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Gastroenterology: Medical Disorders of the Liver

Review of the liver

·         Detoxifies

o   Metabolizers nitrogeneous waste

o   Deactivates some pharmacologic agents

·         Produces albumin

·         Produces  coagulation factors (II,V,VII,X)

·         Major hub of venous traffic between lower body and right atrium

o   Portal tract

Cirrhosis

·         Cirrhosis is a pathologic state of liver , caused by chronic insulin /inflammation . The pathologic changes interfere with the ability of the liver to function properly. As well as the ability of the blood to move properly through the portal tract.

·         #1 cause of cirrhosis in the US is alcoholism.

·         Cirrhosis is irreversible and incurable , the tx is therefore forced on reducing the sx.

·         Cirrhosis always increase risks of hepatocellular carcinoma (liver cance.)

Serum albumin –ascites gradient (SAAG)

·         SAAG = (Albumin in serum )  - (Albumin in ascetic fluid)

·         Ascites can be caused by one of two ways:

o   High portal pressure

o   Transudation

§  Example: Tb , cancer, infection  many others.

·          

·         In the case of cirrhosis (a high portal pressure ) there will be a high SAAG (>1.1)

Ascites

·         All pts presenting with ascites should have a pericentesis  to sample the ascite fluid . and obtain a SAAG.

·         Spontaneous bacterial peritonitis is a potentially lethal complication of ascites . The index of suspicion should be high for any pt w /ascites that develop  or presents w/a fever or abdominal pain.

o   Dx: periocentesis w/ ascites WBC analysis (+ if > 500 WBCs )

o   Tx:3^rd generation w/cephalosporin (cetriaxone, cefotaxime) may also transfuse with albumin (ICU) admission , report periocentesis.

Cirrhosis

·         Alcoholic cirrhosis

·         Chronic hepatisis

·         Primary sclerosing cholangitis (PSC)

·         Primary biliary cirrhosis (PBC)

·         Hemochromatosis

·         Alpha-1 antirypsin deficiency.

·         Wilson’s disease

·         Complication : hepatocelluler carcinoma , hepatorenal syndrome etc.

Chronic Hepatitis

·         Infectious disease(virus )that attacks hepatocytes , results in chronic inflammation and fibrosis.

·         Associated risk factor include IV drug (tattoos ) high risk sexual practices , needle sticks /work in health care.

·         Sx. Pt usually asymptomatic until general signs of cirrhosis develop.

·         Dx: Any pt with signs of cirrhosis should get hepatitis titters as this is so common

o   Hep. B presence of HBsAg

o   Hep. C presence of anti HCV Abs and a positive viral load.

·         Tx : All should get interferon –alpha:

·         Hep B: Iamivudine adefovir

·         Hep C :ribavirin

Primary Sclerosing Cholangitis (PSC)

·         An  idiopathic inflammatory disorder of the biliary ductal system . Rsults in cholestasis which causes inflammatory changes in the hepatocytes.

·         Associated with inflammatory bowel disease!!!

·         Sx: Rather non-specific fatigue , puritus and jaundice are the most common .

·         Labs: Normal ST , ALT: elevated alkaline , phoshatase , elevatd GGTP.

·         Dx: AMA titter will differentiate in from PBC , ERCP or transpheritic cholangiogram will be definitive .

·         Tx: Bile acide binding resins: Liver transplant

Hemochromatosis

·         An inherited disorders  of iron absorption , results in high serum iron levels . Iron deposits in the liver , among other tissues , leading to destruction of hepatocytes and cirrhosis.

·         Sx: General cirrhosis sx: Sx of iron dposition in other tissues restrictive cardiomyopathy .

·         Inquire into FHx of cirrhosis , liver cancer , liver problems .

·         Dx : Iron studies

o   Liver biopsy is definitive

·         Tx : Phlebotomy is most effective , deferoxamine may also be used.

·         Increased risk of infection w/V. vulnificus and Yersinis.

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Wilson’s Disease

·         An inherited  disorder of copper absorption and secretion . Copper deposits in various tissues , including the liver eyes and the bhrain . Copper is toxic to the liver , this result in cirrhosis.

·         Sx: general cirrhosis sx. The accumulation of copper in the eyes results in brown –green i.e Kayser – Fleischer ring.

·         Be sure to inquire in to FHx particularly psychistyric hx and HHxof liver problems.

·         Dx: Low serum ceruloplasmin , high serum copper.

·         Liver biopsy is most specific

·         Tx : penicilliamine.

Alpha 1 –Antitrypsin Deficiency

·         An inherited deficiency of the protein al;pha -1 antitrypsin . This protein inhibits a protease that is responsible for physiologic degradation of certain tissues . Deficiency leads to cirrhosis and pulmonary sx.

·         Sx: Will usually present first w/ emphysema (SOB, wheezing , dyspnea, refractory, ashma, low DLCO) Emphysema at a young age is highly suspicious for A1AD

·         As with many inherited disorder , FHx can be very useful.

·         Dx : Alpha 1 antitrypsin titer (low)

·         Tx: Ezyme replacement ; symptomatic therapy (bronchodilators, etc) DO NOT SMOKE!