Liver diease
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Transcript Liver diease
Renal and Hepatic Disease
Claire Nowlan MD
Liver Function
Secretion of bile for fat absorption
Short term sugar storage
Breakdown of aged red blood cells with
excretion of bilirubin
Synthesis of coagulation factors
Drug metabolism
Hepatitis
Inflammation of the liver from any cause
Most common causes are viral & alcoholic
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Less frequent causes are mononucleosis, secondary syphilis,
TB, acetaminophen overdose, methotrexate, ketoconazole
Acute symptoms
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Abdominal pain, nausea, vomiting, fever, malaise, jaundice,
hepatomegaly, splenomegaly
In the recovery phase, hepatomegaly and abnormal liver
functions may persist
Symptoms of chronic liver disease
May be asymptomatic for 10 to 30 years
Nonspecific signs
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Fatigue, weight loss, itchiness, right upper quadrant
pain
Hepatitis A
Transmission - fecal-oral route
Sources - water, shellfish, restaurants
Incubation - 15-50 days
Serological evidence of infection in 40% of US
populations
No chronic carrier state
Vaccine and immunoglobulin available
Hepatitis B
Transmission - percutaneous/permucosal
High risk groups
healthcare workers, immigrants from Southeast Asia,
hemodialysis patients, IV drug users, recipients of blood
transfusions, unprotected sex (especially anal) with
multiple partners
Incubation - 45-180 days
Hepatitis B
Risk of infection with needle stick injury 6-30%
Prevalence of infection in dentists 8%, oral
surgeons 21%
5-10% risk of becoming a chronic carrier
Carriers have increased risk of cirrhosis and
hepatocellular carcinoma
Vaccine and immunoglobulin available
Hepatitis C
Transmission - mainly percutaneous. Very low
risk with sexual transmission
Incubation 14-180 days
Risk groups
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mainly IV drug users, and blood transfusion prior to
1992
Risk of infection with needle stick injury 2-8%
80-90% risk of becoming chronic carrier
Hepatitis C
Risk of cirrhosis and hepatocellular carcinoma
No active or passive immunization available
Treatment is only suggested in certain
subgroups, but it is expensive, takes up to 1
year, has many side effects, and only 10-30%
are actually cured
Other Hepatitis Viruses
Hepatitis D
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only occurs as a coinfection with B
transmitted both parenterally and sexually
Hepatitis E
–
resembles hepatitis A, transmitted through the fecal
oral route
Dental management
Difficult to identify all patients through history
Many acute cases of Hep B&C are mild
Must use infectious precautions for ALL
patients
Screening recommended for patients from high
risk groups
Guidelines for blood exposure
From patients with Hep B
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determine titer of anti-HBs in the health care
professional
if adequate - no tx needed
if inadequate give HBIG
From patients with Hep C
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exposed professional gets baseline and f/u testing
for anti-HCV and liver enzymes
Alcoholic liver disease
Only 10-15% of alcoholics develop cirrhosis
Early change - fatty liver
Second stage - alcoholic hepatitis
Final stage - cirrhosis
End stage liver disease
Esophageal varicies
deficiency of Vit K dependant coagulation
factors
anemia, leukopenia, thrombocytopenia
esophagitis, gastritis
endocrine disturbances
encephalopathy
dementia
Laboratory abnormalities
Increased
AST
GGT
ALT
Bilirubin
Alk Phos
INR
Decreased
albumin
RBC, WBC, platelets
Dental management - alcoholic liver
disease
Beware a second addiction to pain medication
- no refills, avoid narcotics and sedatives if
possible
Patient may require more local anesthetic or
anxiolytic
Dental management - all liver
disease
Screen for bleeding tendencies
Unpredictable metabolism of specific drugs
Renal function
Control fluid volume
Acid-base balance
Controls secretion of K, Na, phosphate
Excrete wastes
Synthesize erythropoietin
Activates Vit D
Controls blood pressure by secreting renin
Metabolizes drugs
Chronic renal failure
Irreversible destruction of the nephrons
The kidney can lose about 50% of the
nephrons and still maintain normal function
Progressive, most often caused by DM,
hypertension, Glomerulonephritis
Various grades of failure depending on GFR
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50-10 ml/min = moderate
< 10 ml/min = severe
Laboratory assessment
Urinalysis
Increased creatinine
Increased BUN
Changes in Na, K
CBC, INR, PTT
GFR = (140 - age) X lean wt in KG X.85 if female
72 X serum creatinine
Chronic renal failure
Problems
CV - Fluid overload, hypertension
GI nausea, diarrhea
Neurologic “uremic encephalopathy”
Metabolic - Metabolic acidosis, uremia, hypokalemia
Hematologic - Anemia, platelet disfunction
Immunity - decreased
Dermatologic - yellow tinge to skin, pruritis, bruises
Renal rickets
Fatigue
Medical management
Conservative care
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Hemodialysis
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Restrict fluid, K, Na, protein, phosphate
Tx DM, hypertension
Give recombinant human erythropoietin
Patients have arteriovenous shunt
Need heparin infusion during dialysis
Peritoneal Dialysis
Renal Transplantation
Dental management
Screen for bleeding disorder before surgery
Avoid nephrotoxic drugs
Decrease dosages of drugs mainly metabolized
through kidney
NSAIDs – especially ASA
Acyclovir
High dose acetaminophen
Penicillins, erythromycin, opioids
Controversy whether antibiotic prophylaxis needed
Dental management - hemodialysis
Be careful of arteriovenous shunt
Dental care on non hemodialysis days
Be aware of possible Hep B,C, HIV in these
patients