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Jaundice: Work-up of Liver Disease. Murray N. Ehrinpreis, M.D. Wayne State University School of Medicine. Hepatobiliary System. Liver : most important metabolic organ -Regulates -Metabolizes/processes/detoxifies -Synthesizes

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Jaundice: Work-up of Liver Disease


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    1. Jaundice: Work-up of Liver Disease Murray N. Ehrinpreis, M.D. Wayne State University School of Medicine

    2. Hepatobiliary System • Liver: most important metabolic organ -Regulates -Metabolizes/processes/detoxifies -Synthesizes -Secretes/excretes (into blood and biliary tree) • Biliary tree: bile ducts/gallbladder -Transports -Stores -Eliminates

    3. Hepatobiliary Dysfunction • When one or many of these processes are not functioning normally

    4. Symptoms of Liver Disease • Asymptomatic • Fatigue, weakness, malaise • Nausea, vomiting, abdominal pain • Jaundice, dark urine, light stools • Pruritus, xanthomas, xanthalasmas • Ascites, edema, mental status changes

    5. Important Aspects of History • Viral hepatitis risks (IDU, transfusion, unprotected/atypical sexual practices, promiscuity, travel, occupation,family history) • Excessive alcohol use • Medications, polypharmacy • Toxic chemical exposure • Herbal medications

    6. Physical Findings • Jaundice, icterus • Hepatomegaly, hepatic tenderness, firm/hard/nodular liver • Splenomegaly • Ascites, edema, prominent abdominal veins • Gallbladder palpable • Scratch marks, xanthomas/xanthalasmas, spider angiomas, palmar erythema • Ecchymoses, petechiae

    7. Important Hepatobiliary Blood Tests • Hepatocellular disease -AST (SGOT) -ALT (SGPT) this is more specific for liver • Cholestatic disease -Alkaline phosphatase -5’-nucleotidase • General -Bilirubin (total and direct) -Albumin -Prothrombin time -GGT (GGTP) this test is too sensitive

    8. ANA (anti-nuclear antibody) AMA (anti-mitochondrial antibody) Viral hepatitis serologies (for A, B, C) Hepatitis viral titers (B, C) -fetoprotein CA-19-9 Ferritin Ceruloplasmin 1-antitrypsin Other Important Bloods

    9. Abdominal ultrasound Abdominal CT Abdominal MRI MRCP ERCP PTC Liver biopsy Paracentesis TIPS Important Hepatobiliary Procedures

    10. Sequential Approach to Evaluation of Hepatobiliary Disease • History and Physical • Laboratory Tests • Imaging • Liver Biopsy

    11. Jaundice

    12. Bilirubinuria

    13. Sources of Bilirubin

    14. Bilirubin Pathway

    15. Hemolytic Jaundice

    16. Gilbert’s Syndrome-decreased uptake AND decreased conjugation

    17. Ways That Things Can Go Wrong with the Liver • Hepatocellular disease: disease due primarily to loss of function and death of hepatocytes (liver parenchymal cells) • Cholestasis: disease due primarily to decreased bile flow from either liver cell dysfunction or biliary tree abnormalities • Mixed: liver conditions that have features of both of the above • Cirrhosis: cellular loss, scarring, altered architecture and blood flow

    18. Hepatocellular Necrosis and Inflammation-”Hepatitis” • Causes: acute and chronic --Viral, bacterial --Autoimmune --Drugs, toxins --Metabolic disorders --Ischemia --Others

    19. Presentation-Hepatocellular Injury • Asymptomatic • Non-specific: fatigue, malaise, anorexia, nausea, vomiting, abdominal discomfort, fever • Specific: jaundice, dark urine, light-colored stools • Disease specific: urticaria, arthritis, rash, lymphadenopathy

    20. Jaundice in Hepatocellular Necrosis • Conjugated hyperbilirubinemia • Despite loss of hepatocytes, remaining cells have great excess capacity to conjugate • Excretion of conjugated bilirubin is rate-limiting step

    21. Aminotransferase Elevation in Hepatocellular Necrosis

    22. Percutaneous Liver Biopsy

    23. Liver Biopsy

    24. Severe Liver Injury • Hypoglycemia • Serum amino acid alterations • Hyperammonemia • Blood/brain barrier abnormalities • Coagulopathy • Deep jaundice

    25. Presentation of Acute Hepatic Failure • Jaundice • Mental status changes • Seizures • Hypoglycemia • Cerebral edema • Bleeding/bruising • Lactic acidosis • Renal failure

    26. Head CT-Cerebral Edema

    27. Treatment of Hepatocellular Disease • Supportive-rest, diet, fluids, etc. • Discontinue toxic drug or hepatotoxin • Anti-viral agents/Interferon-chronic Hepatitis B & C, HSV, CMV • Corticosteroids/immunosuppressives-autoimmune disease • Liver transplant-acute/chronic hepatic failure

    28. Prevention of Hepatocellular Disease • Vaccines • Sanitation/work safety • Universal precautions • Safe sex • Healthy habits • Blood/blood product testing • Careful use of pharmaceuticals/herbals

    29. Cholestasis-decreased bile flow • Extrahepatic (“surgical,” “mechanical,” “obstructive”): gallstones, tumors, strictures, atresia • Intrahepatic (“medical”): drugs, toxins, metabolic, infectious, inflammatory

    30. Cholestasis: Presentation • Asymptomatic: Alkaline phosphatase elevation in serum • Symptomatic: -Jaundice -Pruritus -Coagulopathy -Malabsorption -Osteoporosis -Xanthomas/xanthalasmas

    31. Cholestasis: Signs • Icterus • Skin excoriation • Ecchymoses • Xanthomas/xanthalasmas • Acholic stool • Hepatomegaly • Dilated gallbladder

    32. Jaundice with Cholestasis-”Obstruction” could be in the hepatocyte (cellular dysfunction), too

    33. Acholic Stool

    34. Xanthomas

    35. CT Scan-Biliary and Pancreatic Obstruction. Ultrasound gives similar information.

    36. Technique of ERCP

    37. ERCP. MRI (MRCP) can give a good image of the biliary system, but does not allow other diagnostic or therapeutic interventions

    38. Biliary Stent

    39. ERCP/Sphincterotomy (for stone removal or large stent placement)

    40. Cirrhosis • Hepatic fibrosis severe • Altered hepatic architecture • Regenerative nodules • Abnormal hepatic blood flow • Portal hypertension • Porto-systemic blood shunting

    41. Causes of cirrhosis • Chronic hepatitis, viral and otherwise • Alcohol • Metabolic disorders (hemochromaosis, Wilson’s disease, steatohepatitis) • Chronic biliary obstruction • Drugs, toxins • Other genetic, congenital,idiopathic diseases

    42. Cirrhotic liver and congested spleen