Liver Disease

• Give a general overview of the liver.

  It's the second largest organ in the body

  located in the righthypochondrium

  divided into 4 lobes (left, right, caudate, quadrate)

  Its blood supply is derived from theportal & hepatic veinandhepatic artery

  It is a centre of first-pass metabolism (metabolism of a drug before it reaches the systemic circulation)

  
• What are the functions of the liver?

  Metabolism, breakdown, & excretion of drugs and endogenous products(e.g. ammonia, urea, bilirubin, hormones, & alcohol)

  Production of albumin, blood clotting factors(II, VII, IX, & X), complement, transporter proteins, cholesterol & bile components

  Storage of substances(e.g. glycogen, fat-soluble vitamins such as vitamin A, D, E, & K, vitamin B12 & folate, minerals such as iron & copper)

  Maintenance of body homeostasis by regulating the glucose & cholesterol blood levels
• How common is liver disease?

  Very common

  Affects at least 2 million in the UK

  Is thefifthcommonest cause of death in UK

  There are more than 100 different causes of liver disease
• How can you categorise causes of liver disease?

  Infectious(viral, bacterial, parasitic)

  Toxins(drug misuse, alcohol misuse)

  Metabolic(non-alcoholic fatty liver disease, Wilson's disease, haemochromatosis)

  Autoimmune(SLE, PBC)

  
• What is compensated/decompensated liver disease?

  Compensated- the liver is coping with working at a reduced capacity

  Decompensated- the liver is failing to cope with its functional demands
• What are some signs & symptoms of acute liver disease?

  Loss of appetite, jaundice, weight loss, along with right upper quadrant pain, nausea, vomiting, malaise
• What is acute liver disease most commonly caused by?

  Hep A, B, & E
• What are some signs & symptoms of chronic liver disease?

  Spider naevi (the more there are, the worse the disease)

  
  

  palmar erythema - redness of palms

  
  

  clubbing

  
  

  jaundice

  
  

  oedema/ascites
• What is jaundice?

  Yellowing of the skin and sclerae, due to build-up ofbilirubinin the blood & body tissues
• What are the different types of causes of jaundice?

  Pre-hepatic(sickle cell anaemia, thalassaemia)

  Intra-hepatic(hepatitis, alcohol, glandular fever, drug misuse, cirrhosis, Gilbert's syndrome)conditions affecting the liver

  Post-hepatic(gallstones, tumours)
• What are some of the symptoms of liver failure?

  Bleeding/bruising

  
  

  Hypoglycaemia

  
  

  Infections

  
  

  Ascites - collection of fluid in abdomen

  
  

  Encephalopathy - loss of consciousness, confusion
• What does cirrhosis result from and what does it lead to?

  Results from necrosis of liver cells followed by fibrosis & nodule formation

  
  

  It is irreversible

  
  

  Leads to interference of blood flow through the liver and loss of liver function
• How do you diagnose cirrhosis?

  Histologically by biopsy
• What are the causes of cirrhosis?

  Common: alcohol, viral (Hep B & C)

  Less common:autoimmune, drugs, haematochromatosis, Wilson's disease
• What are some investigations that would give you good indications regarding the liver?

  Blood tests(LFTs, ALT, AST, GGT, bilirubin, albumin)

  Imaging tests(USS, CT, MRI)

  Liver biopsy
• What are the complications of alcohol-related liver disease (ARLD)?

  Alcoholic hepatitis and cirrhosis
• What are the main signs & symptoms of ARLD?

  Feeling sick

  
  

  Weight loss

  
  

  Loss of appetite

  
  

  Jaundice

  
  

  Swelling in ankles & tummy

  
  

  Confusion or drowsiness

  
  

  Vomiting blood or passing blood in stools
• What is non-alcoholic fatty liver disease?

  Build-up of fat within the liver cells

  
  

  Reversible in early stages

  
  

  (overweight/obese, type II diabetes, high BP, hypercholesterolaemia)
• What are the 4 stages of non-alcoholic fatty liver disease?

  1. Steatosis - fatty deposition within liver cells

  2. Non-alcoholic steatohepatitis

  3. Fibrosis

  4. Cirrhosis

  So, it IS reversible at the start
• What are the risk factors for gallstones (5 F's)?

  Gallstones can be asymptomatic and are a accumulation of hardened cholesterol and calcium deposits in the gallbladder

  
  

  Female

  Forty

  Fertile

  Fat

  Fair
• What are the signs & symptoms, diagnosis, and treatment for gallstones?

  Signs & symptoms:central abdominal pain (intermittent or persistent), jaundice, fever

  Diagnosis: bloods, Ultra sound, other imaging

  Treatment: depends on severity of diseasee.g. avoid fatty foods in diet, cholecystectomy (gallbladder removal surgery)
• What is hepatitis?


  Inflammation of liver (acute or chronic)

  
  

  Only 5% develop chronic infection
• How long can hepadnavirus survive outside the body?

  For at least 7 days (so be mindful of dried blood, fluids, etc.)

  
  

  It is a DNA virus
• How many people with hepatitis C are asymptomatic?

  Up to 80%, can also be acute or chronic.

  
  

  Compared to Hep B, 55-85% of people with Hep C will develop a chronic infection
• Is there a vaccine for hepatitis C?

  NO (but antiviral medicines can cure approx 90% of ppl with hep C infection)
• How is Hepatitis C transmitted?

  RNA virus

  
  

  Transmitted through blood, bodily fluids

  
  

  Incubation period 2-6 weeks
• What are some symptoms of hepatitis B & C?

  Flu-like symptoms

  
  

  Feeling like/being sick

  
  

  Lack of appetite

  
  

  Jaundice
• What is the dental relevance of hepatitis B, C & HIV?

  Risk of needlestick injury:

  
  

  Hep B: 30% chance

  Hep C: 1-3% chance

  HIV: 0.3% chance
• What is the dental relevance of liver disease in terms of anaesthesia?

  Local anaesthesia is safe, relative anaesthesia is preferable to Intravenous sedation with benzodiazepine

  
  

  (because encephalopathy can be triggered by use of sedatives & opioids)
• What is the dental relevance of liver disease in terms of drugs?

  They have an altered drug metabolism (because usually liver breaks it down)

  so things like paracetamol can be given, but reduced dose is necessary

  Take care withNSAIDSas they may precipitate a GI bleed

  In terms of antifungal therapy,miconazole&fluconazoleare metabolised by the liver so dose may need to be reduced

  Same withmetronidazole

  It is recommended thatazithromycinshould be avoided
• What is the dental relevance of liver disease in terms of bleeding?

  Post-operative haemorrhage risk (vitamin K & clotting factors deficiency)

  
  

  INR should be checked before extractions

  
  

  Delayed wound healing
• What is the dental relevance of liver disease in terms of oral manifestations?

  In liver disease due to SLE, you may see oral lichenoid reactions & oral manifestations ofsecondary Sjogren's syndrome

  In liver disease due to PBC, you may see oral manifestations of secondary Sjögren’s syndrome

  They may have non-alcohol related fatty liver disease due to type II diabetes or high bp, so it's something to be aware of as they may be on meds for it that have side effects likegingival hyperplasia
• What has dental hypoplasia & greenish discolouration of the teeth been documented in?

  Disorders associated with an early rise in conjugated bilirubin serum levels (e.g. Rhesus disease)