HEPATIC, BILIARY TRACT AND

PANCREATIC DISORDERS
• Diseases of the Liver
• 1. Hyperemesis gravidarum
• 2. Intrahepatic cholestasis of pregnancy
• 3. Acute Fatty Liver of Pregnancy
• 4. The Liver in Preeclampsia-eclampsia
• 5. Viral hepatitis
• 6. Chronic hepatitis
• 7. Cirrhosis
• 8. Portal HPN & esophageal varices
• 9. Acute acetaminophen overdose
• 10. Liver transplatantion
• Diseases of the gallbladder and Pancreas
• 1. Cholelitihiasis and cholecystitis
• 2. Pancreatitis
• 3. Pancreatic transplantation
• Diseases of the liver
• 1. Hyperemesis gravidarum – persistent
• nausea and vomitting
• there is mild hyperbilirubinemia
• elevated serum transaminases
• may lead to weight loss, dehydration,
• acidosis from starvation,
• alkalosis from loss of HCL in vomitus
• hypokalemia
• -- may be due to increase HCG & estrogen
• severe - ?- female fetus
• Cox- Mallory Weis Tears /esophageal rupture
• pneumothorax, pneumomediastinum
• Wernicke encephalopathy – cns symptoms
•
•
• Management of Hyperemesis
• a. dietary modification
• b. B complex like B6
• c. intravenous fluids
• Intrahepathic cholestasis of pregnancy
• recurrent jaundice of pregnancy
• icterus gravidarum(vomiting)
• cholestatic hepatosis
• char: pruritus, icterus or both
• Management of intrahepatic cholestasis
• a. pruritus – due to elevated serum bile
salts- give antihistamines & topical
emollients
• Pregnancy outcome – increase meconium
• stain passage
• Acute fatty liver of pregnancy
• acute liver failure :
• may be due to fulminant viral hepatitis
• drug-induced hepatic toxicity
• or acute fatty liver of pregnancy or
• called – acute fatty metamorphosis
• or acute yellow atrophy
• grossly – small, soft,yellow and greasy
• liver
• histopath – swollen – hepatocytes with
• central nuclei and cytoplasm filled with
• microvesicular fat
• Etiology – recessively inherited mitochondrial
abnormalities of fatty acid oxidation
• Fatty liver in pregnancy manifest late in
pregnancy.
• more common in nulliparas with male
• fetus
• symptoms: malaise, anorexia, nausea &
vomitting, epigastric pain, & progressive
• jaundice
• major symptom – persistent vomitting in late
• pregnancy
• 50% of women have HPN, proteinuria, edema
• Management – spontaneous resolution
follows after delivery
•
• The liver in preeclampsia- eclampsia-
• regions of periportal hemorrhage in the
• liver periphery
• elevated serum hepatic transaminase
• hemorrhage – hepatic rupture /
• subcapsular hematoma
• Viral hepatitis
• 5 distinct types of viral hepatitis
• 1. hepatitis – A
• 2. hepatitis B
• 3. hepatitis D –caused by hep B-assoc.
• delta agent
• 4. hepatitis C
• 5. hepatitis E
• All hepatitis virus except B are RNA
virus
•
• Viral hepatitis
• infections – subclinical
• nausea and vomitting, headache,
• malaise, may precede jaundice 1-2 wks
• low grade fever with hep A
• Minimize infectivity thro handwashing and
wearing of gloves on handling feces,
• Secretions, bedpans, and other articles in
• Contact with the patient
• Double gloving in delivery – hep B & C
• Recommend – active/ passive vaccination
•
• Hepatitis B
• More Asia and Africa
• DNA hepadna virus with serious
• sequelae – chronic hep, cirrhosis
• hepatocellular carcinoma
• Hep B core antigen (HBcAg)
• Hep B surface antigen (HBsAg) 1st
• serological marker
• Hep B e antigen (HBeAg) intact viral
• particles, early acute , if persistent
• indicates – chronic infection risk for hep Ca
• Hep B infection occurs in
• IV drug users
• homosexuals
• health care personnel
• blood transfusion – hemophiliacs
• Mode of transmission
• infected blood or blood products
• sexually transmitted by saliva, vaginal
secretions, semen, body secretion
• Pregnancy outcome
• Antiviral vaccine contraindicated in
pregnancy
• diagnosed on prenatal screening
• treatment is supportive
• transplacental viral infection of the fetus
• is not common.
• Most neonatal infection is vertically trans
• via peripartum ingestion of maternal
• fluids including breastmilk
• Mothers with HBeAg are more likely to
• Transmit the disease to their infants
• Mothers positive with anti-HBe antibody
are not infective
• Infants infected with Hep B are generally
• asymptomatic but 85% become
chronically infected.
• Prevention of neonatal infection –
• Infants with seropositive mothers are
• given Hep B immunoglobulin very soon
• after birth
• accompanied by the first dose of a
• 3-dose hep B recombinant vaccine
• Chronic hepatitis
• continuing hepatic necrosis, active
• inflammation, and fibrosis that may lead
• cirrhosis --- liver failure
• caused by Hep B or C viruses or
• autoimmune chronic hepatitis with
• high serum titers of homogenous
• antinuclear antibodies
• symptoms – non specific --- fatigue
•
• Diagnosis chronic hepatitis- liver biopsy
• Treatment - non pregnant
• 1. interferons with ribavirin for 6 months
• 2. lamivudine- prob – viral resistance
• 3. adefovir dipivoxil – for e antigen
positive and antigen positive hepatitisB
• With autoimmune chronic hep – cortico-
• steroids alone or + azathioprine
• Nonalcoholic fatty liver disease
• may lead to end-stage liver failure dse
• several names – fatty liver hepatitis
• non alcoholic Laennec disease, diabetes
• hepatitis, alcohol-like liver disease,
• nonalcoholic steatohepatitis “NASH”
• obesity /type 2 diabetes mellitus coexist
• with hyperlipidemia
• some may lead to cirrhosis
• Cirrhosis –
• irreversible chronic liver injury
• fibrosis and regenerative nodules
• in all patients Laennec cirrhosis from
• chronic exposure to alcohol –most
• common cause
• in young and pregnant – postnecrotic
• cirrhosis from hep B or C –most
• common cause
• s/s – jaundice,edema,coagulopathy,
• metabolic abn, portal HPN,gastroesophageal
• varices, splenomegaly
• Cirrhosis and pregnancy
• transient hepatic failure
• variceal hemorrhage
• fetal growth restriction
• preterm birth
• maternal death
•
• Portal HPN and esophageal varices
• from cirrhosis or from extrahepatic
• portal vein obstruction
• Treatment for increase portal pressure
• b-blocking drugs – propanolol
• Acute acetaminophen overdose
• lead to acute liver failure
• symptoms – nausea, vomitting,
diaphoresis, malaise, pallor
• latent 24 – 48 hours then liver failure
• begins to develop and resolve in 5 days
• The antidote for acetaminophen overdose is - N-
acetylcysteine stat oral loading dose of 140mg/kg of N
acetycysteine followed by 17 maintenance dose of
70mg/kg every 4 hours for 72 hours

• Liver transplantation – first successful

• transplant in 1978
• cox- HPN, infection, rejection
• preeclampsia – common
• patient needs close surveillance to detect HPN
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•
•
• Diseases of the Gall bladder
• Cholelithiasis –contain cholesterol,
• biliary sludge increase in pregnancy
• impt precursor to gallstone formation
• Acute cholecystitis due to obstruction in
• cystic duct
• bacterial infection in 85% of cases
• s/s – hx of right upper quadrant pain
• acute pain with nausea &
• vomitting, anorexia, low grade
• fever, mild leucocytosis
• Pregnancy is “lithogenic”
• Management - surgery
• antimicrobials

• Pancreatitis during pregnancy –

• activation of enzyme trypsinogen
• followed by autodigestion
• char: proteolysis cell membrane
destruction, edema, hemorrhage, necrosis
• epigastric pain,nausea and vomitting,
• abdominal distention
• Management of pancreatitis
• Pregnancy same as in nonpregnant
• medical tx – analgesics for pain
• intravenous hydration
• Pregnancy outcome - good