SHS.

420 Lec-10
Dr. M.Nauman
Diseases of Liver
Liver Function tests
 Normal Values

• Alanine aminotransferase (ALT) – 5-35 IU/L

• Aspartate aminotransferase (AST) – 5-35 IU/L
• Alkaline phosphatase (ALP) – 30-130 IU/L
• Serum albumin – 3.5-5.0 g/dL
• Serum bilirubin – 0.1-1.2 mg/dL
• International normalized ratio (INR) – 1.0
 Causes of Elevated Liver Enzymes

• Non-alcoholic fatty liver disease (NAFLD).

• Alcohol.
• Viral hepatitis (Mild in HBV, HCV and severe in HAV, HEV).
• Autoimmune hepatitis.
• Drug toxicity (e.g., paracetamol, anti-TB drugs etc.).
• Wilson’s disease.
• Liver ischemia.
Jaundice
 Definition

• Yellowing of skin, sclera and mucous

membranes due to increased plasma bilirubin
(more than 2.5 mg/dL).
 Classification (Site of Problem)

a. Prehepatic – Overproduction of bilirubin e.g., hemolytic jaundice.

b. Hepatic – Acute or chronic hepatic insufficiency e.g., acute viral
hepatitis.
c. Posthepatic (obstructive/surgical) – Obstruction to flow of
bilirubin from liver to duodenum e.g., carcinoma of head of
pancreas.
 Classification
(Type of Circulating Bilirubin)

• Conjugated (Direct).
• Unconjugated (Indirect).
 Unconjugated Hyperbilirubinemia
(Causes)
• Water insoluble; cannot be excreted in urine.
• Causes include:
a. Overproduction – Haemolysis.
b. Impaired uptake – Drugs, ischemia.
c. Impaired conjugation – Glibert’s syndrome, Crigler-
Najjar syndrome.
d. Physiological – In neonates.
 Conjugated Hyperbilirubinemia
(Causes)
• Water soluble; changes the urine colour.
• Causes include:
a. Hepatocellular dysfunction – Viruses, drugs, alcohol, cirrhosis,
liver metastases, haemochromatosis, autoimmune hepatitis,
septicemia, alpha-1 antitrypsin deficiency, Budd-Chiari syndrome,
Wilson’s disease, right heart failure, toxins.
b. Cholestasis due to impaired drainage of bile – Diseases of biliary
tree, carcinoma of pancreas.
Ascites
 Definition

• Accumulation of free fluid in peritoneal cavity.

• Ascites > 1L causes abdominal distension, shifting dullness on
percussion and fluid thrill.
 Investigations

• Ultrasonography.
• Ascitic tap for biochemistry and cytology.
• LFTs.
 Serum-Ascitic Albumin Gradient
(SAAG Ratio)

• SAAG = Serum albumin – albumin in ascitic fluid.

• > 1.1 g/dL – Transudative ascites.
• < 1.1 g/dL – Exudative ascites.
 Causes (Transudative)

• Cirrhosis.
• Right heart failure.
• Hypoproteinemia – Nephrotic syndrome, protein-losing
enteropathy.
 Causes (Exudative)

• Malignancy.
• Infections (spontaneous bacterial peritonitis (SBP), TB).
 Management

• Sodium restriction.
• Diuretics – Spironolactone.
• Therapeutic ascitic tap.
• TIPSS (transjugular intrahepatic portosystemic stent shunt).
Portal Hypertension
 Definition

• Prolonged elevation of the portal venous pressure (normal 5-6

mm of Hg).
 Causes

• Extrahepatic portal vein obstruction.

• Cirrhosis.
• Malignancy.
• Schistosomiasis.
 Clinical Features

• Splenomegaly.
• Caput medusa (visible blood vessels on anterior abdominal
wall).
• Esophageal varices.
• Rectal varices (resemble haemorrhoids).
• Ascites.
 Investigations

• Upper GI endoscopy.
• Ultrasonography.
• CT or MRI angiography.
• Decreased platelet count (due to splenomegaly).
 Complications

• Life threatening complication of portal hypertension is

acute upper GI bleeding from esophageal varices.
 Management

• Esophageal Varices:
a. Prevention in non-bleeding varices – Beta blockers.
b. Management of acute variceal bleed:
i. Resuscitation (ABC, IV fluids, PPI, prophylactic antibiotics,
terlipressin).
ii. Endoscopic band ligation or sclerotherapy or balloon tamponade.
iii. Secondary prevention – Beta blockers.
Cirrhosis
 Pathophysiology

• Diffuse hepatic fibrosis and nodule

formation.
 Causes

• Viral hepatitis (HBV, HCV).

• Alcohol.
• Non-alcoholic fatty liver disease (NAFLD).
 Clinical Features

• May be asymptomatic.
• Non-specific symptoms like weakness, fatigue, muscle
cramps, weight loss, nausea etc. may be present.
• Hepatomegaly – Most commonly present in alcoholic
cirrhosis.
• Features of portal hypertension or ascites may be
seen in advanced cases.
 Other Features
(Stigmata of Chronic Liver Disease)

• Clubbing.
• Palmar erythema.
• Spider nevi (telangiectasia).
• Gynecomastia.
 Management

• Treatment of underlying cause.

• Liver transplantation.
Hepatic Encephalopathy
 Pathophysiology

• Neurotoxins produced by bacterial action in the gut cannot be

metabolized by diseased liver leading to their accumulation in
the blood.
 Clinical Features (Grading)

• Grade I – Poor concentration, slurred speech,

disordered sleep rhythm.
• Grade II – Drowsy, lethargic, occasional aggressive
behavior.
• Grade III – Marked confusion and drowsiness, sleepy
but responds to pain and voice.
• Grade IV – Unconscious, non responsive to voice.
 Clinical Features (Examination)

• Asterixis (flapping tremors when patient is asked to

stretch forward dorsiflexed hands).
• Inability to perform simple mathematical questions.
• Constructional apraxia (inability to draw simple
objects on paper).
• Hyperreflexia.
• Positive Babinski’s sign.
 Precipitating Causes

• Constipation.
• High protein load (e.g., protein rich diet, GI bleeding).
• Drugs.
• Trauma.
• Infections.
 Management

• Treat or remove precipitating cause.

• Oral laxatives e.g., Lactulose.
• Rifaximin (Non-absorbed antibiotic).
Questions ?
Thank You !!!