How to Approach Patient of Liver Disease

Approach Patient of Liver Disease

• Liver is the largest organ of the body weighing about 1 Kg.
• It is present in the right upper quadrant of the abdo­men under the right lower rib cage and projects into the left upper quadrant.
• 20% of the blood flow is from hepatic artery and rich in oxygen.
• 80% of its blood is rich in nutrients from the portal vein from stomach, intestine, pancreas, and spleen.
• Cells of liver are called hepatocytes.
• Other cells are cells of reticulo-endothelial system of liver called Kupffer cells, fat cells, endothelial cells, blood vessels, bile ductular cells and supporting structures. .

How to Approach Patient of Liver Disease

• Liver cells are organized in lobules with central veins in the centre of lobule and portal areas at the bor­ders.
• Portal areas of the liver consist of small veins, arter­ies, bile ducts and Iymphatics. Blood flows from por­tal areas through sinusoids to the hepatic veins (cen­tral veins). Bile flows from central vein to portal area.
• The hepatocytes synthesize serum proteins like albu­min, coagulation factors, hormonal and growth fac­tors, produce bile acids, cholesterol, and regulate nutrients like glucose, glycogen, lipids, cholestero.L.­amino acids, and excrete bilirubin, anions and cat­ions in the bile or urine.
• Therefore, function of the liver is tested by mea­surement of serum bilirubin, albumin, prothrom­bin time.

DISEASES OF THE LIVER

• 1. Hepatocellular – viral hepatitis, alcoholic liver disease.
• 2. Cholestatic – gall stones, malignancy, biliary cir­rhosis, drug-induced.
• 3. In viral hepatitis, hepatocellular damage as well
• as cholestatic disease is seen.

Presenting features are:

• 1. Jaundice
• 2. Itching
• 3. Fatigue and weakness
• 4. Right upper quadrant pain
• 5. Abdominal distention
• 6. Intestinal bleeding.

Evaluation of patients of liver disease

• 1. For etiology
• 2. For severity
• 3.For staging. Diagnosis is :
• 4. Category – Hepatocellular or cholestatic or both.
• 5. Grading – Active, Inactive, Mild, Moderate, Se­vere.
• 6. Staging – Acute or chronic, early or late, cir­rhotic or precirrhotic, or end-stage.

CLINICAL HISTORY of liver disease

• A complete medical history is the single most important part of the evaluation of the patient with elevated LFTs.
• Important considerations include: The use of or exposure to any chemical or medication (including prescription and over-the-counter medications as well as herbal therapies) which may be temporally related to the onset of LFT abnormalities
• The duration of LFT abnormalities
• The presence of any accompanying symptoms such as jaundice, arthralgias, myalgias, rash, anorexia, weight loss, abdominal pain, fever, pruritus, and changes in the urine and stoo
• Fatigue, weakness, nausea, loss of appetite, malaise, jaundice, dark urine, light stools, itch­ing, pain in abdomen, bloating of abdomen.
• · Fatigue occurs during the afternoon. Nausea oc­curs by the site of food.
• · Jaundice is not detectable when serum bilirubin is less than 2.5 mg/dl.
• · Jaundice without dark urine indicates indirect or unconjugated bilirubinemia as in hemolytic ‘ anaemia and Gilbert’s syndrome and Crigler ­Najjar syndrome.
• History: Alcohol use, herbal drugs, birth control pills, sexual activity, travel, exposure, surgery, blood trans­fusion, exposure to blood or needle, family history of liver disease.
• Sexual exposure is important for hepatitis B but not for hepatitis C.
• Mother to child transmission occurs in hepatitis Band C.

liver disease PHYSICAL EXAMINATION  —

• The physical examination should focus upon findings suggesting the presence of liver disease.
• Specific findings may provide clues toward diagnosis of an underlying cause.
• Temporal and proximal muscle wasting suggest longstanding diseases
• Stigmata of chronic liver disease include spider nevi, palmar erythema, gynecomastia, caput medusae
• Dupuytren’s contractures, parotid gland enlargement, and testicular atrophy are commonly seen in advanced Laennec’s cirrhosis and occasionally in other types of cirrhosis
• An enlarged left supraclavicular node (Virchow’s node) or periumbilical nodule (Sister Mary Joseph’s nodule) suggest an abdominal malignancy
• Jugular venous distension, a sign of right sided heart failure, suggests hepatic congestion
• A right pleural effusion, in the absence of clinically apparent ascites, may be seen in advanced cirrhosis
• Familial causes of liver disease are:
• 1. Wilson’s disease.
• 2. Hemachromatosis – suggested by cirrhosis, dia­betes and liver disease in adult.
• 3. Alpha 1 antitrypsin deficiency
• 4. Benign intrahepatic cholestasis.

P Y le LEA IATIO OF PATIENTS

• 1. Icterus or jaundice
• 2. Hepatomegaly
• 3. Hepatic tenderness
• 4. Splenomegaly
• 5. Spider angiomata
• 6. Palmar erythema
• 7. Excoriations
• 8. Muscle wasting
• 9. Ascites, edema
• 10. Dilated abdominal veins
• 11. Hepatic fetor (foul breaths)
• 12. Asterixis (flapping tremor)
• 13. Mental confusion, stupor, coma.
• Jaundice is seen in the sclera in daylight, in the skin and in mucus membrane below tongue.

Hepatic failure

• Hepatic failure is indicated by presence of signs and symptoms of hepatic encephalopathy in a patient of severe acute or chronic liver disease.
• Features of hepatic failure:
• 1. Change in sleep patterns
• 2. Change in personality
• 3. Irritability
• 4. Mental dullness
• 5. Confusion, disorientation
• 6. Stupor, coma
• 7. Asterixis / flapping tremors of body and tongue
• 8. Fetor hepaticus – sweet ammonia odour in breath
• 9. Trail making test is positive i.e. patient is unable to connect 25 numbered circles using a pencil within 30 seconds
• 10. Ascites with umbilical hernia
• 11. Prominent veins over abdomen and caput me­dusa – veins radiating from umbilicus
• 12. Widened pulse pressure – Hyperdynamic circu­lation – sodium and fluid retention – increased cardiac output – reduced peripheral resistance.
• 13. Hepatopulmonary syndrome – Liver disease with hypoxemia and pulmonary arteriovenous shunt­ing. There is dyspnoea and shortness of breath and oxygen desaturation in the upright or sit­ting position.

Skin changes in liver disorders

• · Hyperpigmentation – Cholestatic liver disease
• · Xanthelasma
• · Tendon xanthomata
• · Gray pigmentation in hemochromatosis
• · Mucocutaneous vasculitis with purpura in cryo­globulinemia of hepatitis C or B.
• Eye changes in liver disorders Jaundice.
• Kayser-Fleischer ring in Wilson’s disease – a golden brown copper pigment in Disemet’s membrane at the periphery of the cornea, seen by slit lamp.
• Metastatic liver disease and primary hepatocel­lular carcinoma
• Features are:
• · Cachexia
• · Wasting
• · Hepatomegaly
• · Hepatic bruit
• · Hepatic failure.

LABORATORY TESTING IN A PATIENT WITH LIVER DISEASE

• Liver panel tests are:
• 1. Serum alanine transferase – ALT (SGPT)
• 2. Serum aspartate aminotransferase – AST (SGOT)
• 3. Alkaline phosphatase
• 4. Direct and total serum bilirubin
• 5. Serum albumin
• 6. Prothrombin time
• 7. GGT (Gamma Glutamyl Transpeptidase)
• 8. Anti mitochondrial antibody – AMA – Autoimmune marker in primary biliary cirrhosis
• 9. P-ANCA – peripheral anti neutrophil cytoplasmic antibody in sclerosing cholangitis
• 10. ANA – antinuclear antibody
• 1 L ASMA – anti smooth muscle antibody; liver, kid­ney, microsomal antibody.

• Disease

  • Hepatitis A
  • Hepatitis B – Acute
  • Hepatitis B – Chronic Hepatitis C
  • Hepatitis D
  • Hepatitis E
• Autoimmune hepatitis Primary biliary cirrhosis Primary sclerosing cholangitis Drug-induced
• Alcoholic
• Alpha-l antitrypsin disease Wilson’s disease Hemochromatosis Hepatocellular cancer

Diagnostic test

• Anti HAV IgM
• HBsAg and anti HBc IgM HBsAg and HBeAg,
• HBV DNA Anti HCV and HCV RNA HBsAg and Anti HDV
• Anti HEV
• ANA or SMA
• AMA – Anti-mitochondrial antibody P – ANCA
• History
• History and histology
• Reduced alpha 1 antitrypsin levels
• Decreased serum ceruloplasmin, increased urinary copper Increased iron saturation and serum ferritin
• Increased alpha fetoprotein level more’than 500, Ultrasound and CT Scan

DIAGNOSTic IMAGING

• 1. Ultrasound
• 2. Computed Tomography (CT)
• 3. Magnetic resonance imaging (MRI)
• 4. Magnetic resonance cholangiopancreato-graphy (MRCP)
• 5. Endoscopic retrograde cholangiopancreato­graphy (ERCP)
• 6. Doppler, ultrasound and MRI for hepatic vascu­lature

LIVER BIOPSY

• For chronic liver diseases:
• • Diagnosis
• · Severity
• · Prognosis
• · Monitoring treatment

Grading and Classification —

• 1. Child-Pugh classification – Serum bilirubin, se­rum albumin, ProthrombinTime, ascites, hepatic encephalopathy are taken into account and A-B­C staging is done.
• 2. Liver biopsy is done and amount of fibrosis is staged from 0 to 4+ (histology activity index) or on Ishak scale from 0 to 6+.
• 3. MELD score – model for end-stage liver disease for assessment for liver transplantation.