Docstoc

Hepatology

Document Sample
Hepatology Powered By Docstoc
					Hepatology

    F1
   2005
ASYMPTOMATIC LIVER BIOCHEMISTRY


             v


SYMPTOMATIC LIVER BIOCHEMISTRY
                            Elevated ALT in Hospital
                               Common causes

 Viral hepatitis                                         High ALT
                                                            > 400 Iu/l
         Drugs
                                                        Very High ALT
      Liver cell
       disease
                                                           Paracetomol
                                                           Ischaemia
Pancreatobilary


     Ischaemia


                   0   10   20   30   40   50   60
                                                     N = 137
                                                     1996-1997
                                                     2 hospitals+ community
Liver Clinic
     Alcoholic Liver Disease
     Non-alcoholic Fatty Liver
     Hepatitis C


     Primary Biliary Cirrhosis
     Haemochromatosis
     Autoimmune Chronic Active Hepatitis
     Drug induced liver disease
     Primary sclerosing cholangitis


Friday morning   General Hepatology
Monday morning   Viral hepatitis
ERCP             Tuesdays and Fridays
                  Abnormal LFTs
                Not always the liver!!

1. Repeat                 ????
2. Stop alcohol           underestimation of amount
3. Always consider drugs (including herbal remedies)
4. Loose weight




Other causes              Polymyalgia rheumatica
                          Thyroid disease
                          Congestive heart failure
                          Rheumatoid arthritis
                          Ca prostate (N GGT!!)
         Causes of elevated serum
             transaminases
MINOR (<100 IU/l)         Chronic hepatitis C and B
                          Haemochromatosis
                          Fatty liver

MODERATE (100-300 IU/l)   As above plus:
                          Alcoholic hepatitis
                          Non-alcoholic steatohepatitis
                          Autoimmune liver disease
                          Wilsons

MAJOR (>1000 IU/l)        Drugs (paracetomol, cocaine)
                          Acute viral hepatitis
                          Autoimmune liver disease
                          Ischaemic liver
                           TIPS


• AST/ALT
  – If < 100 in context of negative chronic liver
    disease screen unlikely to be significant
    disease
  – AST>ALT in alcoholic liver disease
  – May only be mildly elevated in Hep C ie 50
    IU/l and level not related to fibrosis
  – Levels >400 IU/l unlikely in alcoholic
    hepatitis--- consider additional drug toxicity
                         Causes
                 Elevated Alkaline phosphatase

Biliary Obstruction

Infiltration          amyloid
                      metastases
                      granuloma (sarcoid)

Intrahepatic cholestasis of infection or drugs
Intrinsic liver disease (PBC+PSC)
Congestive heart failure
Non hepatic inflammatory disease (PMR/ rheumatoid)
Chronic Liver Disease Screen
•   HCV Ab + HBsAg
•   Fe/TIBC              >55%
•   Liver autoantibodies
•   Immunoglobulins
•   Copper/cauruloplasmin if <40yrs
•   Endomyseal antibody
         Non alcoholic fatty liver disease (NAFLD)


                    1% of USA abnormal LFTS

                    Exclude alcoholic liver disease (histologically identical)

                    Spectrum of injury
                     Simple fatty liver                   no progression
                     non alcoholic hepatosteatosis (NASH) progression to cirrhosis
Hyperinsulinaemia

                    Risk factors for NASH
                    Hypertension/Diabetes/Truncal obesity/ High TG/ ALT>x2 ULN

                     Treatment
                       ?? Metformin/glitazones/weight loss
                          Hepatitis C
Case                                   •   Source
34 year old girl on donating blood     •   Degree of liver damage
   found to be hepatitis C antibody
   positive. Non- specific tiredness
                                       •   Monitoring of liver disease
   for 3 years                         •   Prognosis
ALT 67 IU/l, normal other LFTs,        •   Treatment options
   ultrasound normal                   •   Pregnancy/Transmission

         Investigations
         HCV RNA
         Liver biopsy
         HCV genotype
        Hepatitis B
                                  Infected hepatocyte



          HBV DNA
                          New
                          virus

HBeAg   X protein
        Core protein
HBsAg   Surface protein
        DNA polymerase

                                       Excess surface
                                       particles
                     Hepatitis B
• Increasingly Common In UK
• Is this acute or chronic infection
• Chronic Infection
   –   persistant infection > 6 months
   –   Assess degree of liver damage
   –   Consider antiviral therapy
   –   25% progress to cirrhosis
• Risk factors for acquisition
• Contact tracing
   – sexual partner (infected, immune or need vaccinating)
   – Children (infected at childbirth)
                                 Viruses
                                Hepatitis B

              HBsAg      HBeAg HBV DNA            HBsAb     HBcAb(IgG)


Acute HBV        +        +          +++             -

Chronic HBV      +        +          +++             -
                 +        -          +               -

Cleared          -        -          -               +        +

Vaccination      -        -           -              +        -



  HB Core IgM differentiates acute hepatitis from chronic hepatitis B
                Liver Biopsy


                          • Confirm the diagnosis
                              • Serological blood tests

                          • Establish degree of fibrosis
                               • Serology
                               • Biopsy not representative

                          • Identify cirrhosis

                          • Determine optimum therapy
Route
Risks
Prebiopsy requirements
       ASCITES




Differential Diagnosis

     Ascitic Tap

 Treatment Options

   Complications
Alcoholic Liver Disease


                          Never too late to stop
             ERCP

Diagnostic Test replaced by MRCP

Therapeutic Interventions

        Sphincterotomy (+/-precut)

        Stent               plastic
                            metal
Risks
         5% pancreatitis
         1% bleeding
         Perforation

Requirements
        recent PT/platelets
        lie on front
        good respiratory function
        informed consent
        prophylactic antibiotics.
        venflon right arm

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:66
posted:3/31/2008
language:English
pages:18