Liver Disease And Hepatitis GN PDF

Liver Disease Rhona Mann Biomedical Science GDC learning outcomes Explain general and systemic disease and 1.1.3 their relevance to oral health Describe relevant and appropriate physiology 1.1.6 and explain its applica;on to pa;ent manage...

Liver Disease Rhona Mann Biomedical Science GDC learning outcomes Explain general and systemic disease and 1.1.3 their relevance to oral health Describe relevant and appropriate physiology 1.1.6 and explain its applica;on to pa;ent management Describe the proper;es of relevant medicines 1.1.8 and therapeu;c agents and discuss their applica;on to pa;ent management Aim Outline liver disease and explain its relevance to the dental hygienist/therapist Learning outcomes List the func;ons of the liver Describe how a liver becomes diseased Recognise the symptoms of liver disease Explain the relevance of liver disease to the dental hygienist/therapist State how a dental treatment plan may have to be modiEed because of liver disease Liver Largest internal organ in body Located below the diaphragm in right upper abdominal quadrant Largest gland in body – secretes bile which is stored in gall bladder Can regenerate (whole liver from as liJle as 25%)Can repair itself Posterior and anterior view of liver The many func@ons of the liver Essen;al for life Filters and cleans the blood Makes and breaks down sugar, proteins and fats Stores vitamins A,D,E,K and B12 Produces bile – essen;al for fat diges;on and absorp;on of fat soluble vitamins Stores minerals e.g. iron, copper Removes metabolic products and toxins from blood Fights infec;on - captures and digests bacteria, fungi, parasites, redundant blood cells and cellular debris Func@ons of the liver con@n/ Turns glucose into glycogen which is stored in the liver Regulates glucose and cholesterol levels Makes essen;al proteins e.g. blood cloYng factors, albumin, hormones, transporter proteins and complement Underlies normal haemostasis as it also produces hormone thrombopoie;n which s;mulates bone marrow to produce platelets Breaks down haemoglobin, cholesterol, proteins, sex steroids and many drugs e.g. alcohol, LA, analgesics, an;microbials, seda;ves What causes liver damage? Liver damage Able to renew and repair itself up to a point Damaged by Alcohol Viral infections – Hepatitis A-E Non alcoholic fatty liver disease Body’s own immune system – primary biliary cirrhosis Tumours and cysts Haemochromatosis Alcohol related liver damage Alcohol related liver disease The liver has to Elter alcohol in order to break it down and remove it from the body. Each ;me, some liver cells die during this process The liver needs a break from alcohol to allow it to regenerate and make new cells. Drinking too much alcohol over a long period of ;me means the liver can’t recover. This can result in serious and permanent damage. Three stages of alcohol related liver disease Alcoholic faJy liver disease usually no symptoms, reversible Alcoholic hepa;;s in\amma;on of liver, reversible in early stages if stop drinking permanently permanent damage in later stages Cirrhosis scarring (Ebrosis) of liver prevents normal func;on Irreversible Liver failure Symptoms of cirrhosis O]en no symptoms un;l liver severely damaged Tiredness and weakness Nausea and loss of appe;te Weight loss Palmar erythema (Liver palms) Spider naevi Breakage of capillaries and visible through skin Finger clubbing Sialosis Enlargement of parotid glands Symptoms of cirrhosis con@n/ Jaundice (due to build up of bile pigments) Itching of skin Dark urine and tarry-looking faeces Bleeding or bruising easily Loss of libido Build up of fluid - enlargement of abdomen Swollen legs or abdomen (ascites) Gynaecomas;a or tes;cular atrophy Enlargement of breast tissue Oesophageal varices Enlarged veins in oesophageal area Encephalopathy (leading to confusion) Swelling in certain areas of the brain Liver cancer Treatment of cirrhosis Not possible to cure, only deal with symptoms and complica;ons Lifestyle Stop drinking alcohol altogether Healthy diet to reduce malnutrition Low protein and low salt diet Lose weight Stop smoking Medicines (diure;cs, beta-blockers, creams to reduce skin itching) Liver transplant Non-Alcoholic faJy liver disease Non alcoholic faJy liver disease Build up of fat in liver Not caused by alcohol Usually related to obesity 4 stages – over many years Early stages o]en symptom free and no harm Liver in\amma;on Fibrosis Cirrhosis Symptoms of Ebrosis – abdominal pain, ;redness, weight loss, weakness Symptoms of cirrhosis – see above Non alcoholic faJy liver disease High levels of fat in liver are associated with diabetes, hypertension, liver disease Treatment Healthy lifestyle choices, lose weight, healthy diet, exercise, stop smoking, stop alcohol Treat complications e.g. diabetes, hypertension, high cholesterol Liver transplant if cirrhosis develops Other causes of liver damage Primary biliary cirrhosis Immune system mistakenly aJacks bile ducts Bile builds up in the liver, leads to liver cirrhosis a]er decades Symptoms include bone and joint aches, fa;gue, itchy skin, dry eyes and mouth, abdominal pain Treatment includes ursodeoxycholic acid and obe;cholic acid and medica;ons to relieve symptoms e.g. itching It untreated can also be associated with osteoporosis, portal hypertension, ascites, vitamin deEciencies, liver cancer Tumours and cysts Primary liver cancer Hepatocellular carcinoma most common Link between cirrhosis and cancer More common if pre-exis;ng cirrhosis Secondary liver cancer Metasta;c cancer from another organ e.g. breast, bowel, lung, ovary Liver cysts Simple cyst related to malforma;on of bile duct Congenital – polycys;c liver disease Caused by parasite echinococcus Haemachromotosis It is treatable Inherited condi;on Iron overload Damages liver, joints, pancreas and heart More likely to develop liver cancer Treated with phlebotomy and chela;ng agents (deferasirox) Blood removal and removal of ion Chelating therapy - filtering ion from blood Viral Hepa**s Viral hepa**s Viral infec+on of liver Hepa++s viruses A, B, C, D, E Most relevant ones to den+stry are Hep A, B, C. Hepa**s A Caused by the hepa++s A virus Faeco-oral route. Caught by consuming food and drink contaminated with the faeces of an infected person Most common in countries where sanita+on is poor. Symptoms pass usually within a few months No speciGc treatment for it, other than to relieve symptoms like pain, nausea and itching. Prevented by vaccina+on before travel to high risk countries. Hepa**s B Caused by the hepa++s B virus Common infec+on worldwide Spread in the blood of an infected person. Spread from infected pregnant women to their babies Can be spread through unprotected sex, sharing needles in drug use, needles+ck injuries, sharing razors/toothbrushes 5% become chronic carriers For life Some develop cirrhosis and liver cancer Hepa**s B In children it can persist for years and cause signiGcant liver damage 90% infected babies develop chronic hepa++s Vaccina+on for all healthcare workers Since 2017 added to child immunisa+on list Concentra*on of hepa**s B virus in body :uids  Low/not detectable: High: Urine Blood Faeces Serum Sweat Tears Wound exudates Breast milk Moderate: Semen Vaginal fluid Saliva Transmission con*nued….. Very infec+ous - more easily spread than HIV Can live outside the human body for up to 7 days Resilient and tough Click to add text People with chronic hepa++s B can have very large amounts of the virus in their blood Not spread by hugging, kissing, sneezing, coughing or sharing ea+ng utensils AVer needles+ck injury, seroconversion risk is 1 in 3 if not Pathogenesis Very serious and contagious Incuba*on – 45 to 180 days (average = 60 days) Virus enters hepatocytes via blood Immune response to viral an+gens expressed on hepatocyte cell surface is responsible for clinical syndrome 5% become chronic carriers (have a higher risk of hepatocellular carcinoma) Hepa++s B surface an+body probably confers lifelong immunity Symptoms of Hepa**s B  Symptoms of Hepa**s B May be asymptoma+c. If symptoms develop, they tend to happen 2 or 3 months aVer exposure to the hepa++s B virus. Can be severe Flu-like symptoms, including +redness, a fever, and general aches and pains, loss of appe+te, nausea, diarrhoea, gastric pain, Jaundice. Symptoms will usually pass within 1 to 3 months (acute hepa++s B), although occasionally the infec+on can last for 6 months or more (chronic hepa++s B). Diagnosis Blood tes+ng – serological tests. Hep B an*gens used as a general marker of infec+on Hep B an*bodies - used to document recovery and/or immunity to HBV infec+on Virus persists at low levels even aVer recovery Reac+va+on can occur spontaneously, par+cularly if immune system depressed Treatment for Hepa**s B Emergency treatment following exposure to Hep B Dose of Hep B vaccination Dose of immunoglobulin Acute Hepa++s B Rest, analgesia, symptom-relief e.g. metoclopromide for nausea Chronic Hepa++s B Peginterferon alfa-2a stimulates the immune system to attack the hep B virus, given by weekly injection, flu-like side effects Anti-viral medication e.g. tenofovir or entecavir, side effects nausea, vomiting, dizziness Treatment for Hepa**s B con*n/ avoid unprotected sex partners should be vaccinated against hepa++s B avoid sharing needles avoid sharing toothbrushes or razors eat a healthy balanced diet avoid drinking alcohol Preven*on Vaccina*on – for those at increased risk of HBV infec+on 3 doses: month 0, 1, 6 Immune response: 50% after 1 dose, 95% after 3 doses Duration of protection: >15 years, dependent on initial antibody response PREVENTION ( CONT'D) Hepa++s B immunoglobulin To protect people exposed to Hep B.....most ebec+ve within 48hrs of contact. Other: Screening of blood donors, blood and body duids precau+ons Remember! Hepa++s B carries a deGnite mortality risk As health care professionals you are poten+ally at risk and should be immunised All pa+ents should be treated as poten+al carriers of the disease - universal precau+ons Always wear your PPE – saliva to eye is a poten+al route of infec+on as well as the more obvious Always avoid the chance of needles+ck injury, and always report them if they do happen Hepa**s C Single-stranded RNA virus Pathogenesis, symptoms and routes of transmission same as Hep B Occupa+onal transmission – needles+ck injury case reports of transmission from blood splash to eye. UNIVERSAL PRECAUTIONS!! No vaccine against Hep C Long term complica+ons are cirrhosis, liver failure, liver cancer Chronic hep C is treated with direct ac+ng an+-viral medica+on for 8-12 weeks e.g. ribavarin, simeprevir, sofosbuvir, some+mes combina+ons of drugs. Side ebects include nausea and insomnia Lifestyle changes – stop alcohol, healthy diet, more exercise, stop smoking, don’t share razors and toothbrushes, don’t share needles  Hepa**s D and E Hepa++s D is a delta virus Only infects people who already have Hep B Chronic infec+ons cause liver scarring, cirrhosis and cancer Spread with contact with bodily duids Seen mainly in IV drug users Vaccine available Hepa++s E is an RNA virus Transmiied by faeco-oral route Similar to Hep A No vaccine Dental Aspects Dental ,ndings in liver disease Alcoholic cirrhosis – o+en poor OH, dental neglect, dental erosion from gastric re8ux Sialosis/paro=d enlargement Gingival enlargement if pa=ent is taking ciclosporin a+er liver transplant Children needing liver transplants may have delayed tooth erup=on and discoloured/hypoplas=c teeth Dental neglect Neglect Poor OH Increase in caries Increase in in8amma=on/periodontal disease Lack of professional dental care Due to health issues Sialosis Gingival overgrowth Possible if on anti-rejection drugs due to liver transplant Enlarged appearance on side of face due to enlarged parotid glands Dental management Increased bleeding risk Risk of poor wound healing and infec=on Problems metabolising drugs Dental management Infec=on control – universal precau=ons, staJ should be vaccinated against Hep B If liver transplant, pa=ent will be taking life-long immunosuppressants, increasing risk of infec=on – may need an=bio=c cover for invasive treatment Avoid elec=ve dental treatment un=l six months a+er transplant  What else do we need to consider? Due to issue metabolising drugs Reducing dose of LA? Use Articaine instead of Lidocaine Avoid use of NSAIDS May not be able to metabolize certain drugs including antibiotic: Tetracycline Dental management Preven9on, preven9on, preven9on OHI +++ Diet analysis and advice Fluoride supplements Alcohol cessa=on Smoking cessa=on Summary Func=ons of the liver Main causes of liver disease Symptoms of liver disease Dental implica=ons Further informa9on Waugh, A. and Grant, A. (2018) Ross & Wilson Anatomy And Physiology In Health And Illness. 13th ed. Elsevier. pp361-364 Hepa==s – all 5 forms of viral hepa==s (rapid review) h^ps://www.youtube.com/watch?v=MvxMJGfPp6w Bri=sh Liver Trust h^ps://bri=shlivertrust.org.uk/ NHS Liver Disease h^ps://www.nhs.uk/condi=ons/liver-disease/ Thankyou for your attention! If there is anything you wish to discuss please email me. I am more than happy to help! A short assessment will follow. Rhona Mann EDHEC Tutor Hygienist