APPROACH TO LIVERDISEASE       Dr Anoop R Prasad
ANATOMY
30%70%
Glucose metabolism•    The liver performs several roles in    carbohydrate metabolism:•   Gluconeogenesis•   Glycogenolysi...
Protein                   Lipids• Amino acid synthesis• Protein metabolism,     • Cholesterol synthesis  (synthesis as wel...
Synthesis of plasma proteinsAlbuminAcute phase proteinsClotting factorsSteroid binding and other hormone binding  proteins...
Hematopoesis   Extramedullary hemopoiesis during first   trimester of gestation• STORAGE:   Vitamins   Glycogen   Iron   C...
Detoxification toxins steroids other hormones drugs Bilirubin Urea formation
CLINICAL FEATURES OF h         DISEASE•   Fatigue•   Nausea•   Vomiting•   Jaundice•   Right upper quadrant pain•   Bleedi...
Cholestatic disease•   fatigue, malaise•   anorexia, nausea•   Biliary colic•   Deep jaundice•   +++ pruritus•   +++ abdom...
CIRRHOSIS•   Fatigue•   Muscle wasting•   Hematemesis•   Ascites•   Easy bruising•   Edema
Other points in history• Fever, prodrome (anorexia,vomiting,nausea) –  which disappears with onset of jaundice – acute  vi...
Acute onset jaundice•   Viral hepatitis•   Alcoholic liver disease•   Autoimmune hepatitis•   Ischemic hepatitis•   Medica...
Jaundiced Emergencies• Acetaminophen Toxicity• Fulminant Hepatic Failure• Ascending Cholangitis
Jaundice Unrelated toIntrinsic Liver Disease• Hemolysis (usually T. bili < 4)• Massive Transfusion• Resorption of Hematoma...
Alcohol• A standard drink is any drink that contains  about 14 grams of pure alcohol (about 0.6  fluid ounces or 1.2 table...
SignsAlopeciaPigmentation of faceJaundiceKF ringParotid swellingGynaecomastiaSpider naeviPalmar erythemaDupyutren’s contra...
Testicular atrophyScratch marksEchymotic patchesMuscle wastingPallorClubbingEdemaLeuconychiaHepatomegaly …..SplenomegalyAs...
• Dilated veins• Caput medusae
Biochemical tests in liverdisease• The true tests of liver function:   • INR, PT, Albumin,Bilirubin• Tests of hepatic inju...
INVESTIGATIONS•   AST-ALT-ALP                  • Ammonia•   Bilirubin – total/indirect   • Viral serologies•   Albumin    ...
Hepatocellular          Cholestatic• AST/ALT >> ALP        • ALP>>AST/ALT• Unconjugated bil >>   • Conjugated bil>>  conju...
Non hepatic cause of elevatedtransaminases• Muscle disease• Thyroid diseases• Bone disease - ALP
THANK YOU   QUESTIONS??
Approach to liver disease
Approach to liver disease
Approach to liver disease
Approach to liver disease
Approach to liver disease
Approach to liver disease
Approach to liver disease
Approach to liver disease
Approach to liver disease
Approach to liver disease
Approach to liver disease
Approach to liver disease
Approach to liver disease
Approach to liver disease
Approach to liver disease
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Approach to liver disease

  1. 1. APPROACH TO LIVERDISEASE Dr Anoop R Prasad
  2. 2. ANATOMY
  3. 3. 30%70%
  4. 4. Glucose metabolism• The liver performs several roles in carbohydrate metabolism:• Gluconeogenesis• Glycogenolysis• Glycogenesis• Glucogenesis• Glucose buffer function
  5. 5. Protein Lipids• Amino acid synthesis• Protein metabolism, • Cholesterol synthesis (synthesis as well as • Lipogenesis, the degradation) production of triglycerides (fats). • Lipoprotein synthesis • Beta oxidation
  6. 6. Synthesis of plasma proteinsAlbuminAcute phase proteinsClotting factorsSteroid binding and other hormone binding proteinsHORMONES Erythropoietin IGF-1 Thrombopoietin Angiotensinogen 25 hydrxoy choolecalciferol
  7. 7. Hematopoesis Extramedullary hemopoiesis during first trimester of gestation• STORAGE: Vitamins Glycogen Iron Copper• Immunity Kupffer cells
  8. 8. Detoxification toxins steroids other hormones drugs Bilirubin Urea formation
  9. 9. CLINICAL FEATURES OF h DISEASE• Fatigue• Nausea• Vomiting• Jaundice• Right upper quadrant pain• Bleeding manifestation(echymosis, easy bruising,hematemesis,malena)• Colicky pain• Pruritus Obstructive• Clay colored stools jaundice• Abdominal distension• Muscle wasting• Altered sensorium
  10. 10. Cholestatic disease• fatigue, malaise• anorexia, nausea• Biliary colic• Deep jaundice• +++ pruritus• +++ abdominal pain and pancreatitis• +++ gray or clay-colored stools
  11. 11. CIRRHOSIS• Fatigue• Muscle wasting• Hematemesis• Ascites• Easy bruising• Edema
  12. 12. Other points in history• Fever, prodrome (anorexia,vomiting,nausea) – which disappears with onset of jaundice – acute viral hepatitis• Joint pain, diabetes, pigmentation, jaundice –• Young individual with extrapyramidal symptoms, neuropsychiatric manifestation, anemia• Colicky abd pain, jaundice, fever- gall stones• Rash, arthritis• Drug history
  13. 13. Acute onset jaundice• Viral hepatitis• Alcoholic liver disease• Autoimmune hepatitis• Ischemic hepatitis• Medication-induced liver disease• Common bile duct stones• Pancreatic cancer• Primary Biliary Cirrhosis (PBC)• Primary Sclerosing Cholangitis (PSC)
  14. 14. Jaundiced Emergencies• Acetaminophen Toxicity• Fulminant Hepatic Failure• Ascending Cholangitis
  15. 15. Jaundice Unrelated toIntrinsic Liver Disease• Hemolysis (usually T. bili < 4)• Massive Transfusion• Resorption of Hematoma• Ineffective Erythropoesis• Disorders of Conjugation • Gilbert’s syndrome• Intrahepatic Cholestasis • Sepsis, TPN, Post-operation
  16. 16. Alcohol• A standard drink is any drink that contains about 14 grams of pure alcohol (about 0.6 fluid ounces or 1.2 tablespoons)• One "Standard Drink" equals = one 30ml nip of whisky or other basic spirit = 60ml fortified wine = 150ml table wine = 250ml beer = 425ml low alcohol beer• Strength (ABV) x Volume (ml) ÷ 1000 = No. of units.• 40–80 g/d of ethanol produces fatty liver; 160 g/d for 10–20 years causes hepatitis or cirrhosis. Only 15% of alcoholics develop alcoholic liver disease.
  17. 17. SignsAlopeciaPigmentation of faceJaundiceKF ringParotid swellingGynaecomastiaSpider naeviPalmar erythemaDupyutren’s contractureHalf and half nailAsterixis
  18. 18. Testicular atrophyScratch marksEchymotic patchesMuscle wastingPallorClubbingEdemaLeuconychiaHepatomegaly …..SplenomegalyAscites
  19. 19. • Dilated veins• Caput medusae
  20. 20. Biochemical tests in liverdisease• The true tests of liver function: • INR, PT, Albumin,Bilirubin• Tests of hepatic injury/inflammation: • Aspartate aminotransferase (AST) • Alanine aminotransferase (ALT) • Alkaline phosphatase (ALP) • Gamma-glutamyl transpeptidase (GGT)• Hepatocellular – AST/ALT elevation twice that of ALP• Cholestatic – AST/ALT elevation less than twice ALP
  21. 21. INVESTIGATIONS• AST-ALT-ALP • Ammonia• Bilirubin – total/indirect • Viral serologies• Albumin • ANA-ASMA-• INR AMA• Glucose • Quantitative Ig• Na-K-PO4, acid-base • Ceruloplasmin• Acetaminophen level • Iron profile• CBC/plt • Blood cultures
  22. 22. Hepatocellular Cholestatic• AST/ALT >> ALP • ALP>>AST/ALT• Unconjugated bil >> • Conjugated bil>> conjugated unconjugated• USG – BILE DUCTS • ↑GGT, 5’nucleotidase NORMAL • USG- Intrahepatic biliary duct dilation
  23. 23. Non hepatic cause of elevatedtransaminases• Muscle disease• Thyroid diseases• Bone disease - ALP
  24. 24. THANK YOU QUESTIONS??

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