Transcript: Show how things would improve Pro Conclusion The cells that are still living then multiply in an attempt to replace the cells that died. Challenges and opportunities Con What is Cirrhosis? Describe the next steps Describe the desired state Get your audience excited Idea 2 Pro Pro Con Con Inflammation and repair occur causing scar tissue to form. Identify the problem Refer back to the pros and cons Idea 1 How problems can be resolved Pro Describe the idea you think is best Chronic Liver Disease (Cirrhosis) What if we do nothing? Explain what success will bring Explain how it will help Describe the current situation Based on Jim Harvey's speech structures This results in clusters of newly-formed liver cells in the scar tissue. Cirrhosis is a complication of many different liver diseases, characterized by abnormal function and structure of the liver. The diseases injure and kill liver cells. Con
Transcript: Hypertension kidney failure treatment/management http://heartfoundation.org.au/about-us/what-we-do/heart-disease-in-australia/high-blood-pressure-statistics Signs and Symptoms (high blood pressure) http://www.webmd.com/hypertension-high-blood-pressure/guide/blood-pressure-causes References: stroke medications will not cure the condition many people will have to take it for the rest their life High blood pressure tends to run in families and is more likely to affect men than women age and race is also a role Causes risk of heart attack antihypertensive medication smoking, obesity, lack of physical activity, too much salt, too much alcohol in one day, stress, older age, genetics, sleep apnea. Lifestyle Diseases- Hypertension doesn't often show symptoms, but regular check-ups are important
Transcript: Chief complaints Physical Examination Laboratory workup Typical Chronic Lab Work-up Hep A/B/C serologies, ANA, ASMA, A1AT, AMA, Immunoglobulins, ceruloplasmin, antiTTG, fasting lipid profile, (BHCG), iron studies (TIBC, TSat, Iron), ferritin Developing countries: Schistosomiasis serology Thousands Club 1. Tylenol overdose 2. Ischemic liver injury 3. Viral hepatitis (EBV, CMV, Hep A/B) 4. HELLP syndrome 5. Vascular occlusion (B-C, PVT) 6. (Auto-immune hepatitis) Vital signs Decreased blood pressure HEENT Jaundice, fetor hepaticus, enlarged parotids, muscle wasting Precordial examination Spider angiomata, gynecomastia, loss of chest hair in men Abdominal examination Splenomegaly, hepatic size, findings of ascites, caput medusae Extremity findings Palmar erythema, clubbing, Dupuytren's, pedal edema, muscle wasting Neurologic examination Asterixes, confusion Acute Complications of Liver Disease Chronic Liver Disease 1. Determine etiology History/Physical/Labs Abdominal ultrasound/PV Imaging +/- MRCP +/- Liver biopsy +/- Paracentesis 2. Determine severity and risk of progression MELD and Child-Pugh 3. Screen for associated complications Varices with EGD HCC Paracentesis Chronic Liver Disease Dec 2016 MRI/MRCP Child-Pugh Score The Liver Bomb Variables: Encephalopathy, Ascites, Bilirubin, INR, Albumin Estimates 1- and 2- year survival rate CP A = 100% one year survival rate CP B = 80 % one year survival rate CP C = 45% one year survival rate Also predicts peri-op mortality 10%, 30%, 80% Management of CLD Lab Findings Objectives: Review clinical presentation of CLD Discuss etiologies and work-up of initial presentation Management of the liver bomb Management of common complications MRI Liver Evaluates liver parenchyma Useful for iron overload MRCP Non-invasive ERCP For evaluating the intra and extra hepatic ducts and pancreatic duct Used generally if obstructive pattern of LFTs with normal U/S PSC, cholangiocarcinoma, biliary or pancreatic stones, etc Example 3 45 yo male, hx 3-4 beers per day Presents with ascites AST 300, ALT 200, Bili 38, albumin/INR normal Ferritin 600, Iron stores normal Ultrasound: Fatty liver disease Biopsy? Work-Up of New Diagnosis Symptoms Spontaneous Bacterial Peritonitis Abdominal ultrasound is always first test of choice Non-invasive, no contrast, easily available Provides information regarding cirrhotic state and regarding portal hypertension Can rule out portal vein thrombosis Screens for HCC Low sensitivity for cirrhosis Fibroscan Liver Biopsy UGIB/Coagulopathy Etiologies Constitutional symptoms Anorexia Weight loss Fatigue Relating to ascites Increasing weight, abdominal girth Early satiety SOB/Orthopnea Hepatic decompensation Hepatic encephalopathy Jaundice Upper GIB Variables: Bili, INR, creatinine, (Na) Estimates 3 month mortality For organ allocation Who needs a liver biopsy? Anybody who the diagnosis is uncertain and a biopsy would change management A - Hepatitis A, auto-immune hepatitis, AIAT B - Hep B, Primary Biliary Cirrhosis C - Hep C*, Wilson's disease D - DRUGS E - Ethanol* F - Fatty liver disease* G - Girls H - Hemochromatosis, heart disease I - (Iron), Infiltrative disease (sarcoid, amyloid), Infections * = responsible for >80% of cirrhosis in Canada Similar to above, prevent complications Treat underlying cause Refer for consideration of liver transplant for any transplant candidate! Renal Failure Abdominal Imaging Ascites Metabolic Abnormalities Hepatic Encephalopathy Acute In-Hospital Complications Who to suspect SBP in? Physical Examination Example 2 45 yo female, hx of Type 1 DM and Celiac disease Found to have ALT 600, AST 550, GGT400, bili 35, IgG 23 (high) ANA + ASMA + All other work-up negative Biopsy? Initial Management 1. Alcohol cessation 2. No NSAIDs! 3. Limit sodium restriction 4. Diuretics Lasix/Spironolactone 40:100 dosing No IV diuretics 5. D/C beta-blockers if refractory ascites Refractory Ascites 6. Large volume paracentesis + albumin 7. Consider midodrine 8. Consider TIPS Management of SBP 1. "2 Large Bore IVs, pantoprazole, octreotide, call the surgeon" 2. Supportive care ICU, blood product 3. Correct coagulopathy INR elevated - FFP Thrombocytopenia - Give platelets 4. EGD - timing depends on presentation 5. **SBP Prophylaxis** 1. Antibiotics 2. Albumin 3. Secondary prophylaxis Anybody who comes into hospital with ascites! Anybody with ascites who has any clinical symptoms of: Fever Abdominal pain/tenderness Confusion Diarrhea Ileus Hypotension Hypothermia Sepsis/SBP Coagulopathy/Varices/UGIB Renal Failure / HRS Encephalopathy Ascites Metabolic abnormalities - hypoglycemia, acidosis Out of Hospital Management Liver enzymes AST, ALT, ALP, GGT Liver function tests Bilirubin, albumin, INR CBC Thrombocytopenia Anemia Macrocytosis Chemistry Hyponatremia Elevated creatinine Hypoglycemia Acid-base disturbance 1. Supportive care Intubation, etc 2. Find and treat underlying precipitant Drugs, UGIB, metabolic abns, infection, hypovolemia 3. Lactulose Beware
Transcript: removes toxins from the blood, helps digest food, and fights infections. only organ that can regenerate itself after damage. CLD damage happens over a long period of time. normal repair processes are impaired. only current available treatment with CLD is an organ transplant. transplants are expensive and scarce due to dearth of organ donors. SOURCES STEM CELLS (6-7) iPS are made from skin cells. (# 5, 18) transforms adult cell to pluripotent in the laboratory developed in 2006 by Shinya Yamanaka Using iPS cells: (# 19) based on hepatocyte regeneration/replacement. enhanced liver regeneration in mice and stabilized chronic liver disease. HLCs derived from iPSCs may temporarily support the impaired liver function. hardly be able to restore the original liver structure. still very much at the experimental stage but the possibility of harnessing stem cells to churn out limitless numbers of hepatocytes for transplant therapy is driving the field forward. mouse liver stem cells have been successfully identified and grown in the laboratory but this is not the case with their human counterparts. investigating whether stem cells from other tissue sources can be used to treat various types of liver failure. Cancer: term for diseases in which abnormal cells divide without control and can invade nearby tissues. (# 13) The stem cell theory of cancer: among all cancerous cells, a few act as stem cells that reproduce themselves and sustain the cancer, much like normal stem cells normally renew and sustain our organs and tissues. cancer cells that are not stem cells can cause problems, but they cannot sustain an attack on our bodies over the long term. Only some cells in tumors continue to divide and multiply. The ‘cancer stem cell model’ proposes that cancer stem cells make all other cells found in a tumour. Some tumor cells may briefly divide, but only cancer stem cells can make new cells indefinitely. (# 14, 15) Therapeutic Cloning: removal of a nucleus from a somatic cell (pluripotent) and its transfer by injection into an unfertilized egg. (# 24) Drawbacks/iPS MORAL DILEMMA: requires the destruction of laboratory-fertilized human eggs. (# 21) embyronic and iPS cells have a tendency of forming tumours. many years before seeing widespread clinical application of stem cell therapies Progenitor cells are very similar to stem cells. They are biological cells and like stem cells, they too have the ability to differentiate into a specific type of cell. However, they are already more specific than stem cells and can only be pushed to differentiate into its "target" cell. They act as a repair system for the body. They replenish special cells, but also maintain the blood, skin and intestinal tissues. Progenitor cells can be activated in case of tissue injury, damaged or dead cells. It leads to the recovery of the tissue. (# 6) Friday, October 6, 2017 ADDITIONAL INFORMATION (9) $1.25 STEM CELLS (4-5) DISEASE DESCRIPTION/TREATMENT (2-3) https://stemcells.nih.gov/info/basics/1.htm http://learn.genetics.utah.edu/content/stemcells/ http://stemcellfoundation.ca/en/about-stem-cells/what-is-a-stem-cell/ https://medlineplus.gov/stemcells.html https://www.medicinenet.com/stem_cells/article.htm Blood stem cells primarily reside in bone marrow and make all the cells found in blood, including cells important for the immune system. (# 9, 16) become used to treat diseases such as leukaemia, anaemia and autoimmune diseases. (# 10) Cord blood is contained in the umbilical cord and placenta of a newborn child. (# 11, 16) can be used to treat blood diseases. (# 12) Hepatocytes are the working cells in the liver and they can divide to make copies. Oval cells are the liver's resident stem cells. EMBRYONIC: make new hepatocytes in the lab. (# 4) BONE MARROW: make macrophages to repair damaged liver tissue. (# 10, 4) How they help/how they are used. Cancer unspecialized cells with the ability to differentiate in order to replace damaged cells. (# 1) cell differentiation: embryonic cells become specialized cells; gene expression. (# 7) TYPES OF STEM CELLS: embryonic, cord blood, hematopoietic (# 8), and iPS. (# 2) three main sources: Already existing embryonic stem cell lines; “spare” embryos; somatic cell nuclear transfer technique for the purpose of conducting research.(# 23, 3) help heal injured or diseased tissue. STEM CELLS (8) Vol XCIII, No. 311 CHRONIC LIVER DISEASE Can they be used now to treat CLD?
Transcript: Learning Points Signs and symptoms Thank You! Chronic Liver Disease Hum Chandna - Fourth Year Medical Student Diagnosis Causes of CLD Alcohol liver disease Chronic hepatitis C, B (+/- D) Non-alcoholic steatohepatitis (NAFLD) Metabolic disorders: obesity, haemochromatosis, Wilson's disease, alpha-1 antirtrypsin deficiency PBC, PSC, autoimmune hepatitis Mechanical biliary obstruction, biliary atresia, CF Budd-Chiari syndrome, right-sided HF Amiodarone, methotrexate Causes of chronic liver disease Clinical signs of chronic liver disease Questions? Abdominal distension (decompensated cirrhosis) Jaundice & pruritus (decompensated cirrhosis) Melaena (decompensated cirrhosis) Hand and nail features Facial features Ascites Bruising Hepatosplenomegaly Hepatic bruit Testicular atrophy Altered mental status (decompensated cirrhosis) Derranged liver function tests Long prothrombin time Thrombocytopenia HCV antibodies HBV antigen Abdominal CT/MRI/US can reveal cirrhosis 62 ECG bpm
Transcript: Fibrosis describes encapsulation or replacement of injured tissue by a collagenous scar. Liver fibrosis results from the perpetuation of the normal wound healing response resulting in an abnormal continuation of fibrogenesis (connective tissue production and deposition). Fibrosis progresses at variable rates depending on the cause of liver disease, environmental and host factors (1-3). Cirrhosis is an advanced stage of liver fibrosis that is accompanied by distortion of the hepatic vasculature. It leads to shunting of the portal and arterial blood supply directly into the hepatic outflow (central veins), compromising exchange between hepatic sinusoids and the adjacent liver parenchyma, i.e., hepatocytes. Hepatitis and other viruses Alcohol abuse Nonalcoholic fatty liver disease (this happens from metabolic syndrome and is caused by conditions such as obesity, high cholesterol and triglycerides, and high blood pressure) This chronic liver failure is called end-stage liver disease, when symptoms may become more severe. And you would care for them the way any other resident could. Bed Pan Impact on Family End of life Care Impact on ADL's Chronic Liver Disease (Cirrhosis) Other less common causes of cirrhosis may include: Hepatitis A is found in the stool (feces) of those with Liver Disease. The precautions that should be taken is having all employees vaccinated. While changing a residents incontinence product or wiping after a bowl movement, gloves should be worn and a mask is suggested. What is Liver Disease? Developmental stage Test 1 3.But if left untreated, your liver may become so seriously scarred that it can no longer heal itself. This stage – when the damage cannot be reversed ( is called cirrhosis). 4. The last stage is liver failure which is when the liver looses all function and is life threatening. This is a blood test performed 12 weeks later. By changing the diet and cutting out sugar, carbs, red meat, and dairy. The patient was eating a "clean diet", which would lower the numbers. Along with supplements for the liver and inflamation. There isnt a big change in ADL's, except bathroom use. The diet may be limited but ADL's will not be challenged. The patient had blood work to find out what was wrong. The first test to the right determined the body was inflamed in multiple different areas, especially the liver. Signs and symptoms of liver disease include: Pathophysiology You can see a drastic drop in the numbers 24 weeks later with blood test 3. Progression Autoimmune disorders, where the body’s infection-fighting system (immune system) attacks healthy tissue Blocked or damaged tubes (bile ducts) that carry bile from the liver to the intestine Use of certain medicines Exposure to certain toxic chemicals Repeated episodes of heart failure with blood buildup in the liver Parasite infections 1. In the early stage of any liver disease, your liver may become inflamed. It may become tender and enlarged. Inflammation shows that your body is trying to fight an infection or heal an injury. But if the inflammation continues over time, it can start to hurt your liver permanently. 2. If left untreated, the inflamed liver will start to scar. As excess scar tissue grows, it replaces healthy liver tissue. This process is called fibrosis. (Scar tissue is a kind of fibrous tissue.) Scar tissue cannot do the work that healthy liver tissue can. Moreover, scar tissue can keep blood from flowing through your liver. Cirrhosis is when scar tissue replaces healthy liver tissue. This stops the liver from working normally. Cirrhosis is a long-term (chronic) liver disease. The damage to your liver builds up over time. The liver is your body’s largest internal organ. It lies up under your ribs on the right side of your belly. Skin and eyes that appear yellowish (jaundice) Abdominal pain and swelling Swelling in the legs and ankles Itchy skin Dark urine color Pale stool color, or bloody or tar-colored stool Chronic fatigue Nausea or vomiting Loss of appetite Tendency to bruise easily Cirrhosis severely impacted the family unit with respect to work, finances, and adherence. Those with previous HE had worse unemployment and financial status and posed a higher caregiver burden. Cognitive performance and MELD score were significantly correlated with employment and caregiver burden The most common causes of cirrhosis are: Adaptations for STNA The theory developed by Lawerence Kohlberg would best describe liver cancer. They would most likely be in Post-conventional morality stage. It is when most patients are depressed and the likeness of getting a liver transplant at an older age is lower. And their morals in life change. The use of a bed pan may become necessary when the liver becomes cancerous. The patient may become bed ridden and require a bed pan. T E S T 3
Transcript: Cirrhosis Kennedy Winder What causes Chronic Liver Disease Disease etiology The formation of the disease is when scar tissue takes over healthy tissue on the liver and causes the organ to not function properly. It can lead to liver failure in severe cases. Some of the main causes are hepatitis, long term alcohol abuse, or non-alcoholic fatty liver disease. (Obesity or high cholesterol) Symptoms Symptoms People who are in the early stage of this disease often don't experience symptoms. But at a later stage you can experience: Fluid build up in the stomach Vomiting blood Itching Yellowing of the skin and eyes Kidney failure Easy to bruise Fluid in the stomach and yellowing of the skin Example Example Example Example Example How it is diagnosed ? Blood tests- This tests to see if your liver is working and if your blood clots. MRI- This is where they would inject a dye into your vein. They would then take photographs of your organs, so they can be reviewed. The dye they use would allow them to view the liver more clearly. Diagnosis Liver Biopsy- This is where they get samples from the liver with a needle and test that sample to see which type of liver disease you have Ultrasound- shows how your organs are functioning and how your blood is flowing throughout different areas. How is it treated? Treatment and Medications This disease grows with time and the damage cannot be fixed. -The main goal is to slow down the process and prevent any complications this disease can lead to. -The treatment depends on the cause and degree your liver is in. -For the initial stages it can prevent further damage by eating healthier, lifestyle changes, managing health issues, and medication. -In the later stages, the only treatment is a liver transplant. Health Having a healthy diet is essential. Health Decrease your sodium intake (limit the salt!) Eat fruit and vegetables and lean protein. (fish) Life Life Once you are diagnosed, it is highly suggested that there is no more drinking or using substances for the rest of your life. If you were to continue drinking, you would cause further damage and that can lead to needing a liver transplant or even be fatal. Managing your health problems Managing your health problems Take control of any health problems that lead to this disease. For example, if you have metabolic syndrome, it is important to lose weight. Medications Medication Due to the scarring on the liver, people with this disease are more sensitive to medications. There are certain medications they can no longer take due to this disease. Ursodiol This medication is a natural bile acid that helps move bile out of your liver and into your small intestine. You may need to take this for the rest of your life to reduce the chance of having to have a transplant. Some side effects are diarrhea, constipation, and back pain. Ocaliva might be prescribed if you cannot handle the side effects of Ursodiol. It also boosts bile flow and eases how much bile acid your liver makes Preventions Do not abuse alcohol. This is one of the main causes of this disease. If you are male and drink more than two drinks a day consistently you are increasing your chances to have this disease. If your female it is more than one drink a day consistently, you increase your chances. Eat a well-balanced diet Quit smoking Maintain your body weight, excess fat can damage your liver Prevention and Lifestyle modifications Citations Citations -Chronic liver disease/cirrhosis. Chronic Liver Disease/Cirrhosis - Health Encyclopedia - University of Rochester Medical Center. (n.d.). Retrieved December 5, 2021, from https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=85&ContentID=P00662. -DiLonardo, M. J. (n.d.). PBC: Treatment and complications. WebMD. Retrieved December 5, 2021, from https://www.webmd.com/digestive-disorders/primary-biliary-cirrhosis-treatment. -Mayo Foundation for Medical Education and Research. (2021, February 6). Cirrhosis. Mayo Clinic. Retrieved December 5, 2021, from https://www.mayoclinic.org/diseases-conditions/cirrhosis/diagnosis-treatment/drc-20351492. Alcohol relapse rate among liver transplant recipients identical whether or not there is a 6-month wait before transplant. Johns Hopkins Medicine Newsroom. (2019, April 25). Retrieved December 6, 2021, from https://www.hopkinsmedicine.org/news/newsroom/news-releases/alcohol-relapse-rate-among-liver-transplant-recipients-identical-whether-or-not-there-is-a-6-month-wait-before-transplant. Lifestyle Modifications Do not drink alcohol. Eat a balanced diet. Do not eat raw seafood, raw fish, and shellfish. Not eating these things lowers the risk of infections. Take vitamin or mineral supplements if the doctor says it may help. Have all the medications that you would take approved by a doctor. The damage that your liver has makes it harder to break down medications and that could cause further damage. Get vaccines for flu, pneumonia, and hepatitis. This also helps reduce the risk of
Transcript: Chronic Liver Disease What is Chronic Liver Disease? Chronic Liver Disease can be any condition in the body's gradual degradation and renewal of the tissue cells. Sources of Chronic Liver Disease are listed into five groups: One of the main causes of the Chronic Liver Disease is overuse in alcohol. The highest risk group are people who are immune to alcohol abuse. People who suffer from malnutrition and have tattoos are also at risk for chronic liver disease problems. Types Of Chronic Liver Disease Symptoms There Are 32 Symptoms Of Chronic Liver Diesase Coughing Blood Vomiting Blood Gallstones Hair Loss Yellowing Of The Eyes Reduced Appetite Red Palms Weakness Weight Loss Yellowing Of The Skin What is a lifestyle disease? A lifestyle disease is a disease you are not born with but is resulted in risk factors like smoking, drunk driving, lack of exercise, and poor diet. Facts -The liver is about the size of a football and is located on the right, just below the lower rib cage -16 types of Chronic Liver Disease -Leading cause of death amoung African Americans http://www.cdc.gov http.://www.emedicinehealth.com http://www.hepatitis.about.com http://www.webmd.com/hepatitis/fatty-liver-disease http://www.chronicliver.com http://www.rightdiagnosis.com/c/chronis_liver_disease/symptoms/htm 1. Viral Causes Cause -Long-standing inflammation -Poisons -Infections -Heart Disease Cirrhosis Hepatits C (nonalcoholic) By; Sierra, Hannah, & Nicole Fatty Liver Cause -Accumulation of scar tissue in the liver 5. Miscellaneous Causes Hepatitis B Cause -Drinking too much alcohol 2. Metabolic Causes Site Sources 3.Autoimmune Response Causes Hepatitis A Liver Fibrosis Cause -Overload of Iron, Obesity, & Diet (cc) photo by Metro Centric on Flickr Cause (alcoholic) -Sexual contact, Sharing needles, Work-Related exposure, Childbirth, Body piercings and Tattoos, & Toiletries. Cause -Contaminated Food -Contaminated Water -Contaminated Blood -Direct Contact 4. Toxin-Related Causes Cause -Drinking little amount or no alcohol (cc) photo by Franco Folini on Flickr
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