ig M marker acute infection Ig M Old infection Ig G

hepatitis D virus

Hepatitis E virus

hepatitis markers Hepatitis A virus Ig G acute infection old infection Ig M Ig M Ig G

hepatitis A virus

stool

virus first week viremia detection RT PCR

stool

virus

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GIT Dr. Shaf3y

PCR Polymerase chain reaction RT Reversed transcriptase RNA PCR copies DNA RNA PCR Hepatitis A virus Hepatitis D virus virus PCR

DNA reversed transcriptase

Hepatitis B markers D virus hepatitis B surface antigen D virus Is incomplete virus infection B Positive << hepatitis B marker D virus

stool

virus

Ig G detection RT PCR

A virus Ig M

hepatitis E virus Ig G Ig M Ig M
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Ig G

Hepatitis D virus

GIT Dr. Shaf3y

hepatitis B marker Hepatitis B surface antigen

Hepatitis A

Hepatitis B virus Hepatitis B virus B virus HBs Ag Hepatitis B surface antigen

hepatitis B core antigen ) HBc Ag DNA hepatitis B surface antigen DNA protein DNA hepatitis B core antigen e antigen Proteins

antibodies

antigens antigens antibodies

hepatitis B surface antigen 6- 3- 6 Hepatitis B surface antigen 6- 3- 6 6 3 he is a carrier << 6 Infection carrier
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GIT Dr. Shaf3y

hepatitis B surface antibody persist for life 3 Persist for life 3

hepatitis B surface antigen 6-3 6

carrier antibody And persist for life

hepatitis B vaccine hepatitis B surface antigen vaccine infection Hepatitis B vaccine infection

vaccine

hepatitis B surface antigen infection genetic engineering virus

Killed virus genetic engineering

Hepatitis B virus

infection

risk

Which is very strange hepatitis B virus naturally << Infection for life
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antibodies

GIT Dr. Shaf3y

vaccination antibodies infection natural protection for life antibodies hepatitis B vaccination Protection 5 years booster dose

Hepatitis B surface antigen antibody hepatitis B core antigen core antigen

hepatitis B core antigen Liver biopsy Hepatitis B core antigen only << Liver biopsy

Hepatitis B core antibody Ig M Ig G Ig M replicating is active << virus Old Ig G

dormant infection
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GIT Dr. Shaf3y

hepatitis B e antigen virus Is rapidly replicating proliferate virus Is rapidly replicating is rapidly replicating << virus Replicating e antigen replicating high viremia highly infective e antigen e antibody Immune system attack immune system

proliferating

Hepatitis

vaccine interferon

interferon vaccine hepatitis B virus Mutation Mutation virus e antigen e antibody Hepatitis B virus e antibody e antigen Hepatitis marker virus

Hepatitis B
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GIT Dr. Shaf3y

vaccine hepatitis B virus Interferon virus B e antibody Mutation

Mutation e antigen

DNA DNA

Hepatitis B core antigen

DNA virus core antigen DNA

core antigen

DNA hepatitis B core antigen DNA DNA Partially

e antigen

core antigen e antigen DNA core antigen e antigen Partially

DNA
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virus

GIT Dr. Shaf3y

virus

DNA

virus virus e antigen virus DNA

rapidly proliferating

rapidly replication virus totally << DNA partially << DNA

e antigen virus

Hepatitis markers Hepatitis B markers serological window serological gap What is serological gap ( or serological window ) Hepatitis B surface antigen 6- 3- 6 antibody 3 Persist for life few days antibody few days antibody

antigen

antigen

surface antigen mutation virus

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e antibody

antibody e antigen

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GIT Dr. Shaf3y

antibody surface antigen antibody e antigen

Liver biopsy hepatitis B core antigen hepatitis B Core Ig M serological gap Hepatitis B core Ig M

Most recent hepatitis B PCR hepatitis B virus PCR viruses quantitative virus viruses PCR

Hepatitis C virus Hepatitis C virus antibodies detection Hepatitis C virus 4 ELISA technique antibodies detection ELISA technique Against hepatitis C virus Positive

antibody

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GIT Dr. Shaf3y

ELISA technique false positive negative ELISA hepatitis

positive ELISA Hepatitis false positive

diagnosis confirm Positive Detection of antibody by RIBA technique (Recombinant immune blot assay)

ELISA

Pulmonary edema lasix digitalis

target

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GIT Dr. Shaf3y

Hepatitis C virus antibodies detection Infection 4 ELISA technique detection negative ELISA hepatitis C

RIBA technique

positive diagnosis

ELISA confirm

And finally RT PCR For diagnosis of hepatitis C virus

RT PCR RNA

hepatitis B PCR DNA virus << Hepatitis B

treatment Treatment Hepatitis treatment Prevention how to prevent hepatitis hepatitis A virus to prevent hepatitis A virus Food hygiene

Vaccine hepatitis A vaccine protective 100 % vaccine

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GIT Dr. Shaf3y

protective << vaccine 100 % for ten years vaccine It is actually a heat killed vaccine effect produce

Hepatitis A virus

endemic area vaccine vaccine allergy

If you are travelling to an endemic area vaccine allergic Immune globulins antibodies Against hepatitis A virus Immune globulins immune globulins 0.02 dose protection for two months

0.05 dose protection for 6 months

pre exposure prophylaxis pre exposure prophylaxis

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GIT Dr. Shaf3y

recorded << hepatitis

Hepatitis Incubation period manifestations Infection Immune globulins within two weeks antibodies from exposure Immune globulins within two weeks protection

exposure

Immune globulins vaccine

Protection against Hepatitis B screening for blood donors screening of organ donors

Using disposable needles Disposable syringes

Dialysis dialysis Hepatitis markers Hepatitis B hepatitis B

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GIT Dr. Shaf3y

hepatitis C hepatitis C hepatitis B and C Hepatitis B and C Hepatitis

category vaccine vaccine Hepatitis B surface antigen protein genetic engineering 016 vaccine 016 zero 6 protection 5 5 You have to measure the serum antibodies serum antibodies booster dose

How to protect against hepatitis C virus vaccine How to protect against hepatitis D virus By protecting against B

Pre exposure prophylaxis

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GIT Dr. Shaf3y

hepatitis B vaccine Pre exposure Disposable syringes Disposable needles dialysis Screening of blood donor Screening of organ transplant

Hepatitis B virus How to prevent

surgeon abdomen hepatitis B

hepatitis B

immune globulins within two days Immune globulins From exposure Hepatitis A within two weeks

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GIT Dr. Shaf3y

hepatitis B virus immune globulins Within two days from exposure

Prevention << actually

acute hepatitis

specific treatment

acute hepatitis Bed rest normal 1.5 1.5 enzymes bilirubin bilirubin Bed rest 1.5 bilirubin

bilirubin Jaundice serum bilirubin jaundice

Normal

serum bilirubin Jaundice bilirubin jaundice normal bilirubin

sclera

bilirubin Juandice sclera bilirubin

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GIT Dr. Shaf3y

Normal bilirubin

sclera 1.5

clearance bilirubin jaundice

diet excess carbohydrates proteins fat nauseating << fat

Liver cell failure nausea

Hepatitis

Medical tradition

symptomatic treatment cholestyramine metoclopramide bile salts vomiting

nausea

acute hepatitis acute hepatitis

treatment treatment

Liver cirrhosis
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chronic cirrhosis chronic

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GIT Dr. Shaf3y

Liver Cirrhosis
Liver cirrhosis liver cirrhosis hepatic lobule central vein Portal area hepatic artery central vein Liver columns columns sinusoid Portal vein hepatic artery sinusoid central vein

bile duct

portal vein

replacement

Liver Proliferate Liver One of the cells proliferate

replacement

proliferate sinusoids sinusoids ischemic

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GIT Dr. Shaf3y

Proliferation replacement

Proliferation columns Nodules sinusoid Nodules ischemic fibrosis

regeneration fibrosis cirrhosis nodules Nodules

cirrhosis degeneration regeneration fibrosis fibrosis

regeneration degeneration Liver Loss of hepatic architecture Liver cirrhosis

Definition Liver cirrhosis is degeneration of the liver cells which is associated by regeneration and formation of nodules which surround by fibrosis and this will lead to loss hepatic architecture Liver cirrhosis definition Etiology etiologies

cirrhosis

Morphology
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GIT Dr. Shaf3y

definition specific pathology definition specific pathology pathology cirrhosis definition specific

clinical pictures manifestations of liver cell failure Liver 2/3 damage

Liver Liver

cirrhosis cirrhosis

Liver

cirrhosis

cirrhosis Liver asymptomatic cirrhosis asymptomatic accidently accidently examination shrunken liver Hepatomegaly splenomegaly cirrhosis Liver
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GIT Dr. Shaf3y

health insurance examination hepatomegaly examination shrunken liver splenomegaly shrunken liver cirrhosis

asymptomatic Liver 2/3 Liver 2/3

cirrhosis cirrhosis symptomatic

manifestations of liver cell failure

hepatic encephalopathy

ascites

for example plamar erythema spider navei manifestations

portal hypertension manifestations for example hematemesis, caput medosa, piles

clinical pictures of the cause complicated by hepatocellular carcinoma cirrhosis Investigations liver function test liver function test chronic liver cell failure manifestations Liver function test

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GIT Dr. Shaf3y

chronic liver cell failure SGPT SGOT biphasic bilirubin Prolonged Prothrombin time albumin globulin hepatocellular carcinoma alpha feto protein CT Liver biopsy liver function Investigations Liver function test chronic liver cell failure alkaline phosphatase

Investigations of portal hypertension Endoscopy

Investigations for the cause treatment treatment of liver cell failure chronic liver cell failure look above

treatment of portal hypertension Injection sclerotherapy band ligation

Treatment of the cause

Liver transplantation
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GIT Dr. Shaf3y

cirrhosis post hepatitis Cirrhosis cirrhosis

Post hepatitis cirrhosis

definition Degeneration, regeneration, fibrosis Loss of hepatic architecture Due to hepatitis

etiology Hepatitis B, C ,D << E A

Post hepatitis cirrhosis auto immune hepatitis

Pathology Degeneration, regeneration, fibrosis Loss of hepatic architecture specific pathology hepatocyte Ground glass appearance virus particles

Liver

auto immune hepatitis

pathology

clinical pictures discovered accidently asymptomatic shrunken liver and splenomegaly shrunken liver by finding hepatomeglay symptomatic manifestations of liver cell failure Portal hypertension Clinical pictures of the cause clinical pictures of the cause
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GIT Dr. Shaf3y

History of hepatitis jaundice acute attack C

hepatocellular carcinoma

complicated Investigations investigations Liver function test Investigations Portal hypertension

Investigations of the cause investigations of the cause markers treatment Liver cell failure Portal hypertension cause cause hepatitis cause

Hepatitis liver transplantation cirrhotic phase chronic hepatitis

Post hepatitis cirrhosis

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GIT Dr. Shaf3y

Haemochromatosis
definition Degeneration, regeneration, fibrosis Loss of hepatic architecture Due to deposition of iron in liver definition etiology etiology

haemochromatosis

Primary Secondary

secondary parentral iron therapy of course tissues repeated blood transfusion iron Hemolytic anemia

acidic iron

primary haemochromatosis genetic primary haemochromatosis chromosome 6

iron 1 mucosal block theory

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GIT Dr. Shaf3y

primary haemochromatosis Mucosal block

defect

mucosal block iron haemochromatosis

primary haemochromatosis mucosal block theory Which means iron haemochromatosis iron

6 Pathology Degeneration, regeneration, fibrosis Loss of hepatic architecture specific Hepatocytes iron

shrunken liver and splenomegaly

shrunken liver

clinical pictures Asymptomatic hepatomegaly

Symptomatic Manifestations of liver cell failure Manifestations of portal hypertension Clinical pictures of the cause cause
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GIT Dr. Shaf3y

clinical pictures of the cause

blood blood hemolytic anemia

extravascular hemolysis RBCs heme heme Iron Protoporphyrin tissue iron

bronze diabetes

diabetes

peripheral neuritis << C.N.S. cardiomyopathy << heart interstitial fibrosis << Lung pancreatitis << pancreas

renal tubular dysfunction << Kidney Ulcers pigmentation << skin testis supra renal pituitary damage

pseudo gout pseudo gout calcium pyrophosphate iron

haemochromatosis Investigations Liver function test Investigations for portal hypertension

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GIT Dr. Shaf3y

Investigation for the cause Investigation for the cause Serum iron

total iron binding capacity

transferrin saturation ferrtin

iron MRI Liver iron iron MRI magnetic resonance imaging

reflection reflection iron magnetic waves << MRI reflected reflection iron reflection MRI liver Liver iron density

absorbed by iron

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GIT Dr. Shaf3y

primary haemochromatosis DNA analysis genetic defect

Liver cell failure Portal hypertension desferrioxamine Iron chelating agent vene section

Iron

250

Normal

serum iron 4 3

primary haemochromatosis Hemolytic anemia haemochromatosis vene section Hemolytic anemia

hemolytic anemia

Liver transplantation

Wilson disease

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GIT Dr. Shaf3y

Wilson disease
Hepatolenticular degeneration Wilson disease Hepatolenticular degeneration

cupper diet cupper intestine absorption diet liver ceruloplasmin Liver cupper ceruloplasmin ceruloplasmin ceruloplasmin

cupper

cupper

ceruloplasmin

spot diagnosis

nauseating

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GIT Dr. Shaf3y

cupper

ceruloplasmin

Wilson disease disease Hepatolenticular degeneration 13 defect

ceruloplasmin

Liver Liver ceruloplasmin

intestine Liver ceruloplasmin albumin cupper

cupper Liver cupper albumin Loose attachement

cupper

albumin Loose attachement

tissues Urine

albumin albumin

cupper cupper cupper

albumin

urine urine albumin cupper cupper

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GIT Dr. Shaf3y

albumin urine

cupper tissues

etiology This is a hereditary disease Where there is defect in chromosome 13 Which is responsible for the synthesis of ceruloplasmin According the patient has not ceruloplasmin to attach to cupper So cupper will be loosely attached to albumin cupper is easily precipitated in tissue And lost in urine pathology Degeneration, regeneration, fibrosis Loss of hepatic architecture Due to cupper in the hepatocytes

pathology

clinical pictures Asymptomatic Symptomatic

Manifestations of liver cell failure

Portal hypertension

Clinical pictures of the cause hepatolenticular degeneration disease lenticular Lenticular

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GIT Dr. Shaf3y

parkinsonism basal ganglia Lentiform nucleus disease hepatolenticular degeneration cirrhosis hepato

basal ganglia involuntary

lentiform nucleus lenticular dystonia chorea parkinsonism snake like movement of the hand snake like movement of the trunk dystonia

lens sun flower cataract Kayser Fleischer ring << cornea

lens cupper

lenticular

disease cirrhosis

Hepato

basal ganglia

<< Lenticular lentiform nucleus lens

cupper renal tubules renal tubular dysfunction RBCs Hemolysis Nails sky blue nails Wilson disease sky bule nails Wilson disease By sky blue nails
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GIT Dr. Shaf3y

clinical pictures Hepatocellular carcinoma is rare Which is very strange haemochromatosis hepatocellular carcinoma incidence Is high Wilson Is low protection against cancer cupper We have no idea

Wilson

cancer hepatocellular carcinoma cancer Is very rare

Investigations Liver function test portal hypertension investigations for the cause Investigations for the cause cupper cupper

cupper cupper tissues

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GIT Dr. Shaf3y

cupper Urine Ceruloplasmin DNA analysis

the mother of this patient the mother of this patient Liver cell failure Portal hypertension cause cause Cupper chelating agent Penicillamine liver transplantation general rules

Alcoholic Cirrhosis
cirrhosis alcohol

male

alcohol 20

30 female

male female

30 20

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GIT Dr. Shaf3y

30

30

alcohol

4%

11 % alcohol 4

7% 4% 100 4%

alcohol

100 Stella 7% Which means 400 400

alcohol

30 cirrhosis

70 % 100 40 70

40 %

addict
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GIT Dr. Shaf3y

alcohol 30 cirrhosis

alcohol

30

20

male female

30 20

Liver damage alcohol hepatocytes damage alcohol direct toxic effect alcohol dehydrogenase enzyme Liver metabolism toxic toxic alcohol Metabolism alcohol

Metabolism toxic material metabolism Liver toxic material alcohol surface of hepatocytes hepatocytes wall antigens Hepatocytes Immune system antigenic structure

Liver

damage

alcohol direct toxic Metabolism

toxic material
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GIT Dr. Shaf3y

Immune system Immunogenic Hepatocyte antigenic structure

parentral nutrition parentral

Orally Orally Oral

Liver

detoxication detoxication toxication Intravenous

Liver Liver Hepatotropic factors

Orally stimulate

intestine

Total parentral nutrition resection

cirrhosis sepsis Liver liver

activate

hepatotropic factors Liver stimulation hepatotropic factors

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GIT Dr. Shaf3y

hepatotropic factor

alcoholics

calories

alcoholics

calories

alcohol

alcoholic go and buy a meal go and buy a meal 4

alcoholic stimulated Liver degeneration by time

hepatocytes Malnutrition of this patient

Liver alcohol direct toxic effect which is toxic to the liver << metabolites antigenic structure alteration Hepatotropic factors deficiency

Pathology pathology Degeneration, regeneration, fibrosis Loss of hepatic architecture specific pathology hepatocyte Mallory bodies

inclusion bodies

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GIT Dr. Shaf3y

Mallory bodies bodies

alcoholics

alcoholism Hepatocytes

actin filaments Muscles Myocin actin actin filaments intra cellular actin filaments cells Organelles

ribosomes actin filaments contract actin

package

package

actin filaments contraction

relaxtion

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GIT Dr. Shaf3y

actin filaments alcohol damage

Mallory bodies Mallory bodies clinical pictures Asymptomatic Portal hypertension - manifestation of liver cell failure Symptomatic Clinical pictures of the cause clinical pictures of the cause Alcoholics epilepsy << C.N.S. epilepsy alcohol Korsakoff syndrome alcohol manifestations Oral examination Oral amnesia nystagmus ataxia confabulation Korsakoff syndrome manifestations encephalopathy amnesia nystagmus ataxia confabulation cerebellar ataxia peripheral neuritis

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GIT Dr. Shaf3y

peripheral neuritis Cerebellar ataxia brain Korsakoff syndrome Epilepsy Heart Dilated cardiomyopathy

pancreatitis

alcohol stone

Pancreatitis << stomach gastritis skin

contraction Fibrosis palmer aponeurosis differential diagnosis

Claw hand

ischemia

differential diagnosis supra condylar fracture of the humerus Volkmans ischemic contracture

investigations Liver function test Portal hypertension Investigations of the cause investigations of the cause biopsy Liver function test Gamma G.T. Gamma G.T. follow up of alcoholics Gamma G.T.

alcohol
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Portal hypertension

liver cell failure

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GIT Dr. Shaf3y

And finally Liver transplantation

Liver cirrhosis alcohol

alcohol alcohol

fulminant hepatic failure

alcohol fulminant hepatic failure

fatty liver Liver alcohol

alcohol

diseases fatty liver fulminant hepatic failure cirrhosis

acute hepatitis

metabolized Liver Liver inflammation nausea right hypochondirum pain even jaundice

vomiting

Hepatitis

Acute alcoholic hepatitis

alcoholic cirrhosis
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GIT Dr. Shaf3y

Congestive Cirrhosis
congestive cirrhosis Prolonged hepatic congestion congested viens Liver branches Liver 4 hepatic veins Inferior vena cava

inferior vena cava inferior vena cava right atrium right ventricle right atrium tricuspid

Liver

congestion venous drainage branches veno occlusive hepatic veins Budd Chiari

hepatic veins

inferior vena cava inferior vena caval thrombosis heart right ventricular failure tricuspid regurge tricuspid stenosis Constrictive pericarditis congestive cirrhosis veno occlusive Budd Chiari inferior vena caval occlusion right sided lesion
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GIT Dr. Shaf3y

congestive cirrhosis cirrhosis enlarged and tender Liver

tender << cirrhosis enlarged and tender << cirrhosis

congestive cirrhosis marked ascites Ascites

Absence of hepato-jugular reflux congestive cirrhosis absence of hepato-jugular reflux hepato-jugular reflux Liver neck veins Pressure Liver venous return

hepato-jugular reflux Hepatic veins occlusion of main hepatic veins

Liver Budd chiari

occlusion of the four hepatic veins Budd Chiari main hepatic veins Budd Chiari syndrome etiology veins

idiopathic we have no idea

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GIT Dr. Shaf3y

hypercoagulable state deficiency << S

C Polycythemia Antiphospholipid syndrome Hypercoagulable

is idiopathic Hypercoagulable state

hepatocellular carcinoma hepatic veins invasion

acute Budd Chiari Chronic Budd Chiari

acute

suddenly << veins acute suddenly << hepatic veins fulminant hepatic failure

chronic gradually << hepatic veins gradually << Liver congestion marked ascites enlarged tender liver manifestations of liver cell failure portal hypertension

absent hepato-jugular reflux

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GIT Dr. Shaf3y

investigations Liver function test Investigations for portal hypertension Investigations for the cause investigations for the cause ECHO veins ( Doppler occlusion Venography arterial phase << MRA venous phase MRA

venous phase

veins

occlusion acute fulminant streptokinase

fulminant hepatic failure acute type gradual type chronic

liver cell failure Portal hypertension Oral anticoagulant Liver transplanatation Veno occlusive Budd Chiari Typical branches

liver

veno occlusive Liver branches typical Budd Chiari

typical of occlusion Just intra hepatic << veno occlusive extra hepatic << Budd Chiari
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GIT Dr. Shaf3y

etiology idiopathic etiology idiopathic veno occlusive

disease

3 3

disease

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GIT Dr. Shaf3y

Hepatic veins branches thrombosis tea veno occlusive Budd Chiari biliary cirrhosis Cirrhosis

G.I.T. 53 2013 16

www.facebook.com/dr.tafreegh

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