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

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Liver Function Tests

• Prothrombin Time
• Albumin
• Bilirubin
• Direct Conjugated Water soluble
• Indirect Unconjugated Water insoluble

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Liver Tests

• AST SGOT
• ALT SGPT
• Alkaline Phosphatase
• 5 Nucleotidase
• GGT

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Hepatobiliary Anatomy
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Patterns of Enzyme Elevation

• Hepatocellular
• AST
• ALT
• Alk Phos
• Bilirubin
• Protime nl/?
• Albumin nl/?

• Cholestatic
• Alk Phos
• Bilirubin
• AST
• ALT
• Protime nl/?
• Albumin nl

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The Algorithm
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What Can You Tell Me?

• Hepatocellular Diseases
• Cholestatic Diseases
• Mixed Disorders
• Hepatic Synthetic Function

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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

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Impaired Bilirubin Metabolism

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

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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

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Extrahepatic Cholestasis

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

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MRCP
14
Axial CT Scan
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Hepatocellular Disease

• Hepatitis A, B, C, B(D), E and G
• Autoimmune Hepatitis
• Steatosis and NASH
• Drug Induced Disease
• Hemochromatosis
• Wilsons Disease

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Hepatitis A

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

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Hepatitis A
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Hepatitis B

• Blood and body fluids
• DNA Virus
• Chronicity in adults 10
• Chronicity in children 90
• Risk for hepatocellular carcinoma

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Hepatitis B
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Hepatitis B

• HBsAb HBsAg HBcAb HBeAg HBeAb DNA
• - -
  -
• - - -
  - -
• -
  -
• - -
  - -
• - -
  -

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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

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Cirrhosis

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

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Ascites

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

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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

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Porto-Systemic Encephalopathy

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

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Hepatic Encephalopathy

• Hypovolemia
• Bleeding
• SBP
• Medications

• Acidosis
• Hypoxemia
• Hypoglycemia
• Anemia

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Hepatocellular Carcinoma

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

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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

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Steatosis

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

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Steatosis

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

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Steatosis

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

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Steatosis

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

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Steatosis

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

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Conclusions

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