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מבוא לגסטרואנטרולוגיה ומחלות כבד PowerPoint PPT Presentation


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מבוא לגסטרואנטרולוגיה ומחלות כבד . דר. טיבריו הרשקוביץ המכון לגסטרואנטרולוגיה ומחלות כבד ביה"ח האוניברסיטאי הדסה. Infectious etiology of peptic ulcer disease.

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מבוא לגסטרואנטרולוגיה ומחלות כבד

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Infectious etiology of peptic ulcer disease

Infectious etiology of peptic ulcer disease

Barry Marshall, being a trainee in internal medicine working in Stewart Goodwins Laboratory in Perth, Australia, was with serendipity successful in culturing the bacteria.

Over the Easter holiday the Petri dishes with bacterial cultures were inadvertently left in the incubator in five, instead of two days, as recommended for Campylobacter.

When the dishes were examined after the holidays, small colonies with a shiny appearance were detected. This is the first successful culture and isolation of a bacterium from

the stomach of a patient with gastritis.

The findings were presented at a Campylobacter meeting 1983. Initially the

reports of an association between the bacterium and gastritis were met with great scepticismfrom the established scientific community. The findings were later published in

the Lancet.

One major question is whether the bacterium is the cause of gastritis or simply an innocent bystander that happen to colonise a damaged mucosa.


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In order to rule this out, Barry Marshall and Arthur Morris decided to inoculatethemselves by drinking a solution containing vast amounts of the bacterium under acid suppression with cimetidine

Both developed signs of an acute gastric flu-like illness, with gastric distension, nausea and vomiting.

After 10 days endoscopy revealed contraction of H pylori and chronic gastritis, which gradually subsided over the next two weeks.

Renewed endoscopy could not disclose the organism and the gastritis was

healing.

In the case of Morris the symptoms remained as a common gastritis

These cases are the ones to confirm the Kochs postulate that the bacterium

itself indeed is the cause of disease


Gastroenterology

Gastroenterology

Gastroenterology is the branch of medicine whereby the digestive system and its disorders are studied.

The name is a combination of three Ancient Greek words gaster=stomach, enteron=intestine and logos=reason. Gastroenterology is an Internal Medicine Subspecialty


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Bread butter

Bread & Butter

DATABASE


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  • /

  • MARS

  • / HIGH DEFINITION

  • -

  • : RF


Non invasive markers of liver injury

Non-invasive markers of liver injury

  • Fibroscan- elastometry

  • BioMarkers

  • FibroTest-ActiTes-FibroMax

    • Other markers published

      • Hyaluronic acid

      • SpectroTest: HA, A2M, TIMP1

      • GlycoCirrhotest

      • APRI: AST, platelets

      • Forns: Age,CT,GGT, Platelets

      • Rosenberg: HA, PIIIP, TIMP1

      • Leroy: TIMP1, MMP2

      • FPI: Age, CT, AST, Insulin, OH

      • Laine: HA, CarbohydrateDeficT, Transferrin

      • AP: Age-platelets


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Non-Invasive: Test of Fibrosis

  • Blood tests

    • Fibrotest

    • APRI

    • ELF

    • Forns

    • FIBROSpect

    • Fibrometer

    • Hepascore

    • FIB-4 (coinfected patients)

  • Liver Imaging

    • Transient elastrography

    • MR spectoscopy

    • Diffuse-weighted MRI

Sterling, Hepatology. 2006 43(6):1317-25

Halfon Am J Gastro. 2006; 101: 547-55

Wai Hepatol. 2003; 38: 518-26

Forms, Hepatol. 2002; 36:986-92

Patel, J Hepatol. 2004; 41: 935-42

Rosenberg, Gastro 2004 127:1704-13

Zaman, Am J Gastro. 2007; 120: e9-12

Lewin, Hepatol. 2007; 46: 658-65

Adams, Clin Chem. 2005; 51:1867-167

Cales, J Hepatol. 20054; 42: 1373-1383


Fibroscan transient elastography

-A new noninvasive technique to estimate liver fibrosis by measuring liver stiffness.

- Based on the propagation velocity of

elastic shear waves through the liver tissue.

-The harder the tissue the faster the

shear wave propagates.

Fibroscan(Transient Elastography)


L appareil

L'appareil

Specificelectronicequipment

Ultrasound acquisition chip

Digital signal processing

Integrated computer

Patient data base

Probe

3.5 MHz


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TOXINS:

Bile acids

Bilirubin

Prostacyclins

Nitric oxide

Indol/Phenol-

Metabolites

Toxic fatty acids

Thiols

Digoxin/Diazepam-

like Subst.

...

Ammonia

Lactate

Further liver damage

via vicious cycle:

necrosis/apoptosis !!!

Brain Function

Kidney Function

Cardiovascular Tone

Bone Marrow Activity

Liver failure endogenous intoxication

Ongoing

IMBALANCE

of

watersoluble and non-soluble

substances


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Water-based human body

(free)

(protein bound)

water soluble

toxins

non water soluble

toxins

BINDING SITE RELATED DISTRIBUTION

DIFFUSION

TOXIN REMOVAL

Filtration

(UNSELECTIV)

Plasma exchange

(UNSELECTIV)

DIALYSIS

ALBUMIN DIALYSIS

Balance of watersoluble substances

Balance of protein bound substances

MARS Therapy


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The MARS membrane


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The MARS membrane


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The MARS principle


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The MARSSystem


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Combination with different equipment

Fresenius4008


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  • STARTUP

  • WORKSHPS


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  • NOTES=NATURAL ORRIFICES TRANLUMINAL ENDOSCOPIC SURGERY

  • ESD=ENDOSCOPIC SUBMUCOSAL DISECTION

  • EMR=ENDOSCOPIC MUCOSAL RESECTION


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Sk a 33 year old woman married and a mother of 3 children a travel agency director

SK, a 33 year old woman, married and a mother of 3 children, a travel agency director

2000- 3rd trimester/2nd pregnancy

continuous abdominal pain

elevation of liver enzymes (hepatocellular up to 2 times the upper limit of the normal range -ULN)


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How often do you see such a patient?What is your differential diagnosis?When do you consult the hepatologist?Who is in charge of the case?


Would you suggest a liver biopsy at this stage

Following 3 daysThe classical liver diseases of pregnancy, AFLP, HELLP, IHCP, were ruled outShe underwent a negative evaluation for viral, autoimmune (including celiac disease) and metabolic etiologies Abdominal Ultrasound- normal liver and spleen

Would you suggest a liver biopsy at this stage?


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Following 7 daysThe patient is stable but the serum enzymes levels reach 10 times the upper limit of the normal range

  • Would you consider empiric treatment?

    • Urso-deoxy-cholic acid?/ safe during pregnancy?

    • Steroids?

    • Antiplatelets?

    • Anticoagulation?


Following 10 days abdominal pain continued and she developed severe pruritus

Following 10 daysAbdominal pain continued and she developed severe pruritus

Repeated Abdominal US was normal

Serum bile acids were normal

Would you recommend Ursodeoxycholic acid at this stage?

A liver biopsy?


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A Liver biopsy demonstrated: non-specific chronic hepatitis mildly active and portal fibrosis early septal formation diffuse steatosis

She was treated by ursodeoxycholic acid

with minimal improvement


Following 20 days no improvement

Following 20 days- no improvement

  • Role of MRCP? EUS? ERCP?

  • Following normal delivery abdominal CT scan and MRCP were normal

  • She is overweight , BMI 28 , US Doppler is normal

  • FibroMax- S1, A3,F3


She is very religious and she would like to become pregnant again

She is very religious and she would like to become pregnant again

If you don't approve her pregnancy, how can you prevent it?


2006 she is pregnant again for the 3 rd time

2006- she is pregnant againfor the 3rd time

During pregnancy, 3rd trimester, she developed a

classical picture of recurrent biliary colic, mild pruritus and

elevation of hepatocellular liver enzymes ( 6 times the

normal range) and normal liver in abdominal US

EUS? ERCP?


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EUS

Sludge in gallbladder


Laparoscopic cholecystectomy

Laparoscopic Cholecystectomy

  • The course was at first uneventful, but, liver biopsy during laparoscopy demonstrated - Active cirrhosis, delivery was induced

  • Within 4 weeks -significant deterioration of her liver function: fatigue, ascites without evidence of encephalopathy

  • Transaminases- 100 iu/ml, AlkPhosph- 300iu/ml, AFP-98 IU/ml

  • Albumin 2.4 mg/ml, bilirubin 6 mg%, , INR 2.2 Creatinine 0.7mg%, CBC-normal


Major issues

Major issues

  • What was her main liver problem? NASH?

  • Did she deteriorate due to the cholecystectomy?

  • Was the liver problem described in her previous pregnancy also due to biliary problems?


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