Hepatology PDF

Hepatology Dr. Mohamed Roshdi, MD Assistant Prof. Internal medicine, HOD  Learning Objectives Knowledge Describe epidemiology, manifestations, complications and management of hepatology disorders of dental impact Skills Interpret clinical manifestations and investigations...

Hepatology Dr. Mohamed Roshdi, MD Assistant Prof. Internal medicine, HOD  Learning Objectives Knowledge Describe epidemiology, manifestations, complications and management of hepatology disorders of dental impact Skills Interpret clinical manifestations and investigations of hepatology disorders of dental impact to formulate reasonable diagnosis. Apply evidence-based management plan for hepatology disorders of dental impact Distinguish patients in emergency situations to formulate a comprehensive management plan; ensuring keeping patients in normal homeostasis Liver Diseases of Dental Interest  1- Viral Hepatitis Inflammation of the liver caused by a range of viruses. The disease is seen in acute and chronic forms. Cause : Hepatitis viruses A, B, C, D and E. Other viruses: Epstein-Barr virus (EBV), herpes simplex virus (HSV), cytomegalovirus (CMV), and yellow fever virus.  Hepatitis A virus infection Hepatitis A viruses are RNA viruses Transmitted through the faecal-oral route. Risk groups : food handlers with poor hygiene. Incubation of the virus is between 15 and 50 days. There is no carrier state. Prophylaxis : immunoglobulin (Ig) and vaccine. Immunity following infection is probably for life.  Hepatitis B virus infection Hepatitis B viruses are DNA viruses Transmitted through percutaneous, sexual or perinatal routes. Risk groups for hepatitis B virus infections include IV drug users, healthcare workers dealing with blood, haemodialysis patients, male homosexuals, heterosexuals with multiple partners, and recipients of blood transfusions. Incubation of the virus is 30-180 days. There is a carrier state for this infection. Prophylaxis is through Hepatitis B immunoglobulin (HbIg) & vaccine. Immunity following infection is probably lifelong.  Hepatitis C virus infection Hepatitis viruses are RNA viruses Transmitted through percutaneous, and occasionally sexual or perinatal routes. Risk groups for hepatitis C virus infections include IV drug users, healthcare workers dealing with blood, haemodialysis patients, and recipients of blood transfusions. Incubation of the virus is 15-160 days. There is carrier state for this infection (50-80%). There is no prophylaxis for this infection and no vaccine is available.  Hepatitis D virus infection Hepatitis D viruses are defective RNA viruses Transmitted through percutaneous, sexual or perinatal routes. This virus infects with hepatitis B virus. Risk groups include IV drug users, healthcare workers dealing with blood, haemodialysis patients, homosexuals, heterosexuals and recipients of blood transfusion. Incubation of the virus is 21-140 days. There is a carrier state for this infection. Prophylaxis is not available but HBV vaccine offers some immunity for susceptible persons.  Hepatitis E virus infection Hepatitis E viruses are defective RNA viruses Transmitted through faecal-oral routes. Risk groups for hepatitis E virus infections include travellers to endemic areas as India,Asia, Africa & Central America. Incubation of the virus is 15-64 days. There is no carrier state No prophylaxis available for this infection. Immunity following this infection may last a lifetime. Clinical features of viral hepatitis There are no clinical differences between types of viruses. Generally patients complain of flu like symptoms in the early phase of infection. Three stages of infection are often noticed: Preicteric phase (1-2 weeks before the onset of jaundice): characterised by anorexia, nausea, vomiting, fatigue,myalgia, malaise and fever. Icteric phase: appearance of jaundice & right upper quadrant pain, with anorexia, nausea & vomiting. Hepatomegaly &splenomegaly. This phase lasts from between 2 & 8 weeks. Posticteric phase: In this phase, symptoms disappear but hepatomegaly persists for some time. Recovery is achieved in four months after the onset of jaundice. Oral Manifestations and Dental Management Considerations Jaundice of the oral mucosa in the icteric phase. Identification of carriers of HBV, HCV & HDV is essential. All patients are to be considered potentially infectious. Standard precautions must be used at all times Patients with active hepatitis: Consultation. No dental treatment should be given unless it is urgent. No hepatotoxic drugs are to be prescribed for these patients. Use an isolated operatory & adhere to standard precautions. Patients with a history of hepatitis: standard precautions. Patients at high risk for HBV infection: Screening for HbsAg is recommended before dental treatment is undertaken. Patients who are known hepatitis carriers (HbsAg positive): Adhere to infection control protocols during the treatment. No modification in dental treatment is necessary. Dentists who are hepatitis virus carriers: Dentists should adhere strictly to professional ethics and practice guidelines, and to standard precautions in the operatory. Periodically, the dentist should test his/her HBsAg status. Obtaining informed consent from patients is essential. Until seroconversion, dental practice should be discontinued. Diagnosis/investigations: History, physical findings and blood tests for liver enzymes (elevated) bilirubin (raised), prothrombin time (elevated), and WBCs (increased).  2- Alcoholic liver disease (ALD) Alcoholic liver disease (ALD) refers to liver damage and its function as a result of alcohol abuse. Classification of ALD 1. Fatty liver: is the mildest form of reversible liver injury. 2. Alcoholic hepatitis: features hepatocellular damage. Jaundice, fever and ascites are common at this stage. 3. Cirrhosis: displays fibrosis and nodule formation. Cirrhosis is irreversible. Symptoms and Signs: Suggestive of ALD, these include oedematous puffy face, traumatic or unexplained injuries and scars, memory deficits, slurred speech, jaundice of sclera and oral mucosa, ascites, white nails, oedema, ecchymoses, prolonged bleeding, parotid gland enlargement and a sweet, musty breath odour. Detect ALD by history, clinical examination, alcohol on the breath and obtaining information from family members. Dental considerations include: Referral or consultation with a physician to check current health status, medications, laboratory values and to discuss management issues. Laboratory screening for FBS, AST, ALT, bleeding time (BT), thrombin time (TT) and prothrombin time (PT) Avoidance of drugs metabolised by the liver is essential. If laboratory values are abnormal for surgical procedures, give consideration to fresh frozen plasma, vitamin K, or platelets. Alcohol prevention information must be given to patients. Patients are to be directed to healthcare providers for rehabilitation.  3- Liver cirrhosis Definition/description: Liver cirrhosis is a consequence of chronic liver disease chch by replacement of liver tissue by fibrosis, scar tissue and nodules leading to loss of function Causes: infection (Hepatitis B and C virus infections), metabolic (alcohol), immunological, drugs (methotrexate, methyldopa, isoniazid). Symptoms: These include lethargy, itching (because of deposition of bile salt products in skin),oedema & Ascites. Signs: Hepatomegaly, splenomegaly, jaundice, spider nevi, palmar erythema, finger clubbing, ascites, reduced body hair, oesophageal varices, dark urine and bruising. Normal esophagus Esophageal varices Oral manifestations and dental management considerations o Jaundice of the oral mucosa, bleeding tendencies and poor oral hygiene are common in patients with liver cirrhosis. o Hepatotoxic drugs are to be avoided in these patients. o Consultation with a physician is required before the commencement of any invasive procedure. Diagnosis/Investigations: Liver biopsy is the gold standard for the diagnosis of cirrhosis. Blood tests include CBC, viral serology, clotting studies, albumin, platelets and bilirubin. Endoscopy is done for oesophageal varices. Management: Cirrhosis is irreversible. A liver transplant is possible for those with end-stage cirrhosis. Complications should be treated appropriately.  4- Liver cancer (Hepatocellular carcinoma) Definition/description: A malignant tumour of the liver. This is one of the most common tumors worldwide. Causes: These include chronic HBV or HCV carriage, and cirrhosis from any cause. Symptoms and signs: Male to female ratio: 3:1. Symptoms include abdominal pain, weight loss, ascites, fever, jaundice and hepatomegaly. hypoglycaemia, hypocalcaemia. Oral manifestations: Oral mucosa may show signs of jaundice. Rarely, metastasis from the liver to oral tissues may occur. Consultation with a physician, surgeon or oncologist is required. Diagnosis/Investigations: liver biopsy. Estimation of alpha-fetoprotein (increased in 85% of patients), ultrasounds and CT scan. Management: resection or liver transplant, chemotherapy and opiates for pain.  5- Jaundice Definition/description: Jaundice is yellow discolouration of the tissues. This is noticed especially in the skin and sclera. Jaundice is due to the deposition of bilirubin & clinically visible when circulating bilirubin levels exceed 3 mg/L. Causes: haemolysis (prehepatic jaundice), Indirect liver disease (hepatic jaundice), Both biliary obstruction (cholestatic jaundice). Direct Prehepatic jaundice can occur due to congenital or acquired causes: These include: o Hereditary spherocytosis (congenital disorder) o Sickle cell disease o G6PD deficiency o Thalassaemia o Malaria o Incompatible blood transfusion Hepatic jaundice can occur due to acute or chronic hepatocellular disease. Causes include: o Viral hepatitis: hepatitis A, B or C, o Drugs: paracetamol and halothane o Toxins: carbon tetrachloride o Autoimmune disorders o End stage liver disease due to alcohol, cirrhosis. Cholestatic jaundice can occur due to intrahepatic & extrahepatic causes. These include: o Drugs such as chlorpromazine o Gallstones o Infestations such as schistosomiasis o Cholangitis o Carcinoma of the head of the pancreas Symptoms and signs: Yellow colouration of skin & sclera. In prehepatic jaundice, a family history of jaundice, history of haematuria and drug history offer some clues to the diagnosis. In hepatic jaundice, a history of alcohol abuse, travel, sexual activity, drug history, and blood transfusions offer useful hints. The liver is tender in hepatitis. Signs of liver failure as spider nevi, palmar erythema, finger clubbing, gynaecomastia, ascites, oedema, bruising tendencies. In cholestatic jaundice hepatomegaly, palpable gall bladder (in the presence of obstructive jaundice) and epigastric mass (carcinoma of the pancreas), may be seen. Oral Manifestations and Dental Management Considerations o Oral mucosa may show yellow coloration in patients with jaundice. o In patients with jaundice, bleeding tendencies may be present. In such cases, postoperative haemorrhage due to clotting factor deficiencies need to be identified & managed appropriately. o Hepatotoxic drugs must be avoided. o If the jaundice is due to viral hepatitis, the cross infection risk is to be in mind and appropriate infection control measures must be invoked. Investigations: The following are recommended for a patient with jaundice: o Full blood count (FBC) for haemolysis, malignancy and infections, o Erythrocyte sedimentation rate (ESR) for infections and malignancy, o Blood film for spherocytosis, reticulocyte count for haemolysis, o Liver function tests (LFTs), o Clotting screen, o Viral antibodies for hepatitis, o Ultrasound for gallstones. o CT scan for carcinoma of the head of the pancreas, Management: Since jaundice is a symptom, its management includes identification and elimination of its cause.  6- Ascites Definition/description: Ascites is the accumulation of excess free 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, oedema. Shortness of breath may also be present due to compression on diaphragm by ascites. Oral Manifestations and Dental Management Considerations There are no specific oral manifestations of ascites. but considerations specific to these conditions must be taken into account before offering dental treatment. Infection control measures need to be strictly followed and appropriate positioning of the dental chair for patient comfort must also be considered. Prior consultation with a physician is essential. Thank You