Liver function and disease

 

Liver function

Deaminates amino acids

Forms urea and uric acid

Converts glucose to glycogen

Desaturates fat

Produces bile

Produces heat

Stores, vit B12, ADEK, iron, copper, some B vitamins

Synthesises vit A from carotene            

Synthesises nor essential amino acids

Detoxifies drugs and alcohol

Inactivates hormones

Synthesises plasma proteins

 

Cirrhosis

 

Aetiology

Hepatitis B or C

Alcohol

Non-alcoholic fatty liver disease

Toxin exposure

Biliary cirrhosis

Cardiac cirrhosis

Autoimmune diseases

Alpha 1 antitrypsin deficiency

Haemochromatosis

Wilson’s disease

 

Clinical features

Large or small liver

Hard, irregular, painless liver

Jaundice

Hypoproteinaemia

Ascites

Endocrine sexual changes

Haemorrhagic

Portal hypertension – splenomegaly

Hepatic encephalopathy

Spider formations

Hepatorenal failure

Liver flap 

Liver palms

 

Hepatocellular carcinoma

South East Asia, Southern Europe, Northern Europe

 

Aetiology

Chronic hepatitis B infection

Cirrhosis

Aflatoxins

Male sex

 

Pathology

May be a single mass

Multiple nodules in cirrhosis

 

Clinical features

Weight loss

Anorexia

Abdominal pain

Ascites

Jaundice

Variceal haemorrhage

Possible hepatomegaly

Hepatic rupture with haemorrhage

 

Screening

3-6 monthly ultrasound in high risk patients

 

Investigations

Alpha-fetoprotein in 60% of cases                     Ultrasound                    CT, MRI                        Biopsy

 

Management

Percutaneous ablation injecting ethanol

Resection

Intra hepatic arterial injections

 

Benign liver tumours

Haemangiomas             Adenomas        Focal Nodular Hyperplasia

 

Portal hypertension

Splenomegaly

Hypersplenism, thrombocytopenia, possible leucopenia

Collateral vessels develop, abdominal wall, stomach, oesophagus, rectum                      Fector hepaticus

Viral Hepatitis

Five viruses A, B, C, D and E

The five types give a similar clinical picture so seriological diagnosis is required.

Inflammation of the liver

Variable numbers of liver cells die leading to areas of necrosis

Possible fulminating liver failure (FLF)

 

Clinical features in viral hepatitis

Malaise, lethargy and fatigue with generalised flulike symptoms

A low grade fever is typical

Anorexia and weight loss

Do not feel like smoking

Hepatic inflammation leads to a tender, swollen liver, (hepatomegaly).  

 

Pathophysiology

Bilirubin is not taken from the blood and incorporated into the bile ----- bilirubinaemia

Bilirubinuria (like tea without milk)

Pale and foul smelling stools due to lack of bilirubin in the gut

Bilirubinaemia ---- jaundice

Viral skin rashes may present.

 

Hepatitis A

Incubation 30 days, (range 15-50 days)

HAV replicates in the hepatocytes and is excreted in bile  ----- faeco-oral route

Often occurs in outbreaks or epidemics.

Jaundice -  1 to 10 days after the onset of symptoms

No specific treatment is available

Full recovery after 3-6 weeks.

Vaccination is available and highly advisable for anyone who may be exposed to HAV.

 

Hepatitis B

Hepatitis B virus is found in the blood - the serum route

Clinical, blood, acupuncture, body piercing and tattooing

HBV infection is more severe the HAV and the patient may feel unwell for several months

Incubation 2 to 3 months

Most patients make a full recovery

1% developing fulminant hepatitis

1-10% of cases, DNA from the HBV integrates itself into the host DNA of the hepatocytes

This causes chronic hepatitis B infection and most of these patients become long term carriers of the disease.

A significant risk of developing cirrhosis and hepatocellular carcinoma.

 

Hepatitis C

Serum transmission

Intravenous drug users, tattooing

Vertical and sexual transmission are less likely than is the case with HBV

Incubation 6 to 7 weeks

Acute infection with HCV is often asymptomatic

80% of patients develop chronic liver disease with increased risk of cirrhosis and hepatocellular carcinoma

Alcohol not good

 

Hepatitis D

‘Piggy back’ virus

Serum or sexual route

Co-infection

 

Hepatitis E

Similar to HAV

Faeco-oral

Large epidemics

The risk of fulminant hepatitis is about 1-2% unless the patient is pregnant

Incubation about 40 days

 

Liver failure

Liver failure, end stage of chronic cirrhosis or  fulminant hepatitis

Jaundice

Portal hypertension

Oesophageal varices

Hypoproteinaemia

Ascites

Hepatic encephalopathy

Hypersplenism

Haemorrhage

Hepatorenal syndrome

Hepatopulmonary syndrome

Endocrine complications

Gynecomastia

Spider angiomas (also called spider nevi)

Palmar erythema or ‘liver palms’.

Reduced hepatic metabolism of aldosterone

Liver flap

Fetor hepaticus