Liver disease

Function of the liver

• Largest organ 1-1.5kg or about 1-2% body weight
• Dual blood supply
– 20% is Oxygenated hepatic artery from aorta
– 80% is from portal vein that drains the intestine
• 2/3 rd cells are hepatocyte rest are Kuppfer cell
which are part of reticuloendothelial system
• Liver function test is used to assess liver function-
albumin,bilirubin as well as evidence of
heaptocyte damage via transaminases
 Liver function
• synthesis of most essential serum proteins
(albumin, carrier proteins, coagulation factors,
many hormonal and growth factors),
• production of bile and its carriers (bile acids,
cholesterol, lecithin, phospholipids),
• the regulation of nutrients (glucose, glycogen,
lipids, cholesterol, amino acids), and
• metabolism and conjugation of lipophilic
compounds (bilirubin, anions, cations, drugs) for
excretion in the bile or urine
 Liver diseases
• hepatocellular diseases (such as viral hepatitis or
alcoholic liver disease), features of liver injury,
inflammation, and necrosis predominate
• cholestatic diseases (such as gallstone or
malignant obstruction, primary biliary cirrhosis,
some drug-induced liver diseases), features of
inhibition of bile flow predominate
• Mixed-hepatocellular and cholestatic injury are
present (such as in cholestatic forms of viral
hepatitis and many drug-induced liver diseases
 Specific liver disease
• Inheritable hyperbilirubinemia
– Criglar Najjer syndrome
– Dubin Johnson syndrome
– Rotor syndrome
– Gilbert syndrome
• Viral hepatitis-A,B,C,D,E,CMV
• Immune and autoimmune
– Primary biliary cirrhosis
– Autoimmune hepatitis
– Primary Sclerosing cholangitis
• Genetic disease
– Wilson disease-Abnormal Copper metabolism
– Haemachromatosis-excess iron storage
• Alcoholic liver disease
– Acute fatty liver
– Acute alcoholic hepatitis
– Chronic hepatitis/chronic alcoholic liver disease
– Cirrhosis
– Heaptocellular carcinoma
• Liver disease in systemic disease
– Tuberculosis
– Mycobacteria-intracellulare
– Sarcoidosis and amyloidosis
– Malaria
– Typhoid etc
• Cholestatic disorders
– Benign post operative cholestasis
– Jaundice of sepsis
– Cholestasis disorder of pregnancy
– Extrahepatic obstruction
• Stones/choledocholithiasis
• Strictures of biliary tract ,common bile duct
• Cholangiocarcinoma
• Head of Pancrease tumor
• Prmary sclerosing cholangitis
• Drug induced
– Hepatocellualr pattern eg isoniazid,acetaminophen
– Cholestasis-oral contraceptive,
• Vascular injury
– Budd-chiari
– Ischemic hepatitis in shock
– Portal vein thrombosis
– Venocclusive disorder
• Mass lesions
– Hepatocellualr carcinoma
– Metastatic tumor
– Abscess
– benign tumors eg haemangioma
 History -symptoms
• jaundice
• fatigue
• Itching in cholestasis
• right upper quadrant pain-acute hepatitis
• nausea, poor appetite, abdominal distention,
and intestinal bleeding
• Light stools and Dark urine in cholestasis
 History-risk factors
• details of alcohol use
• medications (including herbal compounds, birth control
pills, and over-the-counter medications), personal habits,
• sexual activity-risk for hepatitis B/C
• exposure to jaundiced or other high-risk persons, injection
drug use
• recent surgery
• remote or recent transfusion with blood and blood
products,
• occupation, accidental exposure to blood or needlestick,
and
• familial history of liver disease.
 signs
• Icterus/jaundice
• Hepatomegaly eg cirrhosis,metastic and primary tumor
• hepatic tenderness, splenomegaly,
• spider angiomata, palmar erythema, and excoriations.
• advanced disease include
– muscle wasting, ascites, edema, dilated abdominal veins,
– hepatic fetor
– asterixis, mental confusion, stupor, and coma (four stages)
of hepatic encephalopathy
– In males with cirrhosis, particularly when related to
alcohol, signs of hyperestrogenemia such as gynecomastia,
testicular atrophy, and loss of male-pattern hair
 Laboratory
• Serum alanine(ALT) and aspartic (AST)aminotransferases
• Alkaline phosphotase(ALP),gamma glutamyl
transferase(GGT)
• Bilirubirin-total and direct
• Prothrombin time index
• Albumin
• Hepatocellular pattern-ALT/AST markedly high.total and
indirect biluribin elevated.ALP/GGT normal or mild increase
• Cholestasis-ALP,GGT markedl elavated.Total and direct
bilirubin ,INR high.transminase normal or mildy increase
• Mixed picture-all of above high
 Diagnostic tests
• Viral serology e. g
– Hepatitis A igm/igG
– Hepatitis Bsag,e antigen,viral DNA etc
– Anti C Hepatitis antibodies
– Hepatitis D antibodies and HEPBs ag
– Anti Hepatitis E antibodies
• Autoimmune disease-Anti-smooth muscle antibodies,antinuclear
antibodies
• Primary biliary cirrhosis-mitochondrial antibodies,
• Wilson disease-decreased ceruloplamin,increased urinary copper
excretion
• Hemochromatosis-high serum ferritin,high iron saturation
• Hepatocellular carcinoma-high alpha-feto protein
 imaging
• Ultrasound-biliary system as well as liver masses
• CT SCAN,MRI-better delineation of masses,bilary
system,fatty liver,staging tumors
• Magnetic imaging cholangiopancreatogram-MRCP in biliary
cholestasis/obstruction and
• Endoscopic retrograde pancreatogram-ERCP are important
for bilary system delineation
• MRCP-no contrast,no ionizing radiation and is less operator
dependent unlike ERCP .impoertant in cholestasis
• ERCP allows for biopsy, direct visualization of the ampulla
and common bile duct. Diagnosis and therapeutic
• Therapeutic s e.g sphincterotomy, stone extraction, and
placement of nasobiliary catheters and biliary stents
• Liver biopsy-standard diagnostic criterion of
diagnosis of chronic liver disease
• Also staging and severity/grade of liver
damage ,predicting prognosis and monitoring
response to treatment
 Prognosis of liver disease-child-pugh
score
factor units 1 2 3

Serum bilirubin micromols <34 34-51 >51

Serum albumin g/dl >35 28-34 <28

Prothrombin INR <1.7 1.-2.3 >2.3

time

ascites none Easily Poorly

controlled controlled

encephalopath none minimal advanced

y
Used to prognosticate patients with cirrhosis in
terms of survival,portal hypertension
complications e.g bleeding from
varices,encephalopathy bacterial peritonitis
A 5-6 compensated cirrhosis
• B 7-9
• C >10 severe.very high mortality
• MELD-model for end stage liver disease has lately
replaced Child pugh for prognosis in chronic liver
disease .uses (INR), serum bilirubin, and
creatinine.more objective
 Hepatic encephalopathy
• Hepatic failure is defined as the occurrence of
signs or symptoms of hepatic encephalopathy in
a person with severe acute or chronic liver
disease.
• Range from subtle changes in sleep patterns,
change in personality, irritability, and mental
dullness.
• Thereafter, confusion, disorientation, stupor, and
eventually coma supervene
• In acute set up it’s a major criteria for fulminant
hepatitis and indicates poor prognosis
 Complications of liver failure
• The hepatopulmonary syndrome is
characterized by platypnea and orthodeoxia,
representing shortness of breath and oxygen
desaturation that occur paradoxically upon
assuming an upright position. Measurement
of oxygen saturation by pulse oximetry is a
reliable screening test for the presence of
hepatopulmonary syndrome.
• Hepatorenal syndrome-deteroriation of renal
function in patients with chronic liver disease
• Two categories
– Type 1-creatinine doubling in less than
2weeks.median survival about same
– Type 2-indolent.median survival months
• Cirrhotic cardiomyopathy-reduced systolic and
diastolic function
• Infections-kuppffer cell dysfunction
• Hepatocellular carcinoma-incidence of 3.5%