Lect 13 Disorders of the Liver and Clinical Manifestations.pdf

Disorders of the Liver and Clinical Manifestations Chapter 16 Lec # 13 Liver Disorders • Hepatitis • Viral Hepatitis – A,B,C,D,E • Alcoholic Liver Disease • Fatty Liver • Cirrhosis • Cholestatic – PBC ( Primary biliary cirrhosis) – PSC (Primary schlerosing cholangitis) • Inherited • Others He...

Disorders of the Liver and Clinical Manifestations Chapter 16 Lec # 13 Liver Disorders • Hepatitis • Viral Hepatitis – A,B,C,D,E • Alcoholic Liver Disease • Fatty Liver • Cirrhosis • Cholestatic – PBC ( Primary biliary cirrhosis) – PSC (Primary schlerosing cholangitis) • Inherited • Others Hepatitis vs Viral Hepatitis • Hepatitis – Inflammation of the liver caused by a virus, bacteria, toxins, obstruction, parasites, or chemical. • Viral Hepatitis – Caused by one of 5 viruses • • • • • A - HAV B - HBV C - HCV D - HDV E - HEV Acute Viral Hepatitis • Hep A (HAV) – Fecal-oral route ‫الغذاء والصرف الصحي‬ – Contaminated drinking water, food & sewage • Symptoms – Anorexia, N/V, dark urine, jaundice • Recovery – possible Acute Viral Hepatitis • Hep B and C (HBV) and (HCV) – Transmitted via blood, semen, and saliva – Spread by sharing needles, open cuts, sexual contact – Blood transfusion or transplants prior to 1992 – Body piercing or tattooing ‫ثقب الجسم أو الوشم‬ – Healthcare workers (HBV) - vaccine – Can lead to cirrhosis and liver failure ‫فيروس التهاب الكبد الوبائي )سي( هو اآلن‬ ‫السبب الرئيسي لعمليات زراعة الكبد‬ – HCV now the leading reason for liver transplants Acute Viral Hepatitis • Hepatitis D (HDV) ‫العدوى املصاحبة أو العدوى الفائقة‬ – Coinfection or a super infection – Dependent on HBV – Usually becomes chronic Acute Viral Hepatitis • Hepatitis E (HEV) – More common in Asia, Africa, Mexico – Transmitted via oral-fecal route – Contaminated water due to overcrowding and poor waste management ‫املياه امللوثة بسبب االكتظاظ و سوء إدارة النفايات‬ – Usually acute and not chronic Alcoholic Liver Disease - ALD • Serious physical, psychosocial, and nutritional implications • Ethanol metabolized in liver by alcohol dehydrogenase to acetaldehyde which is highly toxic. ‫يتم استقالب اإليثانول في الكبد بواسطة الكحول‬ .‫ديهيدروجينيز إلى األسيتالديهيد وهوشديدة السمية‬ Toxic Effects of Excess Alcohol Use Alcoholic Liver Disease Fatty Liver • Steatohepatitis Another name ‫التهاب الكبد الدهني‬ Alcohol Hepatitis • Often Asymptomatic • AST/ALT > 1.0 U/L Cirrhosis • Scar tissue replaces healthy tissue Alcoholic Liver Disease - ALD • Fatty Liver or Steatohepatitis • Increased mobilization of FA from adipose tissue • Increased synthesis of FA in liver • Decreased FA oxidation • Increased TG production • TG trapped in liver ‫يمكن أن يصاب به من ال يشرب الكحول أيضا‬ • In the absence of alcohol – NASH or NAFLD • IS REVERSIBLE Alcoholic Liver Disease - ALD • Alcoholic Hepatitis – Toxic liver injury associated with chronic ethanol consumption – Presents with nausea, fever, jaundice, hepatomegaly, ascites, portal hypertension, ‫يتجلى مع الغثيان والحمى واليرقان‬ hepatic encephalopathy ،,‫البابي‬ ‫ ارتفاع ضغط الدم‬,‫ استسقاء‬,‫تضخم الكبد‬ – Malnutrition a problem ‫اعتالل الدماغ الكبدي‬ AST/ALT > 1.0 U/L Cirrhosis - ESLD • Cirrhosis – Fibrous tissue replace healthy tissue in the liver Scar tissue blocks the flow of blood through the organ – Loss of organ function – Caused by Hep C and ETOH • Or obstruction possibly End Stage Liver Disease Cirrhosis ‫حفظ اللي بالدائرة فقط‬ Clinical Manifestations of Liver Disease • Jaundice What’s it? – Increased bilirubin in blood – Results from: • Increased destruction of RBC • Decreased uptake of bilirubin and/or decreased liver function • Obstruction of bile ducts which prevents excretion of bilirubin into the GI tract Clinical Manifestations of Liver Disease • Ascites – Accumulation of fluid in the peritoneal cavity – Fluid high in serum protein & electrolytes – Due to portal HTN and hypoalbuminemia Ascites Con’t • • • • Increased intrahepatic pressure Fluid “leaks” into peritoneum Intravascular volume decreases Signals kidneys to retain water and sodium to restore vascular volume - RAAS – Renin (kidneys) – Aldosterone (adrenal gland) Ascites Con’t • Ascites Treatment – Medications • Diuretic – Aldactone (aldosterone blocking agent, kidneys release water and sodium) – Medical procedures • Paracentesis – Diet • Low sodium Clinical Manifestations of Liver Disease Clinical Manifestations of Liver Disease • Portal HTN – Obstruction of blood flow through the liver – Increases blood pressure in portal venous system – Causes varices in GI • Esophageal • Gastric • Hemorrhoid – Increased risk of hemorrhage Esophageal Varices Esophageal Varcies Clinical Manifestations of Liver Disease • Hepatic Encephalopathy – A syndrome characterized by impaired mental status, neuromuscular disturbances and altered consciousness. – 4 stages of progressions – 3 major theories • The ammonia hypothesis ‫فرضية األمونيا • فرضية السم العصبي التآزري • الناقل العصبي الكاذب‬ . • The synergistic neurotoxin hypothesis • False neurotransmitter Clinical Manifestations of Liver Disease • Hepatic Encephalopathy - Altered Neurotransmitter Theory – Serum branched chain amino acids (BCAAleucine, isoleucine, valine) are decreased – Serum aromatic amino acids (AAAphenylalanine, tyrosine, tryptophan) are increased – BCAA used as energy source causes levels to fall. Clinical Manifestations of Liver Disease • Hepatic Encephalopathy - Altered Neurotransmitter Theory Con’t – AAA increase due to muscle breakdown and livers inability to use for protein synthesis – AAA inhibit cerebral uptake of BCAA and act as false neurotransmitters resulting in HE ‫ بسبب انهيار العضالت و عدم قدرة الكبد على استخدامه لتخليق البروتني‬AAA ‫– زيادة‬ HE ‫ وتعمل الناقالت العصبية الكاذبة مما يؤدي إلى‬BCAA ‫ االمتصاص الدماغي لـ‬AAA ‫ تمنع‬- Medical Management of Clinical Manifestations • Diuretic therapy • Medications for encephalopathy – Lactulose – Neomycin • Management of portal hypertension – medications • Monitoring of blood glucose Cholestatic Liver Disease (destruction of or the inflammation of bile ducts) PBC • Primary biliary cirrhosis • Immune mediated • Progressive destruction of intrahepatic bile ducts • 90% female • • • • PSC Primary schlerosing cholangitis May be immune mediated Inflammation of extrahepatic bile ducts 60-70% male Cholestatic Liver Disease PBC • Many people asymptomatic • Present with slightly elevated LFT • Positive AMA – Antimitochrondrial Antibody • Meds slow progression • Requires transplant PSC • 50-75% of patients also have IBD • Fat soluble vitamin deficiencies • Meds slow progression but has no effect on survival Summary • Lifestyle issues can play a role in liver disease • Some liver diseases have autoimmune or genetic links • Check any bias you have at the door before assuming the problem is caused by alcohol • The RD will play an important role in preventing or reversing malnutrition in patients with liver disease.