Liver Diseases Flashcards
Functional and organic hepatobilary disease.
Definition, examples
Functional hepato-biliary diseases are diseases that is characterized by persisted and recurrent GI symptoms and does not cause ant structural or biochemical abnormalities.
Examples; Biliary dyskinesia
Organic on the other hand are more advanced stages of diseases with physical, cellular changes and can be identified by diagnostic testing.
Examples; Hepatitis, cholecystitis, cholelithiasis, tumors
Biliary dyskinesia: definition, etiology, classification, diagnosis
This is the uncoordinated excessive or reduced function of the gall bladder and its sphincters.
Etiology
Primary- autonomic dysfunction, heredity, GI pathology
Secondary- viral hepatitis, infections, poisoning, endocrine diseases.
Classification
According to etiology - primary and secondary
According to localization- gall bladder, sphincter of Oddi
According to functional condition- hyperkinetic, hypo kinetic, mixed
Diagnosis
Sphincter manometry, ultrasound + choleretics to check ejection
Diagnostic criteria by Rome
Rome criteria
E1 for biliary pain
Pain the the epigastrium and/or right hypochondrium lasting 30 minutes
Occurs in intervals
Severe enough to inhibit daily activities and cause an emergency visit.
No significant changes in bowel movements
No significant changes in postural change or acid suppression
Pain may be accompanied by nausea, vomiting, waking up from sleep, radiating to back or right infra scapular region
E1a- gall bladder functional disorder
Biliary pain
No gall stones or structural disease
Supportive- low ejection on scintigraphy
Normal liver and pancreatic enzymes
E1b- gall bladder sphincter of Oddi functional disorder
Biliary pain
Elevated liver enzymes or dilated bile duct but not both
No stones or structural abnormalities
Supportive criteria
Normal pancreatic enzymes
Abnormal manometry
E2 pancreatic sphincter of Oddi functional disorder
Recurrent episodes of pancreatitis with increased pancreatic enzymes.
Abnormal manometry
Other etiologies of pancreatitis excluded.
Treatment
Hyperkinetic dyskinesia characterized by recurrent, acute, prickly pain in right hypochondrium, nausea and vomiting,.
Antispasmodic agents- Platyphyline1-1.5mg/kg
Hepatoprotectors- Ursofalk
Hypokinetic dyskinesia characterized by dull constant pain in right hypochondrium
Pain increases when eating or emotional load
Feeling of bursting open, bitter taste in mouth, poor appetite, belching, bloating.
Treatment
Prokinetics- motilium
Cholekinetics- colagon
Ursofalk
Cholecystitis, etiology, classification, symptoms, diagnosis and treatment
This is the inflammation of the gall bladder.
Classification
Calculous and Acalculous
Etiology; motility dysfunction, stones, GI pathology
Symptoms
Charcot’s triad- fever, RUQ pain, jaundice
Nausea, vomiting
Weight loss
Acholic feces
Murphy’s, Kehr’s and Othner’s signs are positive
Diagnosis
CBC- leukocytosis, ESR is elevated
Biochemistry- cholestatic syndrome; elevated alkaline phosphatase ALT, AST, bilirubin, cholesterol, CRP
On ultrasound, there is thickening of wall of gall bladder and stone present with acoustic window
PCR antigen test to determine type of organism in case of acalculous type
CT
Treatment
Bed rest
Diet 5
Antibiotics
Analgesics
Cystectomy is the best choice.
Calculous- dissolution therapy using Ursofalk
Cholelithiasis, etiology, classification, symptoms,diagnosis and treatment
This is when there are stones in the gall bladder. Etiology; motility of gall bladder disorders Detergent activity of bile salts Infection Allergy Classification Cholesterol stones- yellow in color Pigment stones- Brown stones Symptoms Pain in RUQ and epigastrium Dyspeptic syndrome Cholestatic syndrome Syndrome of jaundice Diagnosis X-ray reveals stones Ultrasound Laboratory; elevated bilirubin, acholic feces, elevated alkaline phosphatase and liver enzymes Endoscopic retrograde cholangiography to identify stones and narrowed ducts CT scans Treatment Dissolution therapy using Ursofalk Lithotripsy
Cholangitis, classification, diagnosis and treatment
Inflammation of the bile duct system Classification Primary biliary Primary sclerosing Symptoms Pain in RUQ radiating around the navel, belching, vomiting, forced tongue, vessel stars on skin, fever, jaundice Diagnosis Liver enzymes are elevated, albumin, gamma globulin is elevated Inflammatory markers are elevated MRCP, ERCP Treatment Antibiotics such as 3rd generation cephalosporins are used
Hepatitis ; classification based on etiology, degree of enzyme activity and knodel’s score
Inflammation of the liver Classification Etiology Chronic viral hepatitis A,B,C,D,E Cryptogrnic Drug-induced/toxic Autoimmune Alcoholic Metabolic Nonspecific reactive
Degree of enzyme activity
Mild (<3 times) Moderate ( 3-5 times) severe (>5times)
Knodel score
Grades
0- no fibrosis
1- minimal inflammation and portal fibrosis
2- mild inflammation and periportal fibrosis
3- moderate inflammation and septal fibrosis
4-severe inflammation and cirrhosis
Clinical syndromes,manifestations and complications of hepatitis
Pain syndrome Dyspeptic syndrome Cholestatic syndrome Syndrome of jaundice Portal hypertension Hepatosplenomegaly syndrome Asthenic syndrome Hemorrhagic syndrome
Complications Variceal bleeding Cirrhosis Chronic pancreatitis Glomerulonephritis Hepatic encephalopathy
Laboratory diagnosis of hepatitis , symptoms
Cytolytic syndrome- elevated AST, ALT, GGT, bilirubin, iron, bit B12
Cholestatic syndrome- elevated Alkaline phosphatase,conjugated bilirubin,GGT, cholesterol
Hepapatocellular insufficiency syndrome- decreased fibrinogen, prothrombin, albumin, cholesterol
Mesenchymal inflammatory syndrome- elevated ESR, gamma globulin, Timor test
Symptoms; acholic feces, jaundice, anorexia, spider angioma, palmar erythema, ascites, edema, hepatomegaly
Extrahepatic signs; athralgia, arthritis, amenorrhea, acne, hirsutism, rashes on skin
Hypersplenism- anemia, thrombocytopenia,leukopenia
Liver biopsy- Knodel score
Viral Hepatitis A,B,C, D,E, peculiarities and treatment
Hepatitis A
Fecal- oral transmission with incubation 2-3 weeks
Hepatitis B
Blood, body fluids, sexual contact transmission
1-6 months incubation
HbsAg indicates an active infection
HbeAg indicates carrier and can infect
Anti HBc- past infection
Anti HBs- vaccination
Hepatitis C
AntiHCV positive
Hepatitis D is in patients with hepatitis B
Anti-HDV positive
Treatment
Bed rest
Diet 5
Interferon+ nucleoside analogs for 4-6 months
HBV- interferon +lamivudine 3mg/day
HCV- interferon + ribavirin 10p-1200mg/day
Hepatoprotectors- Ursofalk (8-10mg/kg/day
I
Autoimmune hepatitis
3 types
Type 1
Hyperglobulinemia
Presence of ANA and ASMA or both
Aminotransferase level is elevated 3-10 times higher
Type 2
No ANA and ASMA
Presence of liver/kidney microsome antibody
Type 3
Presence of antibody to soluble liver antigen and liver/pancreas antigen or both
Treatment
Corticosteroids
Combination o prednisone (5-10mg/day) + azathioprine (50-100mg/day)
Liver cirrhosis, definition, classification, clinical syndromes, investigation, treatment
This is an irreversible damage of liver characterized by disorganized organ structure, regenerative nodules surrounded by fibrotic tissues.
Classification
Histopathological; micronodular <3mm, macronodular>3mm, mixed
Degree of progress; active( quickly progressive, slowly progressive, latent), inactive
Severity; compensated, subcompensated, decompensated according to Turcotte and Pugh
Syndromes are same as that of hepatitis
Etiology
Complications of viral hepatitis, genetics, chronic alcoholism
Clinics
Spider nevi, caput medusa( enlarged superficial umbilical veins),
splenomegaly, ascites, portal hypertension
Plan of investigation
CBC, biochemistry, coagulogram, ECG, needle biopsy, endoscopy
Treatment
Diuretics, hepatoprotectors, correct electrolytes imbalance, low salt diet, drain fluid, fluid restriction
Liver transplant
For encephalopathy, lactolone+ rifaximine
Chronic pancreatitis
Chronic pancreatitis is a long-standing inflammation of the pancreas that alters its normal structure and functions.
Etiology of chronic pancreatitis
1.Primary pancreatitis :
Misuse of alcohol (70-80% of all diagnostic cases )
the systematic eating of fatty foods
influence of drugs (azathioprine , isoniazide , tetracycline , sulfonamides )
protein deficiency
Hereditary
Ischemic (in lesions of vascular , which supplies blood pancreas )
Idiopathic
2.Secondary pancreatitis diseases of the biliary tract (in 30-40%) disease of duodenum liver disease bowel disease viral infections (parotitis ) allergic conditions hyperlipidemia hyperparathyroidism
Classification
Chronic pancreatitis of alcoholic etiology
Chronic inflammation pancreatitis Chronic obstructive pancreatitis Others forms chronic pancreatitis (chronic pancreatitis unspecified etiology , infectious , recurrent ) Pancreatic cysts Pancreatic pseudocyst
According to severity
- mild severity - signs of violation exocrine and endocrine function not detected .
- moderate - signs of violation exocrine – and endocrine function
- severe (terminal) - the presence of resistant pancreatic diarrhea , hypovitaminosis , exhaustion .
On the functional characteristics
In violation of exocrine pancreatic function
In violation of the endocrine function of the pancreas
The phases of desease:
exacerbation,
remission .
complication
Symptoms, diagnosis and treatment of chronic pancreatitis
Clinical Symptoms
pain syndrome
dyspeptic syndrome
Syndrome of the external secretory pancreatic insufficiency and its related syndromes and malabsorption with progressive loss of body weight
Endocrine insufficiency syndrome(pancreatic diabetes)
asthenic-neurotic syndrome
The dyspeptic syndrome
vomiting :that does not bring relief
abdominal bloating ,
Disorders of defecation (prevalence diarrhea or change diarrhea with constipation ).
Catch symptom - hyperesthesia of the skin in the innervations zone of the 8-th thoracic vertebra.
Grot symptom – subcutaneous cellular tissue atrophy near the pancreas
Zakcharin symptom – tenderness in the right hypogastria.
Diagnostic criteria
Symptoms
-Pain in epigastric region (pain radiates to the back and is relieved by bending forward)
Pain is exacerbated after eating (15-30minutes)
-Dyspeptic syndrome (nausea and vomiting,diarrhea)
-weight loss
-steatorrhea
*Blood tests
Serum amylase,lipase and trypsin levels may be slightly elevated
*Fecal tests confirm steatorrhea due to pancreatic lipase insufficiency
*Cholecystokinin test;
Cholecystokinin analog is administered Intravenously to stimulate normal pancreatic enzyme secretion.
The secretions; lipase, amylase, protease and pancreatic bicarbonates are collected and placed in duodenal aspirates and analyzed.
- Imaging
- Abdominal x-ray reveals pancreatic calcifications
- CT reveals pancreatic duct dilations and calcification or pancreatic atrophy
- ERCP shows ductal stones and dilation of main pancreatic duct
Degrees of severity of external secretory of pancreatic insufficiency
mild
Activity of fecal pancreatic elastase -1 :150-200 mg / g
moderate
Activity of fecal pancreatic elastase -1 :100 - 150 mg / g
severe
Activity of fecal pancreatic elastase -1 :less than 100 mg / g
Treatment antisecretory drugs (H2 blocking (famotydyn,kvamatel 20mg 2 times a day);omeprazol 20mg,lanzoprazol 30 mg,pantoprazol 40 mg,rabeprazol 20mg,ezomehrazol 20mg-2 times a day; somatostatyn(sandostatyn);central action drugs(dalargin 0,001 mg intraven.or intramus. 2 times a day)
In cases of edema of the pancreas:
Anti-enzyme therapy(kontrykal-1-2 times a day 20000IU
-correction of endocrine function
-correction of dysbiosis: antiseptic drugs (nifuroksazyd – 200 mg 4 times a day, furazolidon – 100mg 4 times a day); probiotics (bifi-form – 1-2 caps. 2 times a day, symbiter – 1-2 doses before sleep)
Physiotherapy (electrophoresis)
