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Approach to the Patient with Liver Disease Chapter 301 Harrison 2012. Baghbanian M. Gasteroentrologist Sadughi hospital 1390/7/27. Diagnosis of liver disease is made by :. Careful history Physical examination Laboratory tests Radiologic examinations
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Approach to the Patient with Liver Disease Chapter 301 Harrison 2012 Baghbanian M. Gasteroentrologist Sadughi hospital 1390/7/27
Diagnosis of liver disease is made by : • Carefulhistory • Physical examination • Laboratory tests • Radiologicexaminations • Liver biopsy • less for diagnosis than for grading and staging
Liver Structure and Function • largest organ of the body • 1–1.5 kg • 1.5–2.5% of lean body mass. • size and shape of the liver vary and match the general body shape
The liver is located in ? RUQ under the right lower rib cage against the diaphragm and projects into the LUQ
The liver is held by ? • Ligamentous attachments to the diaphragm • Peritoneum • Great vessels • Upper gastrointestinal organs
Liver blood supply? Dual blood supply: • 20%: hepatic artery(oxygen-rich) • from celiac artery • 80% : portal vein (nutrient-rich ) • from stomach, intestines, pancreas, and spleen
Liver cells? The majority of cells : • hepatocytes (2/3 of the mass of the liver) The remaining cell are: • Kupffer cells (reticuloendothelial system) • stellate (Ito or fat-storing) cells • endothelial cells and blood vessels • bile ductular cells
Liver structure? In light microscopy: Lobuleswith portal areas at the periphery and central veins in the center of each lobule.
Portal areas? Consist of : • small veins • Arteries • bile ducts • lymphatics organized in a loose stroma of matrix and collagen.
Acini? physiologic unit of the liver : • helps to explain the morphologic patterns and zonality of many vascular and biliary diseases not explained by the lobular arrangement.
Acini • fenestrae in sinusoids→ free flow of plasma but not cellular elements. • plasma is in direct contact with hepatocytesin the subendothelial space of Disse.
Acini Blood flowing: • zone 1 → zone 3 of the acinus • portal veins → hepatic (central ) veins Bile flowing: • zone 3 → zone 1 of the acinus
Hepatocytes function? 1-synthesis of most proteins • (albumin, coagulation factors) 2-production of bile • (bile acids, cholesterol, phospholipids) 3-regulation of nutrients • (glucose, glycogen, lipids, amino acids) 4-metabolism and conjugation of compounds for excretion in bile or urine • (bilirubin, drugs)
most commonly liver "function" tests Serum bilirubin • is a measure of hepatic conjugation and excretion Albumin andprothrombin time • are measures of protein synthesis. hepatic dysfunction: Abnormalities of bilirubin, albumin, and prothrombin time
liver disease patterns? Hepatocellular diseases : inflammation and necrosis • (viral hepatitis or alcoholic liver disease) Cholestatic diseases: inhibition of bile flow • (gallstone or malignancy , primary biliary cirrhosis) Mixed pattern: hepatocellular + cholestatic • ( cholestatic forms of viral hepatitis and many drug-induced liver diseases).
Liver disease patterns is important? pattern of onset + prominence of symptoms can rapidly suggest a diagnosis
symptoms of liver disease? Fatigue Itching RUQ pain Nausea Poor appetite Abdominal distention GI bleeding
liver disease with no symptoms? Many patients with liver disease are no symptomatic Manifestaion : abnormalities in liver tests • As a part of a routine physical examination • Or screening for blood donation • Or for insurance or employment.
Diagnosis : HOW? 1- PATTERN of disease? • (hepatocellular, cholestatic, or mixed injury) 2- Specific ETIOLOGIC ? 3- Grading ? • (severity or activity of disease—active or inactive, and mild, moderate, or severe) 4-Staging ? • (whether acute or chronic; early or late; precirrhotic, cirrhotic, or end-stage)
Clinical history should focus on • symptoms of liver disease: • their nature • patterns of onset • patterns of progression • — potential risk factors for liver disease.
Clinical history Symptoms can also suggest the presence of: • cirrhosis and end-stage liver disease • complications of cirrhosis such as portal hypertension.
Fatigue The most common and most characteristic symptom of liver disease. • Typically after activity or exercise • Rarely present or severe in the morning after adequate rest • afternoonversus morning
Nausea Vomiting • Nausea occurs with more severe liver disease • May be provoked by odors of food or eating fatty foods. • Vomiting can occur but is rarely persistent or prominent.
Poor appetite with weight loss • Poor appetite with weight loss occurs commonly in acute liver diseases but • is rare in chronic disease • Except advanced cirrhosis
Diarrhea Diarrhea is uncommon in liver disease Except with severe jaundice • lack of bile acids can lead to steatorrhea
RUQ pain RUQ pain occurs in many liver diseases and is usually marked tenderness The pain arises from stretching or irritation of Glisson's capsule, which is rich in nerve endings.
Severe RUQ pain Is most typical of: • Gallbladder disease • Liver abscess • Severe venoocclusive disease • Occasional accompaniment of acute hepatitis.
Itching acute liver disease • early in obstructive jaundice • later in hepatocellular disease (acute hepatitis). chronic liver diseases • cholestatic disease (PSC and PBC) occur before the onset of jaundice • Itching can occur in any liver disease, particularly cirrhosis
Jaundice hallmark symptom of liver disease and perhaps the most reliable marker of severity. Patients usually report darkening of the urinebeforescleralicterus. Jaundice is rarely detectable in bilirubinlevel <2.5 mg/dL.
severe Jaundice With severe cholestasis : • lightening of the color of the stools • steatorrhea
Jaundice without dark urine Usually indicates indirect hyperbilirubinemia: • Hemolytic anemia • Genetic disorders of bilirubin conjugation • Gilbert'ssyndrome : common and benign • Crigler-Najjarsyndrome:rare and severe • Gilbert's syndrome affects 5% of the population; jaundice is more : after fasting and stress.
Risk factors for liver disease • Personal habits ( Alcohol use , Injection drug use) • Medications ( herbal , OCP, and over-the-counter) • Sexual activity • Exposure to jaundiced or other high-risk persons • Recent surgery • Remote or recent blood products transfusion • Occupation • Accidental exposure to blood or needlestick • Familial history of liver disease.
assessing the risk of viral hepatitis Careful history of sexual activity include: • the number of sexual partners • for men, a history of sex with men. Sexual exposure is : common mode of spread of hepatitis B rare for hepatitis C
Assessing the risk of viral hepatitis A family history of hepatitis, liver disease, and liver cancer is also important. Maternal-infant transmission occurs with both hepatitis B and C Vertical spread of HBV can now be prevented by passive and active immunization of the infant at birth
Vertical spread of hepatitis C Is uncommon There are no reliable means of prevention Transmission is more common in : • HIV-co-infected mothers • Prolonged and difficult delivery • Early rupture of membranes • Internal fetal monitoring
History of injection drug use Even in the remote past, is important for hepatitis B and C. Injection drug use is now the single most common risk factor for hepatitis C
Blood transfusion Transfusion with blood products is no longer an important risk factor for acute viral hepatitis Before : 1992 is important risk factor for hepatitis C. • HCV Ab didn’t checked 1986is a risk factor for hepatitis B. • anti-HBcdidn’t checked
Risk factors for hepatitis A • Travel to an underdeveloped area of the world • Exposure to persons with jaundice • Exposure to young children in day-care centers • Eating shellfish(rare)
Risk factors for Hepatitis E Is more common in Asia and Africa Eating raw or undercooked pork or game (deer and wild boars)
Tattooing and body piercing? For hepatitis B and C are frequently mentioned but are actually quite rare types of exposure
Alcohol In the United States,70% of adults drink alcohol , but significant alcohol intake is less common more than 2 drinks (22–30 g) per day in women 3 drinks (33–45 g) in men a AAlcoholic liver disease drunk for 10 years
Family history Familial causes of liver disease include: • Wilson's disease • Hemochromatosis • Alfa 1 antitrypsin deficiency • Familial intrahepaticcholestasis • Benign recurrent intrahepaticcholestasis • Alagille syndrome.
Wilson's disease Severe liver disease in childhood or adolescence with a family history of liver disease or neuropsychiatric disturbance investigation for Wilson's disease
Hemochromatosis Liver disease in adulthood WITH: • Family history of cirrhosis • Diabetes • Endocrine failure investigation of iron status