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Definition:
CHRONIC LIVER
DISEASE
Synthesis:
- Albumin
- Coagulation factors
Storage:
Bile excretion - Glycogen
- Iron
- Cu, Iron, vitamins
Portal Vein
Receives 1050 mL/min from
Spleen
Intestines
Pancreas
Stomach
Incompletely saturated
Supplies 60-70% O2 needs
Empty into IVC
Stores 450 mL blood that can
be shifted in times of stress
Circulation of the liver
Dual Blood Supply
Portal system
Hepatic veins drain liver
& empty into IVC
1000-1200 ml/min
(rich in nutrients)
Hepatic artery
400-500 ml/min blood
flow
Oxygenated blood
Liver Histology
PATHOGENESIS OF LIVER FIBROSIS
Normal
Normal Hepatic
Hepatic SInusoid
SInusoid
Retinoid
Retinoid
droplets
droplets
Fenestrae
Fenestrae
Hepatic
stellate cell
Space
Space of
of Disse
Disse
Sinusoidal
Sinusoidal
endothelial
endothelial cell
cell
Hepatocytes
Hepatocytes
PATHOGENESIS OF LIVER FIBROSIS
Alterations
Alterations in Microvasculature in Cirrhosis
Cirrhosis
Activation
Activation of
of stellate cells
Collagen
Collagen deposition
deposition inin space
space of
of
Disse
Disse
Constriction
Constriction of sinusoids
Defenestration
Defenestration of sinusoids
1. Atrterial
3. Venous System
System
2. Capillary
System
5. Venous
System
4. Second
Visceral
Capillary
System 2. First
1. Atrterial
3. Venous Visceral System
System Capillary
3. Visceral System
Venous
System
2. Capillary
System
COMPLICATIONS OF CIRRHOSIS
Variceal
Portal hemorrhage
hypertension Spontaneous
Spontaneous
bacterial
bacterial
peritonitis
peritonitis
Ascites
Cirrhosis Hepatorenal
Hepatorenal
syndrome
syndrome
Encephalopathy
Liver
insufficiency
Jaundice
Overview of liver pathophysiology
Inflammation Obstruction
Edema internal pressure
pressure
external pressure
Hepatocellular damage
breakdown of urea NH3
encephalopathy
absorption of fat soluble vitamins (Vit. K)
synthesis of clotting factors bleeding
synthesis of plasma proteins (albumin)
malnutrition & edema
Signs of CLD
Nutrition & Diet Therapy, 7th Edition
ULTRASOUND IS THE MOST SENSITIVE METHOD TO DETECT ASCITES
Ascites
Ascites
Liver
Liver
Endocrine Problems
Gynecomastia
Loss of axillary/pubic hair
Testicular atrophy
libido/impotence
Na
H20
hyperaldosteronism
K
Esophageal Varices
Gastric & esophageal varices
Clinical Manifestations
Muehrcke's
nails
Terrys nails
Palmar erythema
Spider Nevi
SPIDER NEAVI
Dupuytren's Contracture
Ascites in End Stage Liver Disease
PBC
Portal Hypertension
HCC
Ascites
Varices
HEPATIC ENCEPHALOPATHY
Precipitating factors
GI Bleeding
Excess protein intake
Electrolyte abnormalities, Ascitic Aspiration
Uremia
Dehydration, Constipation
Alcohol
Viral infections, SBP
Anaesthetic agents, Surgery, Narcotics, Tranquilisers
Hepatic toxins, Portosystemic shunts - TIPS
HEPATIC ENCEPHALOPATHY
TreatmentCORRECT/ AVOID PRECIPITATING
FACTORS
Dietary protein restriction-30 - 40 gm protein / day
Non absorbable disaccharide LACTULOSE 15
to 45 ml BID / QID
Lactulose enema
Neomycin 1 gm 6th hrly
Metronidazole 250 mg 8th hrly
Bowel wash / Lactobacillus
NUMBER CONNECTION TEST
Number
Number Connection
Connection Test
Test Draw
Draw aa star
star
70
(NCT)
(NCT)
Time
Time to
to
complete____________________
complete____________________
End
End
66 10
10 25
25
44
77 99 23
23
11 11
11
55 Begin
Begin
14
14
88 24
24
33
22 Sample
Sample handwriting
handwriting
13
13
12
12
17
17
15
15 16
16 22
22
18
18 21
21
19
19 20
20
ELECTROENCEPHALOGRAM IN HEPATIC ENCEPHALOPATHY
Electroencephalogram in Hepatic
Encephalopathy
GRADING OF HEPATIC ENCEPHALOPATHY
0 Normal
1 Inverted sleep rhythm, restless
2 Lethargy, slow response
3 Drowsy, arousable but confused
4 - Coma
CHILD PUGH Scoring
Clinical and biochemical Points scored for increasing
measurements abnormality
1 2 3
Fig.
PERITONEO-VENOUS SHUNT (PVS) IS USEFUL IN THE TREATMENT OF REFRACTORY ASCITES
One-way
One-way
valve
valve
Intraabdominal
Intraabdominal
adhesions
adhesions may
may
complicate
complicate liver
transplant
transplant surgery
surgery
Sengstaken-Blakemore Tube
Fig. 42-
Shunts T.I.P.S.
Black-1158
Portosystemic Shunts
Fig. 42-
NUMBER CONNECTION TEST
Number
Number Connection
Connection Test
Test Draw
Draw aa star
star
70
(NCT)
(NCT)
Time
Time to
to
complete____________________
complete____________________
End
End
66 10
10 25
25
44
77 99 23
23
11 11
11
55 Begin
Begin
14
14
88 24
24
33
22 Sample
Sample handwriting
handwriting
13
13
12
12
17
17
15
15 16
16 22
22
18
18 21
21
19
19 20
20