Untitled Quiz

Hepatology Overview

• Hepatology is the study of the liver and liver diseases.
• Dr. Mohamed Roshdi, MD, is the Assistant Professor of Internal Medicine and HOD.

Learning Objectives

• Knowledge: Describe epidemiology, manifestations, complications and management of liver disorders impacting dental health.
• Skills: Interpret clinical signs and tests for liver disorders to make diagnoses, apply evidence-based treatment plans for liver disorders, and distinguish emergency situations for comprehensive management plans that maintain homeostasis, all concerning dental impact.

Liver Diseases of Dental Interest

• This section focuses on liver diseases relevant to dentistry, a specific area of study.

Viral Hepatitis

• Inflammation of the liver due to viruses (A, B, C, D, and E) and other viruses (Epstein-Barr virus, herpes simplex virus, cytomegalovirus, yellow fever virus).
• Can present in acute or chronic forms.

Hepatitis A

• RNA virus.
• Transmitted through the fecal-oral route.
• Risk factors include poor hygiene practices among food handlers.
• Incubation period: 15-50 days.
• No carrier state.
• Prevention: Immunoglobulin (Ig) and vaccine.
• Lifelong immunity.

Hepatitis B

• DNA virus.
• Spread via percutaneous, sexual and perinatal routes.
• Risk factors: IV drug users, healthcare workers dealing with blood, hemodialysis patients, male homosexuals/bisexuals, and recipients of blood transfusions.
• Incubation period: 30-180 days.
• Carrier state is possible.
• Prevention: Hepatitis B immunoglobulin (Hblg) and vaccine.
• Lifelong immunity likely.

Hepatitis C

• RNA virus.
• Spread via percutaneous (including sexual, but less frequent) and perinatal transmission.
• Risk factors: IV drug users, healthcare workers dealing with blood, hemodialysis patients, blood recipients.
• Incubation period: 15-160 days.
• Carrier state is common (50-80%).
• No prophylaxis/vaccine available.

Hepatitis D

• Defective RNA virus.
• Requires Hepatitis B for infection.
• Transmission routes similar to Hepatitis B.
• Risk factors: IV drug users, healthcare workers dealing with blood, hemodialysis patients, homosexuals/bisexuals, and blood recipients.
• Incubation period: 21-140 days.
• Carrier state is possible.
• HBV vaccine offers some immunity.

Hepatitis E

• Defective RNA virus.
• Transmitted through the fecal-oral route.
• Risk factors: Travelers to endemic areas (India, Asia, Africa, Central America).
• Incubation period: 15-64 days.
• No carrier state.
• No prophylaxis available.
• Likely lifelong immunity.

Clinical Features of Viral Hepatitis

• Similar clinical presentation across different hepatitis types.
• Early symptoms mimic flu-like illness.
• Three stages are common: preicteric, icteric, and posticteric.
• Preicteric: anorexia, nausea, vomiting, fatigue, myalgia, malaise, fever (1-2 weeks before jaundice).
• Icteric: jaundice, right upper quadrant pain, anorexia, nausea, vomiting, hepatomegaly (and splenomegaly) lasts 2-8 weeks.
• Posticteric: symptoms disappear, hepatomegaly persists, recovery within 4 months of jaundice onset.

Oral Manifestations and Dental Management Considerations

• Jaundice of the oral mucosa in the icteric phase.
• All patients are potentially infectious.
• Standard precautions are essential.
• Hepatitis carriers (HBV, HCV, HDV) should be identified.
• Active hepatitis patients require consultation before treatment, unless urgent.
• Hepatotoxic drugs should not be prescribed.
• Use an isolated operatory.
• Patients with a history of hepatitis require standard precautions during dental care.
• Patients with high-risk of HBV infection should be screened before dental treatment.

2- Alcoholic Liver Disease (ALD)

• Liver damage caused by alcohol abuse.
• Three stages: fatty liver, alcoholic hepatitis, and cirrhosis.
• Fatty liver: Mildest & reversible liver injury.
• Alcoholic Hepatitis: characterized by hepatocellular damage, jaundice, fever, and ascites.
• Cirrhosis: irreversible scarring and nodule formation.
• Symptoms: oedematous puffy face, traumatic injuries, scars, memory deficits, slurred speech, jaundice (sclera & oral mucosa), ascites, white nails, oedema, ecchymoses, bleeding, parotid gland enlargement, musty odor.
• Detection by history, clinical exam, breath odor, and family member input.
• Referral to physician for health status, medications, lab values, and management discussion.
• Labs: FBS, AST, ALT, BT, TT, PT.
• Precautions: Avoid drugs metabolized by liver. Consider fresh frozen plasma, Vitamin K, or platelets if abnormal labs.
• Patient education on alcohol prevention and rehabilitation.

3- Liver Cirrhosis

• Liver damage results in scar tissue/fibrosis formation.
• Causes: infections (Hepatitis B&C), metabolic issues (alcohol), immunological issues, medications (methotrexate, methyldopa, isoniazid).
• Symptoms: fatigue, itchiness (due to bile salts), edema, ascites.
• Signs: Hepatomegaly, splenomegaly, jaundice, spider nevi, palmar erythema, finger clubbing, ascites, reduced body hair, esophageal varices, dark urine, and bruising.
• Management: Liver biopsy (gold standard). Blood tests (CBC, viral serology, clotting studies, albumin, platelets, bilirubin). Endoscopy for esophageal varices. Cirrhosis is irreversible; a liver transplant may be an option in end-stage cases. Complication management is crucial.

4- Liver Cancer (Hepatocellular Carcinoma)

• Malignant tumor of the liver.
• Common worldwide.
• Causes: Chronic Hepatitis B or C, cirrhosis from any cause.
• Symptoms: male-to-female ratio 3:1. Abdominal pain, weight loss, ascites, fever, jaundice, hepatomegaly, hypoglycemia, hypocalcemia.
• Oral manifestations: jaundice of oral mucosa, and rarely, oral metastasis.
• Require physician, surgeon, or oncologist consultation.
• Diagnosis/Investigations: liver biopsy, alpha-fetoprotein estimation, ultrasounds, CT scans.
• Management: resection or liver transplant, chemotherapy, pain management (opiates).

5- Jaundice

• Yellow discoloration of tissues (skin and sclera) due to bilirubin > 3 mg/L.

• Prehepatic jaundice: due to (congenital or acquired) hemolysis (e.g., hereditary spherocytosis, sickle cell disease, G6PD deficiency, thalassemia, malaria, or incompatible blood transfusion).

• Hepatic jaundice: due to (acute or chronic) hepatocellular disease (e.g., viral hepatitis, drugs—paracetamol, halothane, toxins—carbon tetrachloride, autoimmune disorders, and end-stage liver disease due to alcohol or cirrhosis).

• Cholestatic jaundice: due to (intrahepatic or extrahepatic) obstruction (e.g., drugs such as chlorpromazine, infestations—schistosomiasis, or carcinoma of the head of the pancreas, gallstones, cholangitis).

• Symptoms and signs: Yellow coloration of the skin & sclera. Clues to prehepatic jaundice: family history of jaundice, history of hematuria, and drug history. Clues to hepatic jaundice: history of alcohol abuse, travel, sexual activity, drug history, and blood transfusions. Clues to cholestatic jaundice: hepatomegaly, palpable gallbladder (in the presence of obstructive jaundice), and epigastric mass (carcinoma of the pancreas).

• Management: Identify and eliminate the cause

6- Ascites

• Accumulation of excess fluid in the peritoneal cavity.
• Causes: liver cirrhosis, hepatic tumors, pelvic or abdominal tumors, cardiac failure, and pancreatitis.
• Symptoms and signs: abdominal discomfort, increasing abdominal girth, edema, shortness of breath (due to diaphragm compression).
• Dental management considerations: no specific oral manifestations but require considerations of the condition. Ensure infection control measures and appropriate positioning for patient comfort. Prior physician consultation is advised.