Podcast
Questions and Answers
What is the primary cause of liver cancer according to the information provided?
What is the primary cause of liver cancer according to the information provided?
Which of the following is NOT a symptom associated with liver disease?
Which of the following is NOT a symptom associated with liver disease?
What is considered the gold standard for diagnosing cirrhosis?
What is considered the gold standard for diagnosing cirrhosis?
Which of the following is a potential cause of prehepatic jaundice?
Which of the following is a potential cause of prehepatic jaundice?
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Which type of jaundice arises from liver disease?
Which type of jaundice arises from liver disease?
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What is one possible management strategy for end-stage liver cirrhosis?
What is one possible management strategy for end-stage liver cirrhosis?
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What is a common laboratory investigation recommended for patients with jaundice?
What is a common laboratory investigation recommended for patients with jaundice?
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Which symptom may indicate hepatic jaundice rather than prehepatic jaundice?
Which symptom may indicate hepatic jaundice rather than prehepatic jaundice?
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What bilirubin level is clinically significant for detecting jaundice?
What bilirubin level is clinically significant for detecting jaundice?
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Which of the following conditions may lead to prehepatic jaundice?
Which of the following conditions may lead to prehepatic jaundice?
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What is a common oral manifestation seen in patients with jaundice?
What is a common oral manifestation seen in patients with jaundice?
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Which condition is NOT identified as a cause of ascites?
Which condition is NOT identified as a cause of ascites?
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Which investigation is used to estimate the presence of liver cancer?
Which investigation is used to estimate the presence of liver cancer?
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What management strategy is essential for treating jaundice?
What management strategy is essential for treating jaundice?
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Which of the following conditions may present with hepatomegaly and a palpable gallbladder?
Which of the following conditions may present with hepatomegaly and a palpable gallbladder?
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What symptom may be present due to ascites?
What symptom may be present due to ascites?
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What is the definition of alcoholic liver disease (ALD)?
What is the definition of alcoholic liver disease (ALD)?
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Which of the following symptoms is NOT associated with liver cirrhosis?
Which of the following symptoms is NOT associated with liver cirrhosis?
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What is the characteristic feature of alcoholic hepatitis?
What is the characteristic feature of alcoholic hepatitis?
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Which diagnostic technique is essential for detecting alcoholic liver disease (ALD)?
Which diagnostic technique is essential for detecting alcoholic liver disease (ALD)?
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What is a common management strategy for patients with liver cirrhosis?
What is a common management strategy for patients with liver cirrhosis?
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Which of the following is a typical sign of liver disease related to bile salt deposition?
Which of the following is a typical sign of liver disease related to bile salt deposition?
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What is a major indicator of liver dysfunction in laboratory tests?
What is a major indicator of liver dysfunction in laboratory tests?
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Which of these symptoms is indicative of cirrhosis rather than other liver conditions?
Which of these symptoms is indicative of cirrhosis rather than other liver conditions?
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Study Notes
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
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Yellow discoloration of tissues (skin and sclera) due to bilirubin > 3 mg/L.
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Prehepatic jaundice: due to (congenital or acquired) hemolysis (e.g., hereditary spherocytosis, sickle cell disease, G6PD deficiency, thalassemia, malaria, or incompatible blood transfusion).
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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).
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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).
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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).
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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.
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