Liver and Biliary Tract Lecture Notes PDF

Liver Disorders Important liver functions Palpation of the Liver To palpate the liver, place left hand under patient, parallel to and supporting the right 11th and 12th ribs and right hand lateral to the rectus muscle with fingertips below...

Liver Disorders Important liver functions Palpation of the Liver To palpate the liver, place left hand under patient, parallel to and supporting the right 11th and 12th ribs and right hand lateral to the rectus muscle with fingertips below the liver border (as identified by dullness during percussion). As shown, press gently in and up as patient takes a deep breath. Palpation of the Liver Another approach is “The hooking technique” to stand by his right shoulder, hook the fingers of both hands (side by side) below the liver border, press in and up toward the costal margin, and ask him to inhale. You may be able to feel the soft, smooth, sharp edge of the liver descending during inspiration. The liver is considered enlarged if the edge extends more than 1.2 inch (3 cm) below the right costal margin. Palpation of the gallbladder  Murphy's sign Murphy's sign is elicited in patients with acute cholecystitis by asking the patient to take in and hold a deep breath while palpating the right subcostal area. If pain occurs on inspiration, when the inflamed gallbladder comes into contact with the examiner's hand, Murphy's sign is positive.  PRESENTING PROBLEMS IN LIVER DISEASE Acute liver injury may present with non-specific symptoms of fatigue and abnormal LFTs, or with jaundice and acute liver failure. Chronic liver injury is defined as hepatic injury, inflammation and/or fibrosis occurring in the liver for more than 6 months. In the early stages, patients can be asymptomatic with fluctuating abnormal LFTs. With more severe liver damage, however, the presentation can be with jaundice, portal hypertension or other signs of cirrhosis and hepatic decompensation. Causes of acute liver failure Clinical assessment of hepatic encephalopathy Investigations  Chronic liver failure Chronic liver injury is defined as hepatic injury, inflammation and/or fibrosis occurring in the liver for more than 6 months. In the early stages, patients can be asymptomatic with fluctuating abnormal LFTs. With more severe liver damage, however, the presentation can be with jaundice, portal hypertension or other signs of cirrhosis and hepatic decompensation. Chronic liver failure  Jaundice Jaundice is usually detectable clinically when the plasma bilirubin exceeds 40 µmol/L (~2.5 mg/dL). Pre-hepatic jaundice is caused either by haemolysis or by congenital hyperbilirubinaemia, and is characterised by an isolated raised bilirubin level. Hepatocellular jaundice results from an inability of the liver to transport bilirubin into the bile, occurring as a consequence of parenchymal disease. Obstructive (cholestatic) jaundice caused by: failure of hepatocytes to initiate bile flow obstruction of the bile ducts or portal tracts obstruction of bile flow in the extrahepatic bile ducts between the porta hepatis and the papilla of Vater Hepatomegaly Ascities Ascites  CIRRHOSIS Cirrhosis is characterised by diffuse hepatic fibrosis and nodule formation. It can occur at any age, has significant morbidity and is an important cause of premature death.  Prognosis The overall prognosis in cirrhosis is poor. Many patients present with advanced disease and/or serious complications that carry a high mortality. Overall, only 25% of patients survive 5 years from diagnosis but, where liver function is good, 50% survive for 5 years and 25% for up to 10 years. The prognosis is more favourable when the underlying cause of the cirrhosis can be corrected, as in alcohol misuse, haemochromatosis or Wilson’s disease.  PORTAL HYPERTENSION This frequently complicates cirrhosis but has other causes. The normal hepatic venous pressure gradient is 5–6 mm Hg. Clinically significant portal hypertension is present when the gradient exceeds 10 mm Hg and risk of variceal bleeding increases beyond a gradient of 12 mm Hg. Classification of portal hypertension according to site of vascular obstruction Viral hepatitis  AUTOIMMUNE LIVER AND BILIARY DISEASE The liver is an important target for autoimmune injury. The clinical picture is dictated by the nature of the autoimmune process and the target cell for immune injury.  Autoimmune hepatitis Autoimmune hepatitis is a disease of immune-mediated liver injury characterised by the presence of serum antibodies and peripheral blood T lymphocytes reactive with self-proteins, a strong association with other autoimmune diseases and high levels of serum immunoglobulins – in particular, elevation of IgG.  Clinical features fatigue anorexia jaundice fever arthralgia vitiligo epistaxis  Cholecystitis Acute cholecystitis is almost always associated with obstruction of the gallbladder neck or cystic duct by a gallstone. Clinical features: Pain: in the right upper quadrant and epigastrium in the right shoulder tip In the interscapular region Fever Jaundice Chronic cholecystitis is associated with gallstones. The clinical features are similar to those of acute calculous cholecystitis but milder. Patients are usually advised to undergo elective laparoscopic cholecystectomy.  Choledocholithiasis Stones in the common bile duct (choledocholithiasis) occur in 10– 15% of patients with gallstones which have usually migrated from the gallbladder. Choledocholithiasis may be asymptomatic, may be found incidentally by operative cholangiography at cholecystectomy, or may manifest as recurrent abdominal pain with or without jaundice. The pain is usually in the right upper quadrant, and fever, pruritus and dark urine may be present. Rigors may be a feature; jaundice is common and usually associated with pain.  Liver function tests Screen for liver infections, such as hepatitis. Monitor a disease, such as viral or alcoholic hepatitis, and determine how well a treatment is working. Look for signs of cirrhosis. Monitor possible side effects of medicines.  Liver function tests Alanine transaminase (ALT). ALT is an enzyme found in the liver that helps convert proteins into energy for the liver cells. When the liver is damaged, ALT is released into the bloodstream and levels increase. Aspartate transaminase (AST). AST is an enzyme that helps the body break down amino acids. Like ALT, AST is usually present in blood at low levels. An increase in AST levels may mean liver damage, liver disease or muscle damage.  Liver function tests Alkaline phosphatase (ALP). ALP is an enzyme found in the liver and bone and is important for breaking down proteins. Higher-than-usual levels of ALP may mean liver damage or disease, such as a blocked bile duct, or certain bone diseases, as this enzyme is also present in bones. Albumin and total protein. Albumin is one of several proteins made in the liver. Lower-than-usual levels of albumin and total protein may mean liver damage or disease. These low levels also can be seen in other gastrointestinal and kidney-related conditions.  Liver function tests Bilirubin. Bilirubin is a substance produced during the breakdown of red blood cells. Bilirubin passes through the liver and is excreted in stool. Higher levels of bilirubin might mean liver damage or disease. At times, conditions such as a blockage of the liver ducts or certain types of anemia also can lead to elevated bilirubin. Gamma-glutamyltransferase (GGT). GGT is an enzyme in the blood. Higher-than-usual levels may mean liver or bile duct damage. This test is nonspecific and may be elevated in conditions other than liver  Liver function tests L-lactate dehydrogenase (LD). LD is an enzyme found in the liver. Higher levels may mean liver damage. However, other conditions also may cause higher levels of LD. Prothrombin time (PT). Increased PT may mean liver damage. However, it also can be higher if patient is taking certain blood-thinning drugs, such as warfarin.  Thank you for your attention!