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Chronic Liver Disease

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

CHRONIC LIVER DISEASE

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?

Chronic Liver Disease (Cirrhosis)

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

Chronic Liver

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

Chronic Liver Disease/Cirrhosis

Transcript: Causes are: * Alcohol abuse one of the main causes of cirrhosis * Hepatitis C & B * Drug use * Chemical exposure * Diabetes * Malnutrition * Cystic fibrosis * Glycogen storage disease * Obesity Treatment continue Physical Activity Chronic Liver Disease/Cirrhosis Causes The American Liver Foundation has information not only for cirrhosis, but also for other liver diseases. http://www.liverfoundation.org/ Another foundation is National Liver Foundation http://www.nlfindia.com/ 1. What is one of the main causes of cirrhosis? Alcohol abuse is one of the main causes of cirrhosis. 2. Why does people with cirrhosis needs to have a high-protein diet? People with cirrhosis needs to have a high-protein diet, because the liver don't produce protein and protein is inhibited. Cirrhosis * A damaged liver by cirrhosis affects almost every bodily process, this includes the functions of the digestive, hormonal, and circulatory systems. * Cirrhosis can lead to liver cancer * Also can lead to kidney failur 2 Questions Pictures The risk of cirrhosis are: * Alcohol abuse * Hepatitis infection * Liver cancer * Use of drugs toxic to the liver * Obesity * Diabetes poorly controlled * Ingestion of too much iron * Females ages of 35-50, Asians, Caucasians, Jews, and Africans are at higher risk of having Cirrhosis * The age range of having cirrhosis is 20-80 years, but it happens at 40-60 years Resources Complications Moderate exercise like walking can help keep the swelling caused by edema in check. Physical activity is essential to keep cirrhosis symptoms in check. Symptoms Risk Factors Treatment * Making dietary and lifestyle changes, a nutritious low-fat diet, high-protein diet, and exercise can help people with cirrhosis * Avoiding alcohol and drugs Notably milk thistle (silymarin) and licorice root (glycyrrhizin) have been used to treat liver diseases. Talk with your doctor about alternative medicine to help cirrhosis. Cirrhosis treatment includes: * Medications such as beta blockers to reduce blood pressure and lower the risk of bleeding * diuretics to remove excess fluid * Having regular endoscopic procedures * Having a liver transplant Mild cirrhosis may not cause any symptoms, some of the symptoms are: * Abnormal nerve function * Fluid buildup in the abdominal cavity * Vomiting blood * Curling of fingers * Gallstones * Hair loss * Kidney failure * Muscle loss * Bruising easily * Fatigue * Appetite loss and weight loss * The common name is Chronic Liver Disease * The scientific name is Cirrhosis * Cirrhosis is a disease in which the liver cells becomes damaged, and the structure and function of the liver are affect dramatically * Scar tissue slowly replaces normal functioning liver tissue * Protein production and other substances produced by the liver are inhibited * The liver don't function properly Foundations * http://www.thirdage.com/hc/c/cirrhosis-risk-factors * http://umm.edu/health/medical/reports/articles/cirrhosis * http://www.mayoclinic.org/diseases-conditions/cirrhosis/basics/definition/con-20031617 * http://www.patient.co.uk/education/cirrhosis * http://www.irtces.com/cirrhosis.htm * http://medicine.med.nyu.edu/conditions-we-treat/conditions/cirrhosis

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