Liver Disease Flashcards
Give a general overview of the liver.
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)
How common is liver disease?
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
What are the functions of the liver?
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
How can you categorise causes of liver disease?
Infectious (viral, bacterial, parasitic)
Toxins (drug misuse, alcohol misuse)
Metabolic (non-alcoholic fatty liver disease, Wilson’s disease, haemochromatosis)
Autoimmune (SLE, PBC)
What is compensated/decompensated liver disease?
Compensated- the liver is coping with working at a reduced capacity
Decompensated- the liver is failing to cope with its functional demands
What are some signs & symptoms of acute liver disease?
Loss of appetite, jaundice, weight loss, along with right upper quadrant pain, nausea, vomiting, malaise
What is acute liver disease most commonly caused by?
Hep A, B, & E
What are some signs & symptoms of chronic liver disease?
-Spider naevi (the more there are, the worse the disease)
-palmar erythema - redness of palms
-clubbing
-jaundice
-oedema/ascites
What is jaundice?
Yellowing of the skin and sclerae, due to build-up of bilirubin in the blood & body tissues.
What are the different types of causes of jaundice?
-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)
What are some of the symptoms of liver failure?
-Bleeding/bruising
-Hypoglycaemia
-Infections
-Ascites - collection of fluid in abdomen
-Encephalopathy - loss of consciousness, confusion
What does cirrhosis result from and what does it lead to?
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
How do you diagnose cirrhosis?
Histologically by biopsy
What are the causes of cirrhosis?
Common: alcohol, viral (Hep B & C)
Less common: autoimmune, drugs, haematochromatosis, Wilson’s disease
What are some investigations that would give you good indications regarding the liver?
Blood tests (LFTs, ALT, AST, GGT, bilirubin, albumin)
Imaging tests (USS, CT, MRI)
Liver biopsy
What are the complications of alcohol-related liver disease (ARLD)?
Alcoholic hepatitis and cirrhosis
What are the main signs & symptoms of ARLD?
-Feeling sick
-Weight loss
-Loss of appetite
-Jaundice
-Swelling in ankles & tummy
-Confusion or drowsiness
-Vomiting blood or passing blood in stools
What is non-alcoholic fatty liver disease?
Build-up of fat within the liver cells
Reversible in early stages
(overweight/obese, type II diabetes, high BP, hypercholesterolaemia)
What are the 4 stages of non-alcoholic fatty liver disease?
- Steatosis - fatty deposition within liver cells
- Non-alcoholic steatohepatitis
- Fibrosis
- Cirrhosis
So, it IS reversible at the start
What are the risk factors for gallstones (5 F’s)?
Gallstones can be asymptomatic and are a accumulation of hardened cholesterol and calcium deposits in the gallbladder
Female
Forty
Fertile
Fat
Fair
What are the signs & symptoms, diagnosis, and treatment for gallstones?
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)
What is hepatitis?
Inflammation of liver (acute or chronic)
Only 5% develop chronic infection
How long can hepadnavirus survive outside the body?
For at least 7 days (so be mindful of dried blood, fluids, etc.)
It is a DNA virus
How many people with hepatitis C are asymptomatic?
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
Is there a vaccine for hepatitis C?
NO (but antiviral medicines can cure approx 90% of ppl with hep C infection).
How is Hepatitis C transmitted?
-RNA virus
-Transmitted through blood, bodily fluids
-Incubation period 2-6 weeks
What is the dental relevance of liver disease in terms of anaesthesia?
Local anaesthesia is safe, relative anaesthesia is preferable to Intravenous sedation with benzodiazepine
(because encephalopathy can be triggered by use of sedatives & opioids)
What are some symptoms of hepatitis B & C?
-Flu-like symptoms
-Feeling like/being sick
-Lack of appetite
-Jaundice
What is the dental relevance of hepatitis B, C & HIV?
Risk of needlestick injury:
Hep B: 30% chance
Hep C: 1-3% chance
HIV: 0.3% chance
What is the dental relevance of liver disease in terms of drugs?
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
What is the dental relevance of liver disease in terms of bleeding?
-Post-operative haemorrhage risk (vitamin K & clotting factors deficiency)
-INR should be checked before extractions
-Delayed wound healing
What is the dental relevance of liver disease in terms of oral manifestations?
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
What has dental hypoplasia & greenish discolouration of the teeth been documented in
Disorders associated with an early rise in conjugated bilirubin serum levels (e.g. Rhesus disease).
