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LIVER HEALTH
- 3. Chronic hepatitis • diffuse polyetiological inflammatory-destructive process in the liver that lasts at least 6 months • can persist for years, even decades • does not cause significant changes in liver structure • continued inflammation slowly damages the liver, eventually resulting in cirrhosis, liver failure, and sometimes liver cancer
- 5. Etiological classification of hepatitis: • Viral (hepatitis A, B, C, D, E, G, TTV, SEN, herpes, citomegalovirus) • Bacterial (Treponema pallidum) • Parasitic (toxoplasma, echinococcus) Infections • Alcohol • Drugs • Non-alcoholic steatohepatitis (NASH Metabolic • Physical (radiation) • Secondary (another digestive organs diseases) Reactive Autoimmune • Hemochromatosis • Wilsons disease Hereditary
- 6. Classification according to stage of fibrosis A0- Inactive A1- Minimal activity A2-Significant activity A3-Severe activity Classification according activity of inflammatory prosess - F0- no fibrosis - F1- portal fibrosis (minimal) - F2- portal fibrosis with few septa (moderate) - F 3- septal fibrosis (advanced) - F4 – cirrhosis (severe fibrosis)
- 7. HISTOLOGY ACTIVITY INDEX (Knodell Score) Periportal +- Bridgind Necrosis 0-10 Intralobular Degeneration and Focal Necrosis 0-4 Portal Inflammation 0-4 Fibrosis 0-4 HAI: 1-3 бали – minimal, 4-8 балів – mild, 9-12 балів – moderate, 13-18 балів - high
- 9. Fibro- Acti Test • ALPHA-2-MACROGLOBULIN • ALANINEAMINOTRANSFERASE (ALT) • APOLIPOPROTEIN A1 • GAMMA- GLUTAMYLTRANSFERASE (GGT) • HAPTOGLOBIN • BILIRUBIN, TOTAL
- 11. FibroScan
- 12. Hepatitis clinical syndromes: • Asthenovegetative (80-100%) • Hepatomegaly (90-100%) • Pain syndrome (70-80%) • Dyspeptic (80-90%) • Jaundice (30-50%) • Increased bleeding (30-50%) • Skin itchiness (15-20%) • Fever (15-30%) • Small liver sins syndrome (10-15%) • Arthralgia, myalgia (5-12%)
- 13. Asthenovegetative syndrome: • Fatigue • Loss of appetite • Dizziness • Drowsiness • Anxiety
- 14. Hepatomegaly
- 16. Pain syndrome Dull chronic pain in the right hypochondriac region
- 17. Dyspeptic syndrome: • Nausea • Vomiting • Diarrhea • Postprandial fullness • Belching • Early satiety • Weight loss
- 18. Jaundice • Yellow discoloration of skin, mucous, whites of the eyes • Light - colored stools • Dark – colored urine
- 19. Small liver sins syndrome Тelangioetasies, "spiders" Hepatic palms (palmar erythema) "Liver tongue" Хanthelasma
- 20. Small liver sins syndrome
- 21. Biochemical Blood analysis 1.Bilirubin level (increased) 2. ALT activity, AST (more than twice increased) 3. Timol sample 4.Sulemic test 5. Level of albumins: globulins(> 25 g/l) 6. Alkaline phosphatase 7. Gamaglutamatranspeptidase 8. The level of fibrinogen, prothrombin
- 22. Conclusion. An increase in alkaline phosphatase and bilirubin due to conjugated (biochemical signs of cholestasis) with normal transaminase values (absence of cytolysis), one can think of mechanical jaundice, which can be caused by the presence of calculi in the biliary system, a tumor or a large cyst in the pancreas, a tumor of the large duodenal papilla, etc. To clarify the diagnosis, it is necessary to take into account the clinical manifestations and results of other laboratory (examination of urine and feces) and instrumental (EGD, ultrasound, CT, etc.) research methods. Parameter Result Reference ranges Serum bilirubin 130 <20,5 mcmol/L Conjugated bilirubin 115 <5,1 mcmol/L Unconjugated bilirubin 15 >75% serum bilirubin ALT 32 F <31 U/L M <41 U/L AST 29 F <31 U/L M <37 U/L Alkaline phosphatase 205 F 35-104 U/L M 40-129 U/L
- 23. Parameter Result Reference range Serum bilirubin 130 <20,5 mcmol/L Conjugated bilirubin 32 <5,1 mcmol/L Unconjugated bilirubin 98 75% serum bilirubin ALT 81 F <31 U/L M<41 U/L AST 72 F<31 U/L M<37 U/L GGTP 50 F 5-36 U/L M 8-61 U/L Alkaline phosphatase 89 F 35-104 U/L M 40-129 U/L Total protein 78 66-87 g/L Serum albumin 48 53-63 g/L Globulins 30 23-35 g/L α1-Globulins 3,3 3,8-6,5% α2-Globulins 6,0 6,5-10% β-Globulins 11,0 10-15% γ-Globulins 18,2 14,5-19,5% Thymol test 4 0-5 S-H An increase in bilirubin is mainly due to unconjugated, it can be assumed that the patient has parenchymal jaundice on the background of hepatitis with minimal activity. An increase in the level of transaminases is less than 3 times, which reflects the presence of cytolysis and may indicate an inflammatory process in the liver of minimal activity. Most often, parenchymal jaundice indicates hepatitis. Cytolytic syndrome is characterized by: -Increasing the activity of enzymes-indicators of cytolysis and hepatocellular necrosis - ALT, AST -Hyperbilirubinemia with an increase in the content of mainly direct Levels of hepatitis activity are determined by increasing the activity of ALT and AST serum relative to the upper limit of normal: -Minimum - no more than 3 times -Moderate - 3-5 times -Expressed - more than 5 times
- 24. • Considering the small (less than three-fold) increase in the level of transaminases, which indicates minimal activity of the process in the liver, the absence of changes in protein fractions, a very significant increase in gamma-glutamyl transpeptidase with a normal level of alkaline phosphatase, we can assume the probability of alcoholic liver damage (alcoholic hepatitis). Parameter Result Reference range Serum bilirubin 20 <20,5 mcmol/L Conjugated bilirubin 3 <5,1 mcmol/L Unconjugated bilirubin 17 75% serum bilirubin ALT 78 F <31 U/L M<41 U/L AST 108 F<31 U/L M<37 U/L GGTP 194 F 5-36 U/L M 8-61 U/L Alkaline phosphatase 91 F 35-104 U/L M 40-129 U/L Total protein 70 66-87 g/L Serum albumin 44 53-63 g/L Globulins 26 23-35 g/L α1-Globulins 4,5 3,8-6,5% α2-Globulins 6,8 6,5-10% β-Globulins 9,8 10-15% γ-Globulins 16,0 14,5-19,5% Thymol test 3 0-5 S-H
- 25. Viral Hepatitis Viral hepatitis is caused different viruses: - Hepatitis A and E virus - Hepatitis B virus (HBV) - Hepatitis C virus (HCV) - Hepatitis D virus (HDV) - Hepatitis G, TTV, SEN viruses - Herpes virus - Citomegalovirus
- 27. Hepatitis B symptoms, treatment and prevention
- 28. Hepatitis B • Is an infectious disease caused by the hepatitis B virus (HBV) that affects the liver and can cause both acute and chronic liver disease • The virus is most commonly transmitted from mother to child during birth and delivery, as well as through contact with blood or other body fluids, including sex with an infected partner, injection-drug use that involves sharing needles, syringes, or drug-preparation equipment and needle sticks or exposures to sharp instruments. • Over 750,000 people die of hepatitis B each year • The infection has been preventable by vaccination since 1982. Vaccination is recommended by the World Health Organization in the first day of life if possible. Two or three more doses are required at a later time for full effect.
- 30. HBV The virus particle (virion) consists of an outer lipid envelope and an icosahedral nucleocapsid core composed of core protein The genome of HBV is made of circular DNA Hepatitis B virus primarily interferes with the functions of the liver by replicating in hepatocytes During HBV infection, the host immune response causes both hepatocellular damage and viral clearance. It contributes to most of the liver injury by killing infected cells and producing antiviral cytokines
- 31. Clinical symptoms of chronic viral hepatitis: • Fatigue • Reduced working capacity • Sleep disturbances • Emotional lability • Loss of appetite • Discomfort in right hypochondriac region • Bitterness in the mouth • Sub febrile temperature • Hepatosplenomegaly
- 32. HBV serum markers Chronic hepatitis B diagnostic: 1.HBsAg in blood more than 6 month -HBeAg; -HBcAg; -Anti-HBc (total) antibodies 2. Ig M anti-HBc 3. Anti-HBe antibodies HBV DNA in blood more than 6 month
- 33. Treatment - Еntecavir – 500-1000 mkg per 1 day -48 weeks - Тenofovir - 300 мg per 2 days 1 year (can be 7 years) - -Аdefovir– 10 mg per 1 day Control amount of HBV DNA in blood ( treatment if more than 2000)
- 34. Hepatitis C: symptoms, transmission, causes, treatment
- 35. Extrahepatic sings of HCV Endocrinological hypothyroidism, hyperthyroidism, autoimmune thyroiditis, diabetes mellitus Dermatological cutaneous necrotizing vasculitis, cutaneous porphyria, lichen planus, erythema multiforme, urticaria, erythema nodosum Ophthalmological uveitis, ulcerative keratitis Nephrological glomerulonephritis Hematological mixed cryoglobulinemia, idiopathic thrombocytopenia, aplastic anemia Autoimmune periarteritis nodosa, hypertrophic cardiomyopathy, antiphospholipid syndrome, dermatomyositis, arthritis
- 36. Viral hepatitis diagnostic: Hepatitis C • Ig G anti-HCV • Ig M anti-HCV • HCV RNA • Genotypes 1b and 3- worse prognosis
- 37. Geographical distribution of HCV subtypes HCV genotypes Subsets Geographical distribution Genotype 1 1a, 1b North America, Central Africa, Europe Genotype 2 2a, 2b, 2c, 2d Western Africa Genotype 3 3a, 3b, 3c, 3d, 3e, 3f Southeast Asia Genotype 4 4a, 4b, 4c, 4d, 4e, 4f, 4g, 4h, 4i, 4j Central Africa Genotype 5 5a South Africa and Asia Genotype 6 6a Southeast Asia
- 38. Treatment of hepatitis C • Without cirhosis - Sofusbuvir velpatasvir – 12 weeks - Glecaptovir / pibrentasvir – 8 weeks • With cirhosis : - Sofusbuvir velpatasvir – 24 weeks
- 39. Autoimmune Hepatitis | Pathogenesis, Signs & Symptoms, Diagnosis, Treatment
- 40. Autoimmune hepatitis • chronic necrotic-inflammatory disease of the liver of unknown etiology, which lasts more than 6 months, is characterized by periportal process, the presence of hypergammaglobulinemia and a high range of tissue autoantibodies
- 41. AIH is more common in women The course from asymptomatic to severe: • - fever • - resistant jaundice • - appearance of "vascular stars" • -the appearance of devices, bruises Extrahepatic manifestations: • -dermal vasculitis • - polyarthritis, arthralgia, myalgia • -lymphadenopathy • pleurisy, pulmonary infiltrate • -myocarditis • -glomerulonephritis • ulcerative colitis and others.
- 42. Diagnostic of AIH 1. Leukocytosis, increased SCE 2. Determination of blood bilirubin level 3. Determination of ALT, AST activity 7. High antibody titers depending on type: ANA, SMA, anti-LKM-1, LKM-3, anti-SLA 8. The presence of antimitochondrial antibodies (AMA) 9. Absence of markers of viral hepatitis 10. Histological signs of inflammatory necrotic process by R.G.Knodell 11.Response to corticosteroid treatment
- 43. Treatment 1.Prednisolone 40-80 mg daily (two thirds dose in the morning, one third in the evening) 1-2 weeks with a gradual reduction to 10-20 mg 2. Prednisolone 20-40 mg and azathioprine from the second week to 50 mg per day - in the first week, then reduce the dose of prednisolone to 5-10 mg per week 3. Prednisolone 10-15 mg daily in the morning - from several months to many years
- 44. Treatment ( depend on severety) 1. Azathioprine 50 mg daily for 2 weeks or 2. Azathioprine 100 mg per day and prednisolone 10 mg per day or 3. Azathioprine 100 / day and budesonide 3 mg / 2-3 times a day until complete biochemical remission - from several months to many years Apply other cytostatics: • Mycophenolate mofetil (Mifenax) (instead of azathioprine) • Cyclosporine • Tacrolimus • Sirolimus
- 46. Drug-Induced Liver Disease, Causes, Signs and Symptoms, Diagnosis and Treatment.
- 48. Drugs induced liver injury treatment • Immediately remove drugs that cause liver injury • Specific antidotes • Diet # 5 • Glucocorticoids (prednisolone) • Symptomatic treatment
- 49. Fatty Liver, Causes, Signs and Symptoms, Diagnosis and Treatment.
- 51. Fatty liver etiology: Metabolic changes • Obesity • Diabetes mellitus • Hyperlipidemia • Starvation • Acute weight loss Surgical interventions • Bariatric surgery • Gastro jeynum anastomosis • Biliary-pancreatic stoma • Colon resection Drugs • Amiodarone • Glucocorticoids • Tamoxifen • Estrogen
- 52. Clinical characteristics of fatty liver patients: • Age • 41-60 years • Gender • Female • Additional diseases • Obesity • Diabetes mellitus • Hyperlipidemia • Complains • Asymptomatic • Discomfort in abdominal cavity • Pain in right hypochondriac reason • Fatigue • Objectively • Hepatosplenomegaly • Laboratory changes • Increasing AST and ALT in 2 and more times
- 54. Treatment: •Weight loss •Hypoglycemic agents •Hypocholesterinic therapy •Hepatoprotectors
- 56. Alcohol liver disease – group of functional and structural liver diseases that occurs due to alcohol abuse. •Alcohol steatosis •Acute alcohol hepatitis •Chronic alcohol steatohepatitis •Alcohol liver fibrosis •Alcohol liver cirrhosis
- 57. Clinical sings of alcohol liver disease: • Anorexia • Abdominal pain • Fever • Hepatomegaly • Jaundice • Portal hypertension • Telangiectasia
- 58. Alcohol liver disease diagnostic: Biochemical • AST/ALT>1 • Increasing level of GGT • Increasing main erythrocyte volume Clinical • Small liver sings • Extra liver alcoholic sings