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Title:

Etiologies of Chronic Liver Disease

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Bile acid, copper accumulation. Alterations in cannicular membrane and ... to this theory ulceration and acid reflux are considered important, but this is ... – PowerPoint PPT presentation

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Title: Etiologies of Chronic Liver Disease


1
Etiologies of Chronic Liver Disease
  • Infections, esp. viral
  • Toxins
  • Genetic
  • Drugs
  • Autoimmune
  • Vascular
  • Biliary

2
Mechanisms of Chronic Liver Injury
  • Hepatocyte Injury
  • Inflammation primary
  • Injury primary followed by inflammation
  • Biliary Obstruction
  • Hepatic venous obstruction

3
Cystic Fibrosis Wilsons Disease
Biliary Obstruction
Genetic
Hepatocellular Necrosis and Inflammation
Fibrosis
INH Estrogens
Hepatic Venous Outflow Obstruction
Drug
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6
Target Cell
(Activated Target)
Fibrogenesis
PrimaryAgent
Cytokines
Altered Matrix Matrix Peptides
Inflammation
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8
Etiologies of Chronic Hepatitis
  • Hepatitis C
  • Hepatitis B (w/wo Delta)
  • Autoimmune Hepatitis
  • Drugs
  • Wilsons Disease

9
Pathogenesis of Liver Injury with Chronic Biliary
Obstruction
  • Obstruction of bile flow
  • Bile acid, copper accumulation
  • Alterations in cannicular membrane and tight
    junctions
  • Condensation of pericannicular microfilaments
  • Fibrosis (necrosis and inflammation)

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12
Cirrhosis
Hepatic Resistance
Splanchnic blood flow
Decreased NO
Increased NO
Potential Mechanisms to Regulate NOS Activity (?)
  • Increased phosphorylation
  • hsp90 signaling
  • eNOS gene expression (with sustained flow)
  • Increased caveolin levels
  • Decreased phosphorylation

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16
Why Do Varices Bleed?
Erosion
Explosion
According to this theory ulceration and acid
reflux are considered important, but this is not
supported by histological observations
Depends on size and pressure (tension in a
balloon radius x pressure)
17
Options for Control of Variceal Bleeding
  • Medical
  • Vasopressin (or glypressin) NTG
  • Somatostatin (or octreotide)
  • Beta blockers
  • Procedures
  • SB, Minnesota, or Linton tube
  • Endoscopic sclerotherapy or band ligation
  • TIPS
  • Surgical
  • Shunts
  • Variceal interruption
  • Transplant

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19
Elements of Ascites Formation in Cirrhosis
  • Portal hypertension
  • Decreased renal excretion of Na and water
  • Decreased serum oncotic pressure
  • Lead to an increased formation of hepatic lymph
    exceeding the capacity of the thoracic duct

20
  • Classical Underfilling Theory
  • Overflow Theory
  • Sinusoidal Portal Hypertension

Sinusoidal Portal Hypertension
Hepatic Pressure Receptors
Lymph Formation gt Lymph removal
PRIMARY SODIUM AND WATER RETENTION
Ascites Formation
Reduction of Plasma Volume
High and Low- Pressure Baroreceptors
Plasma Volume Expansion Ascites Formation
Increased Activity of Renin-Angiotensin-Aldosteron
e and Sympathetic Nervous Systems and Vasopressin
SECONDARY SODIUM AND WATER RETENTION
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22
Hepatorenal Syndrome (Functional Renal Failure)
  • Kidney pathologically normal
  • Reduced blood flow to renal cortex
  • Reduced GFR
  • Hypertonic urine, reduced urine Na
  • Distinguish from other causes of renal failure

23
Complicated Ascites in Cirrhosis
  • Spontaneous bacterial peritonitis
  • Tuberculous peritonitis
  • Pancreatic ascites
  • Cancer (esp. hepatoma)
  • Budd-Chiari syndrome

24
Serum complement
GI haemorrhage
BACTERAEMIA
RE Function
Invasive procedures
BACTERASCITES
Ascitic fluid opsonic activity good
Ascitic fluid opsonic activity poor
SBP
Resolution
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First Known Description of Hepatic Encephalopathy
  • Im a great eater of beef but believe it does
    harm to my wit

Shakespeare Twelfth Night
27
Stages of Hepatic Encephalopathy
  • Stage 0 - Subclinical psychomotor test
    abnormalities
  • Stage 1 - Lethargy and confusion or excitation,
    sleep disturbance, decreased attention
  • Stage 2 - Somnolence, inappropriate behavior
  • Stage 3 - Stupor but arousable, speech
    incomprehensible
  • Stage 4 - Coma

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31
Hypotheses Concerning the Mechanism of Hepatic
Encephalopathy
  • Ammonia
  • Synergistic toxins ammonia, mercaptans, and
    free fatty acids
  • Increased activity of GABA benzodiazepine
    neurotransmission
  • False neurotransmitters aromatic amines

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34
Precipitants of Hepatic Encephalopathy
  • Excess nitrogen load
  • Drugs (sedatives, analgesics, diuretics)
  • Renal failure
  • Electrolyte/acid-base abnormalities
  • Infection
  • Surgical procedures
  • Constipation

35
Management of Hepatic Encephalopathy
  • Search for and correction of precipitating
    factors
  • Reduce dietary protein (40 g or less)
  • Laxatives, enemas
  • Lactulose, antibiotic (neomycin), or combination
  • Criteria of response

36
Lactulose Mechanism of Altering Colonic Nitrogen
Metabolism
  • Stimulate bacterial growth and nitrogen
    incorporation
  • Inhibit bacterial catabolism of amino acids,
    peptides,
  • Cathartic effect
  • (Ammonia trapping)
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