le il v Introduction to Clinical is u Liver Disease

le il v Introduction to Clinical is u Liver Disease o L f o ty i s r e iv n U Professor of Medicine Director of Clinical and Transplant Hepatology Luis S. Marsano, MD Objectives n U Recognize common presentations of liver disease and patterns of liver injury Differentiate acute from chronic hepatitis Recognize clues in history, physical exam, and basic laboratory tests. Basic knowledge of common liver diseases (alcoholic, NASH, hepatitis B and C) it s r e iv o y L f le il v is u o Presentations of Liver Disease Jaundice Hepatomegaly +/- splenomegaly Abnormal Liver Chemistries (ALT, AST, Alkaline phosphatase, Bilirubin) Portal hypertension (ascites, bleeding from esophageal varices, encephalopaty, thrombocytopenia) Viral markers for hepatitis B or C. Right Upper Quadrant pain n U it s r e iv o y L f le il v is u o Jaundice n U Yellow skin and sclera (bilirubin > 2.8 mg/dl) Differential Dx: • Parenchymal (hepatocellular and/or canalicular) • Biliary obstruction-choledocholithiasis, carcinoma of the pancreas • Brisk hemolysis (unconjugated bilirubin) it s r e iv o y L f le il v is u o n U it s r e iv o y L f le il v is u o le il v is Hepatocellular: injury mostly to u hepatocytes; dominant o L aminotransferase elevation (ALT usually f o > AST); “Hepatitis” tycholestasis: damage i Intrahepatic svery small biliary canaliculi; mostly r eto elevation of alkaline dominant iv n phosphatase and GGT +/- bilirubin. U Types of Liver Injury le il v Extrahepatic cholestasis:is u damage/obstruction of large bile ducts; o phosphatase L dominant elevation of alk. f studies show and bilirubin. Radiologic o of bile ducts. dilation or stricture ty i Mixed rs e Micro and macrovascular: portal iv hypertension with normal liver enzymes n U Types of Liver Injury Classification of Hepatitis Acute: elevation of ALT / AST for days or weeks. Fulminant: acute hepatitis with hepatic encephalopathy within 8 weeks of onset Subacute or subfulminant: development of encephalopathy 8 to 24 weeks from onset of acute hepatitis. Chronic: elevations of ALT / AST for more than 6 months or due to etiology that is always chronic (Wilson’s disease, Autoimmune hepatitis) n U it s r e iv o y L f le il v is u o le il v is u Anorexia - related to change in taste/smell o Weight loss - >10 lbs. f L (Malignancy?) o Fatigue, mild fever, myalgia – viral hepatitis typain – biliary tract Chills, fever, si RUQ disease er iv– cholestatic liver disease Pruritus n U Liver Disease: History le il v is Exposures – blood transfusions, IVDA, u o sexual exposure, history of sexually L solvents f transmitted disease, organic o products” – Medications or “natural y tarthralgia, rash, i FARE – fever, s r eosinophilia euse/abuse Alcohol iv n U Liver Disease: History le il v s img/dl Scleral icterus – if bilirubin >2.8 u o Muscle wasting: cirrhosis, malignancy L f HIV Needle tracks: viral o hepatitis, ty Excoriations: cholestasis i s >12: portal hypertension r Spider angiomas e contracture, gynecomastia, iv Dupuytren’s nparotid enlargement: alcohol abuse and U Physical Examination n U it s r e iv o y L f le il v is u o n U it s r e iv o y L f le il v is u o le il v is Ascites u o Hepatic encephalopathy (confusion L often with asterixisf/flapping) o apple smell) Fetor hepaticus (sweet ty (caput medusae) i Collateral circulation s r of fingers e Clubbing iv n U Physical Examination (Likely Cirrhosis) n U it s r e iv o y L f le il v is u o n U it s r e iv o y L f le il v is u o le il v is Hepatocellular – AST/ALT ou Alkaline phosphatasef– L obstructive or infiltrative disease o (confirm with GGTP) y talbumin, PT Biosynthesis – i sbilirubin, bile acids Transportr e– iv n U Laboratory Testing ALT Almost all from liver cytosol; injury causes rise Alcohol injury: usually < 200 IU/L + AST/ALT ≥ 2 Hepatocellular injury: usually > 300 IU/L Obstruction: usually < 400 IU/L Acute bile duct obstruction or liver ischemia n U > 300 IU/L x < 48 h it s r e iv o y L f le il v is u o Patterns of Aminotransferase Elevation Rapid and high (> 300 IU/L) up and down: acute biliary obstruction or liver ischemia viral or toxic hepatitis HCV Sustained and high (> 300 IU/L x > 1 week): Prolonged (months) with peaks and troughs: n U Prolonged (months) mild/moderate elevation: chronic viral hepatitis, metabolic, immune or toxic liver disease it s r e iv o y L f le il v is u o le il v is Found in liver, bone, kidney,u intestine, o placenta L f ‘Inducible’ enzymeo ty obstructive, and Elevated in cholestatic, i disease (infiltrative = s infiltrative liver r e tuberculosis, liver abscess, sarcoidosis, iv malignancy) n metastatic U Alkaline Phosphatase Alkaline Phosphatase n U Elevation ≥ 4-fold suggests intra- or extra-hepatic cholestasis Elevation < 3-fold is less specific “Isolated” elevation (normal bilirubin): partial bile duct obstruction, infiltration or focal liver mass Elevated hepatic alkaline phosphatase without liver involvement: Hodgkin’s, myeloid metaplasia, congestive heart failure, renal cell carcinoma, intra-abdominal infections it s r e iv o y L f le il v is u o Synthetic Function n U Albumin – 12-15 gm/d normally synthesized, synthesis inhibited by malnutrition, alcohol, and inflammation. Low albumin suggest advanced liver disease. Prothrombin time (PT): Coagulation factors – I, II, V, VII, IX, X, XII, XIII produced in liver, II, VII, IX, X- vitamin K dependent; Lack of response of PT to vitamin K injection suggest severe liver disease. it s r e iv o y L f le il v is u o Bilirubin n U Bilirubin ≥ 10 mg/dl in absence of biliary tree dilatation supports non-obstructive jaundice Degree of bilirubin elevation do not correlate well with severity of acute disease Bilirubin in urine usually indicates hepatobiliary disease (direct bili) Urobilinogen (in urine) is decreased in biliary obstruction (but also with antibiotics) it s r e iv o y L f le il v is u o Hepatitis Bo n U r e iv ty i s L f le il v is u o Hepatitis B n U 42 nm, partially double-stranded circular DNA virus. 350 million carriers world-wide; causes 250000 deaths a year. 1.25 million carriers in USA.(0.5 %); > 8% in Alaskan Eskimos. Transmission: In USA predominantly sexual and percutaneous during adult age. In Alaska predominantly perinatal. it s r e iv o y L f le il v is u o Hepatitis B Transmission n U Sexual: heterosexual in 41% of acute cases. Men having sex with men have 10% risk. Percutaneous (mostly illicit drug use):15% of acute HBV cases Perinatal: 10% of acute cases (motherchild) Transfussion: 1/63000 transfusions. Other: organ transplant, tattoo, piercing, acupuncture, … it s r e iv o y L f le il v is u o Hepatitis B High-Risk Groups Born in high prevalence area Active homosexual men Promiscuous heterosexuals Healthcare & Public Safety workers Attendant/family of institutionalized mentally handicapped n U it s r e iv o y L f Intravenous drug abuser Person requiring frequent transfusions Inmate in long-term correctional facility Hemodialysis patient Traveler > 6 months to endemic area Sexual partner of HBsAg(+) person le il v is u o le il v All children and adolescents is u All highIf not previously vaccinated: o L risk groups f Post-Vaccinationo testing: ty i s r e iv n U Hepatitis B Vaccination Healthcare & Public-Safety workers Infants from HBsAg(+) mother Hemodialysis patients Sexual partner of HBsAg(+) persons Acute Hepatitis B n U Incubation: 1-4 months Prodrome: arthralgia, arthritis, skin rash Symptoms: malaise, anorexia, jaundice, nausea, fatigue, low-grade fever, myalgia, change in taste and smell. Tender hepatomegaly in most patients; splenomegaly in 5-15%. Infrequently: confusion, edema, coagulopathy, coma (Fulminant Failure in 0.5%) it s r e iv o y L f le il v is u o le il v is u Diagnosis: anti-HBc IgM antibody; o phase and L frequently HBsAg in early f o anti-HBs in late phase. ty Evolutionito Chronicity: s r e iv n U Acute Hepatitis B a) Infants: 90%, b) Children 1-5: 25-50%, c) Adults & older children: 5% Treatment: Supportive Chronic Hepatitis B n U In low prevalence areas (USA) 30-50% history of acute hepatitis (rare in high prevalence) Symptoms: frequently asymptomatic; sometimes RUQ or epigastric pain or acute-like hepatitis episodes. Extrahepatic: serum-sickness, polyarteritis nodosa, membrano- or membranoproliferativeglomerulonephritis, mixed cryoglobulinemia, IgA nephropathy, papular acrodermatitis. it s r e iv o y L f le il v is u o le il v (+) is Diagnosis: HBsAg (+) & HBV-DNA u IgM (-) for > 6 months , with anti-HBc o L but anti-HBc total (+) [excludes f o incubation] ty HBV-DNA < 10 i Carrier state: sor < 0.35 pg/ml. r copies/ml e Injury: HBV-DNA > 10 iv Chronic n U copies/ml or > 0.35 pg/ml Chronic Hepatitis B 5 5 Chronic Hepatitis B Treatment Candidates n U HBsAg(+) and HBV-DNA > 20000 IU/mL for wild virus, or > 2000 IU/mL for mutant virus. With elevated ALT, or With moderate or severe activity in liver biopsy Interferon or Peg-Interferon: if noncirrhotic Lamivudine, Adefovir, Entecavir, Telbivudine, or Tenofovir: cirrhotic or noncirrhotic. it s r e iv o y L f le il v is u o Hepatitis Co n U r e iv ty i s L f le il v is u o le il v is 50 nm enveloped, positive-sense, u single-stranded RNA hepacivirus. osubtypes. Six genotypes and f L > 100 o worldwide; 4 170 million infected ty(1.8%); 38,000 new i million in USA s r infections/year. e iv n U Hepatitis C Prevalence of HCV GROUP Hemophilia <’87 IVDA Hemodialysis Transfusion < ’90 Person w STD n U it s r e iv o y % 82 80 10 7 6 L f GROUP % Infant of RNA(+) mother 5 Homosexual men 4 Monogamous partner 2 General population 1.8 Volunt. blood donor .16 le il v is u o Risk of HCV in IVDU (% infected) 100 90 80 70 60 50 40 30 20 10 0 78 83 n U it s r e iv year 1 o y L f 94 le il v is u o % HCV infected year 5 year 10 Acute HCV n U Incubation: 2-26 weeks (usually 7-8) Symptoms in < 30%, mild & < 1month: anorexia, arthralgia, myalgia, fatigue; rarely jaundice, fever or skin rash. Very rare FHF. DX: HCV-RNA (+) days to weeks after acquisition ; anti-HCV (+) in 6 weeks. Spontaneous HCV clearance: it s r e iv o y L f le il v is u o Children < 2 y.o. & young women = 45%; Others = 23% Acute HCV Treatment n U If HCV-RNA(+) 3 months after inoculation, spontaneous clearance is rare. Best regimen is unknown: starting 3 months after inoculation, IFN 5 MU QD x 4 wks + 3 MU TIW x 20 wks gave 98% clearance; the mildest & shortest effective therapy is unknown. Patients should be abstinent from alcohol and drugs (anti-HCV is not protective). it s r e iv o y L f le il v is u o Chronic HCV n U Most are asymptomatic; 6% symptomatic before diagnosis. Symptoms: fatigue, RUQ discomfort, anorexia, nausea, itching, arthralgia, myalgia. Extrahepatic: mixed cryoglobulinemia, purpura, mononeuritis multiplex, PCT, membrano-proliferative glomerulonephritis, xerostomy, low-grade B-cell lymphoma, corneal ulcers and idiopathic pulmonary fibrosis, lichen planus. it s r e iv o y L f le il v is u o Pattern of ALT Elevation in Chronic HCV Pattern of ALT Elevation 15 n U it s r e iv 42 12 o y L f le il v is u o 31 Normal ALT ALT < 2X-ULN ALT 2-3X-ULN ALT > 3X-ULN Degree of Fibrosis in Chronic HCV Degree of Fibrosis n U 16 it s r e iv 22 o y 24 L f 19 le il v is u o 19 None Stage 1 Stage 2 Bridging Cirrhosis Outcome of HCV 25-30 year Follow-up 20 n U it s r e iv 80 o y L f 60 13 3 3 1 le il v is u o Resolves @ acute hepatitis Chronic / No-cirrhosis Compensated Cirrhosis Decompensated Cirrhosis Death/ Decompensated Death/ HCC HCV Cirrhosis Survival 100 80 60 % 40 20 SURVIVAL IN CIRRHOSIS n U 0 it s r e iv 0 2 o y 6 L f 8 le il v is u o COMPENSATED DECOMPENSATED 10 4 YEARS HCV Cirrhosis 100 90 80 70 60 % 50 40 30 20 10 0 Decompensation & Hepatocellular CA n U it s r e iv 0 2 4 o y 6 L f 8 10 le il v is u o DECOMPENSATION HCC Years le il v is Chronic Hepatitis C u o L f o ty i Treatment s r e iv n U PEG-Interferon + Ribavirin 1-1200 Genotype & Viral Load on SVR 100 90 80 70 60 50 40 30 20 10 0 n U it s r e iv 41 44 33 G-1 high o y 56 56 L f 74 le il v is u o 81 68 Rebetron PEG-Ifn+R G-1 low G-2/3 high G-2/3 low Alcohol Liver Disease Most prevalent liver disease in the USA Correlation between per capita consumption of alcohol and the frequency of cirrhosis 1 oz “spirit”=4 oz wine=12 oz beer=11.5 gm alcohol. Males 40-80 gm/day (3.5-7 beer); females 20-40 gm/day for more than 5 years (10 years) Lab – AST/ALT ratio 2/1, total usually less than 300, other labs variable (WBC, bilirubin, PT) Spectrum – fatty liver – alcohol induced hepatitis cirrhosis n U it s r e iv o y L f le il v is u o Non-Alcoholic Steatohepatitis Histologically similar to alcohol induced liver disease; fatty liver & Mallory bodies or fibrosis Risk factors • Central obesity, hypertension, insulin resistance, diabetes, hypertrigliceridemia • Total Parenteral Nutrition • Protein calorie malnutrition • Jejuno-Ileal bypass • Drugs n U it s r e iv o y L f le il v is u o le il v isto 300,000 yearly deaths in US u o due complications of obesityL fis increasing – o Prevalence of obesity ty Kentucky – 22.3% year 2000 i sphysical inactivity account r Obesity and eof US healthcare expenditures for 9.4% iv n U NASH - Obesity le il v is Natural history u o • Slow progression, often silent L f ALT > AST o • Cirrhosis ty i • Portal rs hypertension e • Liver failure iv n U NASH Cirrhosis n U Final Stage of chronic liver injury. Can be reversible if cause of injury is eliminated. Diagnosis is by liver biopsy; in absence of biopsy, evidence of chronic liver disease + portal hypertension (ascites, gastroesophageal varices, hepatic encephalopathy, thrombocytopenia) support the diagnosis. it s r e iv o y L f le il v is u o Cirrhosis Decompensated cirrhosis: associated with ascites, or variceal bleed, or hepatic encephalopathy. Has a 50% mortality at 1 year. Risks associated with cirrhosis: n U it s r e iv Hepatic encephalopathy with sedatives & narcotics Bleeding with procedures and NSAIDS. Ascites with Sodium intake. Ascites and renal failure with NSAIDS. o y L f le il v is u o le il v s Careful titration of sedativesiand u narcotics. o L Avoid NSAIDS f ogood choice if patient Acetaminophen is ty drinking alcohol; try is eating si not and r 2 gm a day. not to exceed e iv n U Medications and Cirrhosis n U it s r e iv o QUESTIONS ? y L f le il v is u o HCV Infection: Risk Factors Known risk: Injection – drug use (shared paraphenalia) Receipt of clotting factor before 1987 Immigration from areas without universal precautions Centers for Disease Control and Prevention. MMWR. 1998;47(RR-19):4-9 n U it s r e iv o y L f Unproven/low risk: Perinatal transmission Transfusion after 1992 Body piercing/ scarification Long-term hemodialysis Occupational exposure (healthcare worker) Intranasal cocaine use Sex with multiple partners le il v is u o Risk Factors for Fibrosis/Cirrhosis Poynard T et al. Lancet. 1997;349:829. n U Alcohol consumption Advanced age at infection Longer duration of infection Male sex Overweight Genotype or viral load not associated with progression it s r e iv o y L f le il v is u o le il vhave Frequently asymptomatic; many is u fatigue. o years L Slow progression over 20-30 fby alcohol, obesity, o unless aggravated HIV co-infection, etc. ty be curative in 45% ican s Treatment rwith genotype 1, and 80% e infected iv with genotype 2 or 3. infected n U Spectrum of Hepatitis C le il v is u Viral hepatitis – A, B +/- D and E o herpes L Epstein-Barr virus, adenovirus, f viruses o ty Drug inducedi – acetaminophen s tetrachloride, Toxin –er carbon trichloroethylene, mushrooms – iv and Galerina species n Amanita U Acute Liver Failure: Etiology le il v s iprognosis Encephalopathy – grade ¾ poor u pressure o Cerebral edema – cerebral perfusion L f <50mm/Hg (CPP=MAP-ICP) o Renal failure ty– hypoglycemia, acidosis, i s Metabolic disorders r alkalosis e iv Coagulopathy n – common due to invasive procedures U Sepsis ALF: Complications n U it QUESTIONS ? s r e iv o y L f le il v is u o le il v is Direct bilirubin – ‘conjugated’ u with glucuronic acid o Lalbumin Delta bilirubin – bound to f o Indirect bilirubin y unconjugated, most – it common in serum s product of deconjugation in r Urobilinogen – e bacteria, small amount may be the gut by iv in urine (due to enterohepatic n excreted U circulation) Bilirubin le il v is uNecrosis Markers of Hepatocellular o L f o ALT – alanine aminotransferase or ty SGPT i s r e aminotransferase, or ASTivaspartate – n SGOT U Aminotransferases AST n U Higher in: liver, heart, skeletal muscle, kidney, brain, pancreas, lungs, WBC and RBC; injury causes rise In liver: 80% mitochondrial/20% cytosol In serum: mostly from cytosol Alcohol injury: usually < 300 IU/L and AST/ALT ≥ 2 Hepatocellular injury: usually > 300 IU/L Obstruction: usually < 400 IU/L it s r e iv o y L f le il v is u o GGT (ϒ-Glutamyl Transpeptidase) n U Not in bone Normal range in children > 4 y.o. and during pregnancy Elevation: alcohol, Dilantin, COPD, diabetes, renal failure Elevated alkaline phosphatase with: it s r e iv o y L f le il v is u o Elevated GGT suggest liver origin Normal GGT, unlikely liver origin