approach to liver disease

APPROACH TO LIVER DISEASE

Dr Anoop R Prasad

ANATOMY

70%

30%

Glucose metabolism

• The liver performs several roles in carbohydrate metabolism:

• Gluconeogenesis • Glycogenolysis • Glycogenesis • Glucogenesis • Glucose buffer function

Protein• Amino acid synthesis • Protein metabolism,

(synthesis as well as degradation)

Lipids

• Cholesterol synthesis • Lipogenesis, the

production of triglycerides (fats).

• Lipoprotein synthesis• Beta oxidation

Synthesis of plasma proteins

Albumin

Acute phase proteins

Clotting factors

Steroid binding and other hormone binding proteins

HORMONES

Erythropoietin

IGF-1

Thrombopoietin

Angiotensinogen

25 hydrxoy choolecalciferol

Hematopoesis

Extramedullary hemopoiesis during first trimester of gestation

• STORAGE:

Vitamins

Glycogen

Iron

Copper• Immunity

Kupffer cells

Detoxification

toxins

steroids

other hormones

drugs

Bilirubin

Urea formation

CLINICAL FEATURES OF h DISEASE

• Fatigue• Nausea• Vomiting• Jaundice• Right upper quadrant pain• Bleeding manifestation(echymosis, easy

bruising,hematemesis,malena)• Colicky pain• Pruritus• Clay colored stools • Abdominal distension• Muscle wasting• Altered sensorium

Obstructive jaundice

Cholestatic disease

• fatigue, malaise• anorexia, nausea• Biliary colic• Deep jaundice• +++ pruritus• +++ abdominal pain and pancreatitis• +++ gray or clay-colored stools

CIRRHOSIS

• Fatigue• Muscle wasting• Hematemesis • Ascites • Easy bruising• Edema

Other points in history

• Fever, prodrome (anorexia,vomiting,nausea) –which disappears with onset of jaundice – acute viral hepatitis

• Joint pain, diabetes, pigmentation, jaundice –• Young individual with extrapyramidal symptoms,

neuropsychiatric manifestation, anemia• Colicky abd pain, jaundice, fever- gall stones• Rash, arthritis • Drug history

Acute onset jaundice

• Viral hepatitis• Alcoholic liver disease• Autoimmune hepatitis• Ischemic hepatitis• Medication-induced liver disease• Common bile duct stones• Pancreatic cancer• Primary Biliary Cirrhosis (PBC)• Primary Sclerosing Cholangitis (PSC)

Jaundiced Emergencies

• Acetaminophen Toxicity• Fulminant Hepatic Failure• Ascending Cholangitis

Jaundice Unrelated to Intrinsic Liver Disease

• Hemolysis (usually T. bili < 4)• Massive Transfusion• Resorption of Hematoma• Ineffective Erythropoesis• Disorders of Conjugation

• Gilbert’s syndrome• Intrahepatic Cholestasis

• Sepsis, TPN, Post-operation

Alcohol

• A standard drink is any drink that contains about 14 grams of pure alcohol (about 0.6 fluid ounces or 1.2 tablespoons)

• One "Standard Drink" equals = one 30ml nip of whisky or other basic spirit = 60ml fortified wine = 150ml table wine = 250ml beer = 425ml low alcohol beer

• Strength (ABV) x Volume (ml) ÷ 1000 = No. of units.

• 40–80 g/d of ethanol produces fatty liver; 160 g/d for 10–20 years causes hepatitis or cirrhosis. Only 15% of alcoholics develop alcoholic liver disease.

Signs

Alopecia

Pigmentation of face

Jaundice

KF ring

Parotid swelling

Gynaecomastia

Spider naevi

Palmar erythema

Dupyutren’s contracture

Half and half nail

Asterixis

Testicular atrophy

Scratch marks

Echymotic patches

Muscle wasting

Pallor

Clubbing

Edema

Leuconychia

Hepatomegaly …..

Splenomegaly

Ascites

• Dilated veins• Caput medusae

Biochemical tests in liver disease

• The true tests of liver function:• INR, PT, Albumin,Bilirubin

• Tests of hepatic injury/inflammation:• Aspartate aminotransferase (AST)• Alanine aminotransferase (ALT)• Alkaline phosphatase (ALP)• Gamma-glutamyl transpeptidase (GGT)

• Hepatocellular – AST/ALT elevation twice that of ALP

• Cholestatic – AST/ALT elevation less than twice ALP

INVESTIGATIONS

• AST-ALT-ALP• Bilirubin – total/indirect• Albumin• INR• Glucose• Na-K-PO4, acid-base • Acetaminophen level• CBC/plt

• Ammonia• Viral serologies• ANA-ASMA-

AMA• Quantitative Ig• Ceruloplasmin• Iron profile• Blood cultures

Hepatocellular • AST/ALT >> ALP• Unconjugated bil >>

conjugated• USG – BILE DUCTS

NORMAL

Cholestatic • ALP>>AST/ALT• Conjugated bil>>

unconjugated• ↑GGT, 5’nucleotidase• USG- Intrahepatic biliary

duct dilation

Non hepatic cause of elevated transaminases

• Muscle disease• Thyroid diseases• Bone disease - ALP

THANK YOU

QUESTIONS??