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Liver in One Hour

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... Hepatocellular Cholestatic Recognize common complications of cirrhosis Understand the evaluation of steatosis Liver Function Tests ... Pancreatic Cancer ... – PowerPoint PPT presentation

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Title: Liver in One Hour


1
Liver in One Hour
  • Christopher Deitch
  • Assistant Professor Medicine
  • Gastroenterology/Hepatology

2
Objectives
  • Evaluate a liver profile
  • Understand the algorithm for evaluation
  • Formulate a differential diagnosis
  • Hepatocellular
  • Cholestatic
  • Recognize common complications of cirrhosis
  • Understand the evaluation of steatosis

3
Liver Function Tests
  • Prothrombin Time
  • Albumin
  • Bilirubin
  • Direct Conjugated Water soluble
  • Indirect Unconjugated Water insoluble

4
Liver Tests
  • AST SGOT
  • ALT SGPT
  • Alkaline Phosphatase
  • 5 Nucleotidase
  • GGT

5
Hepatobiliary Anatomy
6
Patterns of Enzyme Elevation
  • Hepatocellular
  • AST
  • ALT
  • Alk Phos
  • Bilirubin
  • Protime nl/?
  • Albumin nl/?
  • Cholestatic
  • Alk Phos
  • Bilirubin
  • AST
  • ALT
  • Protime nl/?
  • Albumin nl

7
The Algorithm
8
What Can You Tell Me?
  • Hepatocellular Diseases
  • Cholestatic Diseases
  • Mixed Disorders
  • Hepatic Synthetic Function

9
Whos it Going to Be?
  • AST ALT Alk Phos Bili PT Albumin
  • 1020 1278 275 4.8 13 s 3.9
  • 212 265 1285 16.9 18 s 4.2
  • 84 41 139 5.3 17 s 2.8
  • 13 17 78 2.9 10 s 4.5

10
Impaired Bilirubin Metabolism
  • Unconjugated hyperbilirubinemia
  • Bilirubin overproduction
  • Impaired bilirubin uptake
  • Impaired bilirubin conjugation
  • Examples
  • Gilberts syndrome
  • Crigler Najar I and II

11
Impaired Bilirubin Metabolism
  • Conjugated Hyperbilirubinemia
  • Intrahepatic cholestasis
  • Dubin-Johnson Syndrome
  • Primary Biliary Cirrhosis
  • Rotor Syndrome
  • Progressive Familial Intrahepatic Cholestasis
  • Benign Recurrent Intrahepatic Cholestasis
  • Alagilles Syndrome

12
Extrahepatic Cholestasis
  • Obstructive diseases Extrahepatic Cholestasis
  • Choledocholithiasis
  • Cholangiocarcinoma
  • Sclerosing Cholangitis
  • Pancreatic Cancer
  • Choledochol Cysts
  • Metastatic Disease
  • Parasitic Disease

13
MRCP
14
Axial CT Scan
15
Hepatocellular Disease
  • Hepatitis A, B, C, B(D), E and G
  • Autoimmune Hepatitis
  • Steatosis and NASH
  • Drug Induced Disease
  • Hemochromatosis
  • Wilsons Disease

16
Hepatitis A
  • Fecal - Oral Route
  • Incubation 30 days
  • Self limited illness
  • Rarely Fatal
  • Never Chronic
  • Immunity follows

17
Hepatitis A
18
Hepatitis B
  • Blood and body fluids
  • DNA Virus
  • Chronicity in adults 10
  • Chronicity in children 90
  • Risk for hepatocellular carcinoma

19
Hepatitis B
20
Hepatitis B
  • HBsAb HBsAg HBcAb HBeAg HBeAb DNA
  • - -
    -
  • - - -
    - -
  • -
    -
  • - -
    - -
  • - -
    -

21
Hepatitis C
  • 3-4 Million US infected
  • Blood borne pathogen
  • Chronicity 75
  • Cirrhosis 25
  • Decompensation 5-10
  • Curable with Interferon/Ribavirin combination
  • Genotypes 1-6 worldwide

22
Cirrhosis
  • Compensated vs. Decompensated
  • Ascites and Edema
  • Spontaneous Bacterial Peritonitis (SBP)
  • Variceal Hemorrhage
  • Porto-Systemic Encephalopathy (PSE)
  • Hepatocellular Carcinoma
  • Jaundice

23
Ascites
  • 60 develop within 10 years
  • 50 mortality after 24 months
  • Diagnosis
  • Paracentesis
  • Cell counts
  • Serum Albumin Ascites Gradient (SAAG)

24
Ascites SBP
  • PMNgt250 SBP and Treat!
  • PMNgt5000 Intra-abdominal perforation
  • SAAG gt1.1 g/Dl
  • Portal hypertension
  • Diuretics / sodium restriction / Paracentesis
  • SAAGlt1.1 g/Dl
  • Nephrotic syndrome
  • Pancreatic duct rupture
  • Malignancy
  • Tuberculosis

25
Porto-Systemic Encephalopathy
  • Neuro-psychiatric dysfunction
  • Ammonia levels?
  • Inaccurate assessment
  • Insensitive therapeutic index
  • Treat underlying cause
  • Lactulose
  • Xifaxin

26
Hepatic Encephalopathy
  • Hypovolemia
  • Bleeding
  • SBP
  • Medications
  • Acidosis
  • Hypoxemia
  • Hypoglycemia
  • Anemia

27
Hepatocellular Carcinoma
  • Cirrhosis
  • Hepatitis B without cirrhosis
  • Hepatic decompensation
  • Cure Resection or transplant
  • Palliative measures
  • Alpha-fetoprotein elevated in 75

28
Steatosis
  • NAFLD Non-Alcoholic Fatty Liver Disease
  • NASH Non-Alcoholic Steato-Hepatitis
  • Absence of alcohol
  • Distinction by liver biopsy
  • Hepatic manifestation of the metabolic syndrome

29
Steatosis
  • Parallels conditions associated with insulin
    resistance
  • Obesity
  • Hyperlipidemia
  • Diabetes
  • Hypertension

30
Steatosis
  • NAFLD
  • 3-36 population
  • Benign course
  • Low risk of fibrosis and progression
  • NASH
  • 15 population
  • More aggressive course
  • Higher risk of cirrhosis

31
Steatosis
  • Ultrasound
  • Computerized Tomography
  • Magnetic Resonance Imaging
  • Transient Elastography
  • Limitations?

32
Steatosis
  • Cirrhosis 15-25 of NASH
  • 30-40 succumb to liver related death
  • Mortality worse than hepatitis C
  • Common cause of cryptogenic cirrhosis

33
Steatosis
  • Medical Treatment
  • Increase insulin sensitivity
  • Modify risks for NASH
  • Protect from oxidative stress
  • Surgical Treatment
  • Lose the weight!

34
Conclusions
  • Evaluate a liver profile carefully
  • Differential diagnosis
  • Cholestatic
  • Hepatocellular
  • Primer on viral hepatitis
  • Cirrhosis complications
  • Steatosis
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