Chronic liver disease

1. ASSIGNMENT
GONOBISHWABIDYALAY
Subject:Clinicalpharmacy&pharmacology-I..
Coursecode:Pharm(4704) .
SUBMITTEDBY :
Name:Md.MoshiurRahman
Roll:07(2047) .
Batch:31 .
Semester:7th .
Department:Pharmacy. .
SUBMITTEDTO :
ROZINAPARUL .
SeniorLecturer. .
Departmentofpharmacy.
Gonobishwabidyalay .
Submissionsdate:22/6/2020

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QuestionsNo.1.Whatarethecausesofchronicliverdisease?
Ans:Chronicliverdiseaseoccurswhenthescartissuereplaceshealthytissueinthe
body’sliver.Chronicliverdiseaseisthe12thleadingcauseofdeathintheUnitedStates
Commoncausesofchronicliverdiseaseare:
 Hepatitisandotherviruses
 Long-termalcoholabuse
 abuseabus
 Non-alcoholicfattyliverdisease(thishappensfrommetabolicsyndromeand
iscausedbyconditionssuchasobesity,highcholesterolandtriglycerides,and
highbloodpressure)
Otherlesscommoncausesofcirrhosismayinclude:
 Autoimmunedisorders,wherethebody’sinfection-fightingsystem(immune
system)attackshealthytissue
 Blockedordamagedtubes(bileducts)thatcarrybilefromthelivertothe
intestine
 Useofcertainmedicines
 Exposuretocertaintoxicchemicals
 Repeatedepisodesofheartfailurewithbloodbuildupintheliver
 Parasiteinfections
Somediseasespassedfromparenttochild(inheriteddiseases)mayalsocause
cirrhosis.Thesemayinclude:
 Alpha1-antitrypsindeficiency
 Highbloodgalactoselevels
 Glycogenstoragediseases
 Cysticfibrosis
 Porphyria(adisorderinwhichcertainchemicalsbuildupintheblood)

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 Hereditarybuildupoftoomuchcopper(Wilsondisease)oriron
(hemochromatosis)inthebody
QuestionNo.2.Writetheclinicalmanifestations,investigation,
managementofthepatientinliverdisease.
Clinicalmanifestations:
 Conteneoussign:fingerclubbing,plamererythmia,whitenails,spidernavei&
deficiencyofclottingfactors.
 Abnormalsign:Hepatomegaly,splenomegaly&cirrhosis.
 Generalsignoflivecellfailure:Ascites
Acute:
 Anorexia
 Nausea/vomiting
 RUQ(rightupperquadrant)painbowelirregularity
 Malaise
 HA(hyoertoniaarterials:hyoertoniaissurroundingdamagetothecental
nervoussystemnamelyuppermotorlesions)
 Lightstool
 Fatigue
 Fever
 Jaundice
 Weightloss
 Hepatomegaly
 Pruritus
 Bilirubinuria

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 Urticaria
 Arthralgias
Chronic:
 Malaise
 Easyfatigability
 Hepatomegaly
 Slpenomegaly
Investigatoion:
 Bilirubin
 Transaminases
 Albumin
 Alkalinephosphatase
 Prothombintime
 Ultrasound
Managementofpatientsinliverdisease:
 Pruritus
 Clottingabnormalities
 Portalhypertension
 Acites
 Encephalopathy
QuestionsNo.3.Writedownaboutliverbiopsy.

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Definition:Aliverbiopsyisaproceduretoremoveasmallpieceoflivertissue,soit
canbeexaminedunderamicroscopeforsignsofdamageordisease.Thisinformation
helpsguidetreatmentdecisions.
Abiopsyoftheliverisamedicalprocedureinwhichasmallamountoflivertissueis
surgicallyremovedsoitcanbeanalyzedinthelaboratorybyapathologist.
Liverbiopsiesareusuallydonetodetectthepresenceofabnormalcellsintheliver,
likecancercells,ortoevaluatediseaseprocessessuchascirrhosis.
LiverBiopsyIsPerformed
1.digestivesystemissues
2.persistentabdominalpain
3.rightupperquadrantabdominalmass
4.laboratorytestspointingtotheliverasanareaofconcern
Aliverbiopsyisusuallydoneifyoureceivedabnormalresultsfromotherlivertests,
haveatumorormassonyourliver,orsufferfromconsistent,unexplainablefevers.
WhileimagingtestslikeCTscansandX-rayscanhelpidentifyareasofconcern,they
can’tdifferentiatebetweencancerousandnoncancerouscells.Forthis,youneeda
biopsy.
Aliverbiopsycanbeusedtodiagnoseormonitoranumberofliverdisorders.
Someconditionsthataffecttheliverandmayrequireabiopsyinclude:
 alcoholicliverdisease
 autoimmunehepatitis
 chronichepatitis(BorC)
 hemochromatosis(toomuchironintheblood)
 nonalcoholicfattyliverdisease(FLD)
 primarybiliarycirrhosis(whichleadstoscarringontheliver)
 primarysclerosingcholangitis(whichaffectstheliver’sbileducts)

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 Wilson’sdisease(aninheritedanddegenerativeliverdiseasecausedbyexcess
copperinthebody)
PreparationforaLiverBiopsy
1.undergoaphysicalexaminationandcompletemedicalhistory
2.stoptakinganymedicationsthataffectbleeding,includingpainrelievers,
anticoagulants,andcertainsupplements
3.haveyourblooddrawnforabloodtest
4.notdrinkoreatforuptoeighthoursbeforetheprocedure
5.arrangeforsomeonetodriveyouhome
HowaLiverBiopsyIsPerformed
Justbeforetheprocedure,you’llchangeintoahospitalgown.Yourdoctorwill
giveyouasedativethroughanintravenous(IV)linetohelpyourelax.
Stoptakingcertainmedications:
Beforeyourliverbiopsy,you'lllikelybeaskedtostoptakingmedicationsand
supplementsthatcanincreasetheriskofbleeding,including:
 Aspirin,ibuprofen(Advil,MotrinIB,others)andcertainotherpainrelievers
 Blood-thinningmedications(anticoagulants),suchaswarfarin(Coumadin)
 Certaindietarysupplementsthatmayincreaseriskofuncontrolledbleeding
Therearethreebasictypesofliverbiopsies.

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Percutaneous:Alsocalledaneedlebiopsy,thisbiopsyinvolvesputtingathin
needlethroughtheabdomenandintotheliver.TheMayoClinicstatesthatit’sthe
mostcommontypeofliverbiopsy.
Transjugular:Thisprocedureinvolvesmakingasmallincisionattheneck.Athin
flexibletubeisinsertedthroughtheneck’sjugularveinandintotheliver.This
methodisusedforpeoplewhohavebleedingdisorders.
Laparoscopic:Thistechniqueusestube-likeinstrumentsthatcollectthesample
throughasmallincisionintheabdomen.
RiskfactorsofLiverBiopsy
Anymedicalprocedurethatinvolvesbreakingtheskincarriestheriskofinfection
andbleeding.Theincisionforaliverbiopsyissmallandneedlebiopsiesareless
invasive,sotheriskismuchlower
Pain.atthebiopsysiteisthemostcommoncomplicationafteraliverbiopsy.Painafter
aliverbiopsyisusuallyamilddiscomfort.Atuncomfortable,maybegivenanarcotic
painmedication,suchasacetaminophenwithcodeine(TylenolwithCodeine).
Bleeding.Bleedingcanoccurafteraliverbiopsy.Excessivebleedingmayrequireyouto
behospitalizedforabloodtransfusionorsurgerytostopthebleeding.
Infection.Rarely,bacteriamayentertheabdominalcavityorbloodstream.

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Accidentalinjurytoanearbyorgan.Inrareinstances,theneedlemaystickanother
internalorgan,suchasthegallbladderoralung,duringaliverbiopsy.
Inatransjugularprocedure,Ifyouhaveatransjugularliverbiopsy,
otherinfrequentrisksinclude:
Collectionofblood(hematoma)intheneck:Bloodmaypoolaroundthesitewhere
thecatheterwasinserted,potentiallycausingpainandswelling.
Temporaryproblemswiththefacialnerves:Rarely,thetransjugularprocedurecan
injurenervesandaffectthefaceandeyes,causingshort-termproblems,suchasa
droopingeyelid.
Temporaryvoiceproblems;maybehoarse,haveaweakvoiceorloseyourvoicefora
shorttime.
Punctureofthelung;Iftheneedleaccidentallysticksyourlung,theresultmaybea
collapsedlung(pneumothorax).
Complications
 Punctureoflungorgallbladder
 Infection
 Pain
 Bleeding
QuestionsNo.4.Writeshortnoteson
I.Hepaticencephalopathy
II.Esophagealvarices
Hepaticencephalopathy
Definition:Hepaticencephalopathyisasyndromeusuallyobservedinpatientswith
cirrhosis.Hepaticencephalopathyisdefinedasaspectrumofneuropsychiatric
abnormalitiesinpatientswithliverdysfunction,afterexclusionofbraindisease.
Hepaticencephalopathyischaracterizedbypersonalitychanges,intellectual
impairment,andadepressedlevelofconsciousness.

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Differenttypesofhepaticencephalopathy
1.Acutefulminantviralhepatitis.Thisisaseveretypeofviralhepatitisthatcomes
onsuddenly.
2.Toxichepatitis.Toxichepatitismaybecausedbyexposuretoalcohol,chemicals,
drugs,orsupplements.
3.Reye’ssyndrome.Thisrareandseriousconditionisprimarilyseeninchildren.It
causessuddenswellingandinflammationoftheliverandthebrain.
Symptomsofseverehepaticencephalopathyare:
 confusion
 drowsinessorlethargy
 anxiety
 seizures
 severepersonalitychanges
 fatigue
 confusedspeech
 shakyhands
 slowmovements
 Getcranky
Causeshepaticencephalopathy
Theexactcauseofhepaticencephalopathyisunknown.However,it’susuallytriggered
byabuildupoftoxinsinthebloodstream.Thisoccurswhenyourliverfailstobreak
downtoxinsproperly
Thefivestagesofhepaticencephalopathy,accordingtotheWestHavenCriteria,are:
Stage0.Atthisstage,symptomsareminimal.
Stage1.Symptomsaremild.Theymayincludeashortenedattentionspanandchanges
toyoursleephabits,suchashypersomniaorinsomnia.

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Stage2.Symptomsaremoderate.Atthisstage,youmayfeeldisorientedorlethargic.
Stage3.Symptomsaresevere.You’llbeunabletoperformbasictasks.You’llalsofeel
confusedandexperiencepersonalitychanges.
Stage4.Thisstageischaracterizedbycoma.
Treatment
Lactulose.Thisisatypeofsugarthatcanmakeyouhavemorebowelmovements.This
helpsgetridofsometoxinsfromyourbody,likeammonia,whichcantriggerHE.Your
doctorornursewillexplainhowtofigureouttherightamount.Forexample,youwill
needtoadjustyourdoseuntilyouarehaving2to3bowelmovementsaday.
Antibiotics:Drugslikeneomycin(Neo-Fradin)andrifaximin(Rifagut,Xifaxan)may
help.Theycurbbacteriathatcreatetoxinswhentheydigestyourfood.
Selfmanagements
Changediet:Ifyoueatalotofmeat,yourbodymaymaketoomuchammonia.But
youstillneedtogetenoughproteinfromothersources.Trydairyandveggies.Alsoeat
frequentsmallmealsratherthanthreebigonesaday.
Skipalcohol:Evenalittlebitcanberiskyforyoubecauseitdamagesyourliver.
Treatinfections:Theycanaffectthewayyourliverworks.Youmayneedantibioticsto
getridofthem.
Treaturinaryblockages;Ifyoucan'tpeenormally,itcantriggeryourHE.Treatment
fortheinfectionordiseasethat'scausingitcanhelp.
Stopcertainmedications.Certainmedicines,suchassedativesornarcotics,maycause
problemswithyourliver.
Treatconstipation:Needtoeatlessmeatandmorevegetables.Thiscanhelpmore
regularbowelmovementssoyoucanflushtoxinsfromyourbody
Hepaticencephalopathybeprevented
Thebestwaytopreventhepaticencephalopathyistopreventormanageliverdisease.
Onecanlowerchancesofgettingliverdiseasebytakingthesesteps:

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1.Avoidalcoholorconsumeitinmoderation.
2.Avoidhigh-fatfoods.
3.Maintainahealthyweight.
4.Don’tsharecontaminatedneedles.
5.Toavoidgettingviralhepatitis:
6.Washyourhandswellafterusingthebathroomorchangingadiaper.
7.Don’tsharecontaminatedneedles.
8.Avoidclosecontactwithpeoplediagnosedwithviralhepatitis.
9.GetvaccinatedagainsthepatitisAandhepatitisB.
Esophagealvarices
Definition:Esophagealvaricesareabnormal,enlargedveinsinthetubethatconnects
thethroatandstomach(esophagus).Thisconditionoccursmostofteninpeoplewith
seriousliverdiseases.
Esophagealvaricesdevelopwhennormalbloodflowtotheliverisblockedbyaclot
orscartissueintheliver.Togoaroundtheblockages,bloodflowsintosmallerblood
vesselsthataren'tdesignedtocarrylargevolumesofblood.Thevesselscanleak
bloodorevenrupture,causinglife-threateningbleeding.
Sign&Symptoms
Esophagealvaricesusuallydon'tcausesignsandsymptomsunlesstheybleed.Signs
andsymptomsofbleedingesophagealvaricesinclude:
 Vomitinglargeamountsofblood

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 Black,tarryorbloodystools
 Lightheadedness
 Lossofconsciousnessinseverecases
signsofliverdisease,including:
 jaundice
 Easybleedingorbruising
 Fluidbuildupinyourabdomen(ascites)
Causes
Esophagealvaricessometimesformwhenbloodflowtoyourliverisblocked,most
oftenbyscartissueinthelivercausedbyliverdisease.
Thisincreasedpressure(portalhypertension)forcesthebloodtoseekother
pathwaysthroughsmallerveins,suchasthoseinthelowestpartoftheesophagus.
Thesethin-walledveinsballoonwiththeaddedblood.Sometimestheveinsrupture
andbleed.
Causesofesophagealvaricesinclude:
 Severeliverscarring(cirrhosis).Anumberofliverdiseases—including
hepatitisinfection,alcoholicliverdisease,fattyliverdiseaseandabileduct
disordercalledprimarybiliarycirrhosis—canresultincirrhosis.
 Bloodclot(thrombosis).Abloodclotintheportalveinorinaveinthatfeeds
intotheportalvein(splenicvein)cancauseesophagealvarices.
 Parasiticinfection.Schistosomiasisisaparasiticinfectionfoundinpartsof
Africa,SouthAmerica,theCaribbean,theMiddleEastandEastAsia.The
parasitecandamagetheliver,aswellasthelungs,intestine,bladderandother
organs
Riskfactors
Althoughmanypeoplewithadvancedliverdiseasedevelopesophagealvarices,most
won'thavebleeding.Esophagealvaricesaremorelikelytobleedifyouhave:
 Highportalveinpressure.Theriskofbleedingincreasesasthepressureinthe

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portalveinincreases(portalhypertension).
 Largevarices.Thelargertheesophagealvarices,themorelikelytheyareto
bleed.
 Redmarksonthevarices.Whenviewedthroughathin,flexibletube
(endoscope)passeddownyourthroat,someesophagealvaricesshowlong,red
streaksorredspots.Thesemarksindicateahighriskofbleeding.
 Severecirrhosisorliverfailure.Mostoften,themoresevereyourliverdisease,
themorelikelyesophagealvaricesaretobleed.
 Continuedalcoholuse.Yourriskofvaricealbleedingisfargreaterifyou
continuetodrinkthanifyoustop,especiallyifyourdiseaseisalcoholrelated
Diagnosis
Maintestusedtodiagnosisesophagealvaricesare:
Endoscopicexam:Insertathinflexible,lightedtube(endoscope)throughyourmouth
andintoesophagus,stomacandduodenum.
Imagingtests:bothabdominalCTscansandDopplerultrasoundsofthesplenic&
portalveinthatcansuggestpresenceofesophagealvarices.
Capsuleendoscopy:Inthistestshallowavitaminsizedtabletcontainatinycamera
,whichtakespicturesofEsophagealasitgoesthroughdigestivetract.
Treatment
Inemergencysituationscareisdirectedatstoppingbloodloss,maintainingplasma
volume,correctingdisorderincoagulationinducedbycirrhosis&appropriateuseof
antibioticssuchasquinolone,ceftriaxone.Bloodvolumeresuscitationshouldbedone
promptly&withcaution.
 Treatmenttopreventbleeding
 Medicationtoslowbloodflowinportalvein
 Usingelasticbandtotieoffbleedingvein
 Divertingbloodflowawayfromportalvein
 Medicationtoreducepressureinportalvein
Selfmanagements

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 Avoidalcohol
 Eathealthydiet
 Reduceriskofhepatitis
 Usechemicalsparingly&carefully