12.3 Liver Diseases Hepatitis Liver Cirrhosis Biliary Colic Acute Cholecystitis Liver Abscess Hepatitis • It is inflammation of the liver. • The different types are: – Hepatitis A – Hepatitis B – Non-infectious Hepatitis Hepatitis A • Caused by hepatitis virus. •Spreads by the oral-fecal route. Hepatitis B • Caused by hepatitis virus • Spread by blood, body fluids, and sexual intercourse Non-infectious Hepatitis • Causes: – Alcohol intoxication – Anti TB medications – HIV medications – Medications used to treat leprosy Signs and Symptoms • Jaundice (gets worse for 2 weeks then slowly gets better) • Malaise- generally feeling bad Signs and Symptoms • Mild fever • Loss of appetite Signs and Symptoms • Nausea and vomiting • Right upper quadrant pain Signs and Symptoms • Smooth, tender and slightly enlarged liver Signs and Symptoms • Dark urine and stools Diagnosis • Check a liver function test in the laboratory- AST and ALT • Check for specific liver antibodies Treatment • Supportive treatment • This means if the patient is dehydrated- give fluids, if in pain- give pain medicine Treatment • Encourage the patient to drink and eat or give dextrose 5% IV • NO alcohol Treatment • Treat any primary infections • Stop any medications that may be affecting their liver Prevention • For Hepatitis A: improve sanitation – Clean water – Wash hands after using the bathroom – Keep toilet away from water used for cooking and cleaning Prevention • For Hepatitis B: general precautions for health workers and vaccinations – Caution with dirty needles – Wearing glasses when things might splash into your eyes – Wearing gloves Vaccination • The best time to give a vaccine for Hepatitis B is: – At birth, 6 weeks, and 14 weeks of life Liver Cirrhosis • Is a chronic disease that destroys the cells of the liver • Causes scar tissue Causes • History of Hepatitis B or C virus • Alcohol abuse • Blood disorders • Cirrhosis can lead to: – Liver failure – Encephalopathy – Hypoglycemia – Bleeding – Ascites – infections Signs and Symptoms • Jaundice • Malaise Signs and Symptoms • Weakness • Body Itching Signs and Symptoms • Palms of the hands are red • Slow hand tremor Signs and Symptoms • Ascites • Oedema of the legs and back Signs and Symptoms • Enlarged spleen • Gastrointestinal bleeding Normal spleen Enlarged spleen Signs and Symptoms • Muscle wasting • Spider naevi: red spider-like blood vessels on the skin Diagnosis • Check the liver function tests: AST and ALT • Ultrasound the liver if possible – Does the liver have many nodules? Treatment • There is no cure for cirrhosis • There are ways to control the symptoms and to delay liver failure. Treatment • Nutrition: patients need a high protein, low salt diet • If there is gastrointestinal bleeding, give a blood transfusion and vitamin K 1 mg IM Treatment • To prevent gastrointestinal bleeding, give omeprazole • Watch their BP, too high might cause bleeding Treatment • If there is oedema and ascites, give Spironalactone or Furosemide Prevention • No more alcohol! • No more medications that damage the liver (anti TB or leprosy medications) Biliary Colic • Severe abdominal pain caused by a stone going through a bile duct • The stone blocks the bile duct and causes the patient to become jaundiced Biliary Colic • The blockage can be caused by gallstones and worms. • It is very common to have gallstones during pregnancy. Signs and Symptoms • Pain that comes in waves and radiates to back and right shoulder • Guarding in right upper quadrant Signs and Symptoms • Central abdominal pain moving to right upper quadrant • Vomiting Signs and Symptoms • No fever • No jaundice Diagnosis • Look at the patient, what are their signs and symptoms? • Ultrasound of the gallbladder if possible. Are there stones? Treatment • Buscopan IM or IV to stop the bile duct from spasming • Pentazocine IM or SC for pain Treatment • If there is still pain after two injections of buscopan/pentazocine ask a doctor for help • Treat worms Prevention • Regular deworming, especially in pregnant women • A diet that is healthy and low in fat Acute cholecystitis • A bacterial infection of the gall bladder mostly due to an obstruction of the gall ducts. • It may happen after biliary colic Acute cholecystitis • It may also be caused by malnourishment or typhoid fever. Signs and Symptoms • Pain, tenderness, and guarding of the right upper quadrant • vomiting Signs and Symptoms • Fever, chills • Jaundice Diagnosis • Look at the patient. Do they have pain specifically in the right upper quadrant when touched but not in the left upper quadrant? Diagnosis • Ultrasound the gallbladder. Is there inflammation? Complications • Empyema: when the gallbladder fills with pus • Peritonitis: inflammation of the membrane that lines the abdominal cavity Treatment of complications • Bed rest • Pain relief: buscopan IV or IM, codeine or tramadol Treatment of complications • Nothing by mouth. • Give IV fluids. Treatment of complications • Ceftriaxone 1 gram IV daily and Metronidazole 500 mg IV three times a day until fever settles • Then oral ciprofloxacin and metronidazole 500mg three times a day for 10 days. Treatment of complications • Think about surgery to removed the gallbladder. • Without surgery there is a 25% chance this will occur again. Prevention • Surgically remove the gallbladder to prevent further attacks of cholecystitis. Liver abscess • A collection or collections of pus in the liver • There are two types: – Amoebic – Bacterial Amoebic abscess • Most common type of abscess • The patient may have had a recent episode of dysentery • Treat with metronidazole, with or without drainage. Bacterial abscess • Mostly from bacteria ascending into the bile ducts • The patient is often very sick • Treat with broad spectrum antibiotics, with or without drainage Signs and Symptoms • Fever and chills • No appetite, nausea Signs and Symptoms • Painful and enlarged liver (hepatomagely) on palpation or percussion • Sometimes chest pain with a right- sided pleural effusion Signs and Symptoms • Usually there is no jaundice, no splenomegaly, and no ascites • If those are present, think of other diagnosis Diagnosis • Look at the patient, what are their symptoms? • Ultrasound is very helpful is possible. Look for a pocket in the liver. • Test the stool. Are there amoebas? Treatment • For a stable patient: – Start metronidazole orally • Child 7.5-10 mg/kg three times a day • Adult 750-800 mg three times a day Treatment • If the patient improves, continue for 14 days • If patient is not improving after 3-5 days, follow the unwell/septic protocol Treatment • For a unwell/septic patient: – Start IV ampicillin, gentamicin, and PO/IV metronidazole – Continue for 14 days, stop gentamicin after 8 days Treatment • Some abscesses need to be drained with surgery. • If they are greater than 6 cm and if the patient is not responding to antibiotic treatment Prevention • Adequate and early treatment of amoebic dysentery could prevent a liver abscess.