Liver Disease

Question 1

Give a general overview of the liver.

Answer 1

It’s the second largest organ in the body

located in the right hypochondrium

divided into 4 lobes (left, right, caudate, quadrate)

Its blood supply is derived from the portal & hepatic vein and hepatic artery

It is a centre of first-pass metabolism (metabolism of a drug before it reaches the systemic circulation)

Question 2

How common is liver disease?

Answer 2

Very common

Affects at least 2 million in the UK

Is the fifth commonest cause of death in UK

There are more than 100 different causes of liver disease

Question 3

What are the functions of the liver?

Answer 3

Metabolism, breakdown, & excretion of drugs and endogenous products (e.g. ammonia, urea, bilirubin, hormones, & alcohol)

Production of albumin, blood clotting factors (II, VII, IX, & X), complement, transporter proteins, cholesterol & bile components

Storage of substances (e.g. glycogen, fat-soluble vitamins such as vitamin A, D, E, & K, vitamin B12 & folate, minerals such as iron & copper)

Maintenance of body homeostasis by regulating the glucose & cholesterol blood levels

Question 4

How can you categorise causes of liver disease?

Answer 4

Infectious (viral, bacterial, parasitic)

Toxins (drug misuse, alcohol misuse)

Metabolic (non-alcoholic fatty liver disease, Wilson’s disease, haemochromatosis)

Autoimmune (SLE, PBC)

Question 5

What is compensated/decompensated liver disease?

Answer 5

Compensated- the liver is coping with working at a reduced capacity

Decompensated- the liver is failing to cope with its functional demands

Question 6

What are some signs & symptoms of acute liver disease?

Answer 6

Loss of appetite, jaundice, weight loss, along with right upper quadrant pain, nausea, vomiting, malaise

Question 6

What is acute liver disease most commonly caused by?

Answer 6

Hep A, B, & E

Question 7

What are some signs & symptoms of chronic liver disease?

Answer 7

-Spider naevi (the more there are, the worse the disease)

-palmar erythema - redness of palms

-clubbing

-jaundice

-oedema/ascites

Question 8

What is jaundice?

Answer 8

Yellowing of the skin and sclerae, due to build-up of bilirubin in the blood & body tissues.

Question 9

What are the different types of causes of jaundice?

Answer 9

-Pre-hepatic (sickle cell anaemia, thalassaemia)

-Intra-hepatic (hepatitis, alcohol, glandular fever, drug misuse, cirrhosis, Gilbert’s syndrome) conditions affecting the liver

-Post-hepatic (gallstones, tumours)

Question 9

What are some of the symptoms of liver failure?

Answer 9

-Bleeding/bruising
-Hypoglycaemia
-Infections
-Ascites - collection of fluid in abdomen
-Encephalopathy - loss of consciousness, confusion

Question 9

What does cirrhosis result from and what does it lead to?

Answer 9

Results from necrosis of liver cells followed by fibrosis & nodule formation

It is irreversible

Leads to interference of blood flow through the liver and loss of liver function

Question 10

How do you diagnose cirrhosis?

Answer 10

Histologically by biopsy

Question 11

What are the causes of cirrhosis?

Answer 11

Common: alcohol, viral (Hep B & C)

Less common: autoimmune, drugs, haematochromatosis, Wilson’s disease

Question 12

What are some investigations that would give you good indications regarding the liver?

Answer 12

Blood tests (LFTs, ALT, AST, GGT, bilirubin, albumin)

Imaging tests (USS, CT, MRI)

Liver biopsy

Question 13

What are the complications of alcohol-related liver disease (ARLD)?

Answer 13

Alcoholic hepatitis and cirrhosis

Question 14

What are the main signs & symptoms of ARLD?

Answer 14

-Feeling sick
-Weight loss
-Loss of appetite
-Jaundice
-Swelling in ankles & tummy
-Confusion or drowsiness
-Vomiting blood or passing blood in stools

Question 15

What is non-alcoholic fatty liver disease?

Answer 15

Build-up of fat within the liver cells

Reversible in early stages

(overweight/obese, type II diabetes, high BP, hypercholesterolaemia)

Question 15

What are the 4 stages of non-alcoholic fatty liver disease?

Answer 15

1. Steatosis - fatty deposition within liver cells
2. Non-alcoholic steatohepatitis
3. Fibrosis
4. Cirrhosis

So, it IS reversible at the start

Question 16

What are the risk factors for gallstones (5 F’s)?

Answer 16

Gallstones can be asymptomatic and are a accumulation of hardened cholesterol and calcium deposits in the gallbladder

Female
Forty
Fertile
Fat
Fair

Question 16

What are the signs & symptoms, diagnosis, and treatment for gallstones?

Answer 16

Signs & symptoms: central abdominal pain (intermittent or persistent), jaundice, fever

Diagnosis: bloods, Ultra sound, other imaging

Treatment: depends on severity of disease e.g. avoid fatty foods in diet, cholecystectomy (gallbladder removal surgery)

Question 17

What is hepatitis?

Answer 17

Inflammation of liver (acute or chronic)

Only 5% develop chronic infection

Question 18

How long can hepadnavirus survive outside the body?

Answer 18

For at least 7 days (so be mindful of dried blood, fluids, etc.)

It is a DNA virus

Question 19

How many people with hepatitis C are asymptomatic?

Answer 19

Up to 80%, can also be acute or chronic.

Compared to Hep B, 55-85% of people with Hep C will develop a chronic infection

Question 20

Is there a vaccine for hepatitis C?

Answer 20

NO (but antiviral medicines can cure approx 90% of ppl with hep C infection).

Question 21

How is Hepatitis C transmitted?

Answer 21

-RNA virus

-Transmitted through blood, bodily fluids

-Incubation period 2-6 weeks

Question 21

What is the dental relevance of liver disease in terms of anaesthesia?

Answer 21

Local anaesthesia is safe, relative anaesthesia is preferable to Intravenous sedation with benzodiazepine

(because encephalopathy can be triggered by use of sedatives & opioids)

Question 22

What are some symptoms of hepatitis B & C?

Answer 22

-Flu-like symptoms

-Feeling like/being sick

-Lack of appetite

-Jaundice

Question 23

What is the dental relevance of hepatitis B, C & HIV?

Answer 23

Risk of needlestick injury:

Hep B: 30% chance
Hep C: 1-3% chance
HIV: 0.3% chance

Question 24

What is the dental relevance of liver disease in terms of drugs?

Answer 24

They have an altered drug metabolism (because usually liver breaks it down)

so things like paracetamol can be given, but reduced dose is necessary

Take care with NSAIDS as they may precipitate a GI bleed

In terms of antifungal therapy, miconazole & fluconazole are metabolised by the liver so dose may need to be reduced

Same with metronidazole

It is recommended that azithromycin should be avoided

Question 25

What is the dental relevance of liver disease in terms of bleeding?

Answer 25

-Post-operative haemorrhage risk (vitamin K & clotting factors deficiency)

-INR should be checked before extractions

-Delayed wound healing

Question 26

What is the dental relevance of liver disease in terms of oral manifestations?

Answer 26

In liver disease due to SLE, you may see oral lichenoid reactions & oral manifestations of secondary Sjogren’s syndrome

In liver disease due to PBC, you may see oral manifestations of secondary Sjögren’s syndrome

They may have non-alcohol related fatty liver disease due to type II diabetes or high bp, so it’s something to be aware of as they may be on meds for it that have side effects like gingival hyperplasia

Question 27

What has dental hypoplasia & greenish discolouration of the teeth been documented in

Answer 27

Disorders associated with an early rise in conjugated bilirubin serum levels (e.g. Rhesus disease).