Functional and organic diseases of liver and bile ducts. Etiology, pathogenesis, clinical features,...

Functional and organic diseases of liver and bile

ducts. Etiology, pathogenesis, clinical features, diagnostics, treatment and prophylactic

Lecturer:Lecturer:

Gorishna Ivanna LubomyrivnaGorishna Ivanna Lubomyrivna

Plan of the lecture Definition of biliary dyskinesiaDefinition of biliary dyskinesia Biliary dyskinesiaBiliary dyskinesia classification Clinical manifestation Methods of examinations Treatment of the different kinds of biliary dyskinesia biliary dyskinesia Definition of the chronic hepatitisDefinition of the chronic hepatitis Hepatitis classification Clinical manifestation Methods of examinations Treatment of the different kinds of hepatitis

Definition of the Biliary Dyskinesia

is a disorder of the sphincter’ tonus and is a disorder of the sphincter’ tonus and kinetics of the gall-bladder and bile ducts.kinetics of the gall-bladder and bile ducts.

Classification

hypertonic-hyperkinetic dyskinesia hypertonic-hyperkinetic dyskinesia hypotonic-hypokinetic dyskinesiahypotonic-hypokinetic dyskinesia

Clinical manifestation of hypertonic-hyperkinetic

dyskinesia Duration of the disease up to 1 yr.Duration of the disease up to 1 yr. Pain syndromePain syndrome Dyspeptic syndromeDyspeptic syndrome Manifestations of vegetative dysfunction, Manifestations of vegetative dysfunction,

neurotic symptomsneurotic symptoms

Clinical manifestation of hypotonic-hypokinetic dyskinesia

Pain syndromePain syndrome Dyspeptic syndromeDyspeptic syndrome HepatomegalyHepatomegaly Gallbladder symptoms are positive Gallbladder symptoms are positive

Plan of examination

Fool blood count Fool blood count Biochemical test of bloodBiochemical test of blood

Serum aminotransferaseSerum aminotransferase Serum bilirubin (predominantly the direct reacting Serum bilirubin (predominantly the direct reacting

fraction)fraction) Serum alkaline phosphataseSerum alkaline phosphatase Albumin and globulin levelAlbumin and globulin level

Stool test Stool test USE of the abdominal cavity + cholekynetics for USE of the abdominal cavity + cholekynetics for

functional investigationsfunctional investigations

Stool test:Norma Norma Biliary Biliary

dyskinesiadyskinesia

indigested indigested muscular fibers muscular fibers non-digestable non-digestable cellulose cellulose digestable digestable cellulosecellulose

fatty acids fatty acids mucous mucous epithelium epithelium leucocytes leucocytes erythrocyteserythrocytes

1-2-31-2-3

+ ++ +

++++ ++ ++

1-21-2 1-2-3 1-2-3

0-10-1

++++++++

Duodenal intubation

Portion phase Duration (min)

Color Speed of bile excretion

Total volume, ml

AA

II 10-20 10-20 GoldeGolden-n-yellowyellow

0.2-0.2-1.41.4

8-228-22

IIII 2-62-6 -- -- --

IIIIII 3-53-5 yellowyellow 0.6-0.6-1.81.8

3-53-5

Duodenal intubation

Portion phase Duration (min)

Color Speed of bile excretion

Total volume, ml

B IV 20-30 Brown 1.1-2.5

15-30

C V 20-30 Golden-yellow

0.2-1.0

Constant

Duodenal intubationPortion Colour pH Epithelium Leucocyte Lamblia Mu-

cus

A Golden yellow

↑ 7 5-10 5-10 - -+

B Brown ↑ 7 5-10 5-10 - -

C Bright yellow

↑ 7 5-10 5-10 - -

Duodenal intubation

Portion Color pH Epithelium Leucocytes Lamblia Mu-cus

A Yellow-green

6.2 5-6 5-6 - -

B Brown-green

5.5 3-5 3-6 - -

C yellow 7.2 4-6 2-4 - -

USE of the abdominal cavity + cholekinetics for functional

investigations

cholekinetics lead to a contraction of the cholekinetics lead to a contraction of the gallbladder for 1/2-2/3 of the previous volume gallbladder for 1/2-2/3 of the previous volume

hypertonic dyskinesia - contraction of the hypertonic dyskinesia - contraction of the gallbladder more than 2/3 of the previous gallbladder more than 2/3 of the previous volume volume

hypotonic dyskinesia - contraction of the hypotonic dyskinesia - contraction of the gallbladder less than 1/2 of the previous gallbladder less than 1/2 of the previous volume volume

Diet 5 Exclude heavy fats (like pork), spices, fried Exclude heavy fats (like pork), spices, fried

foods, "fast food"”; avoid stimulators of foods, "fast food"”; avoid stimulators of gastrointestinal secretions, the diet must be rich gastrointestinal secretions, the diet must be rich by metionine, lecithin, and choline to stimulate by metionine, lecithin, and choline to stimulate synthesis of proteins and enzymes in the liver. synthesis of proteins and enzymes in the liver. Diet with normal value of proteins and vitamins, Diet with normal value of proteins and vitamins, with restriction of fats and carbohydrates is with restriction of fats and carbohydrates is administered, also restrict salt. administered, also restrict salt.

Foods boiled, steamed and baked are Foods boiled, steamed and baked are recommended; food taking 5 times dailyrecommended; food taking 5 times daily

Treatment of hypertonic-hyperkinetic dyskinesia

1.1. Diet N 5Diet N 52.2. Spasmolitics: Spasmolitics:

platyphyllini hydrotartratis (amp. 0.2 % 1 ml)platyphyllini hydrotartratis (amp. 0.2 % 1 ml) papaverini hydrochloridum (tab. 0.01, amp. 2 % 2 ml)papaverini hydrochloridum (tab. 0.01, amp. 2 % 2 ml) no-spa (tab. 0.04 or amp. 2 % 2 ml)no-spa (tab. 0.04 or amp. 2 % 2 ml)

3.3. CholereticCholeretic:: cholagoncholagon allocholum allocholum cholenzynumcholenzynum galstenagalstena hepabenehepabene

Treatment of hypotonic-hypokinetic dyskinesia

1.1. Diet N 5Diet N 5 Prokinetic: motilium, domperidone (tabl. 0.01 g) 1 Prokinetic: motilium, domperidone (tabl. 0.01 g) 1

mg/kg/day mg/kg/day

3.3. Choleretic and cholekinetic drugsCholeretic and cholekinetic drugs:: cholagoncholagon allocholum allocholum cholenzynumcholenzynum galstenagalstena hepabenehepabene chophytolchophytol

Hepatoprotectors

Essentiale (cap., amp.) 1-2 cap. 3 times a Essentiale (cap., amp.) 1-2 cap. 3 times a dayday

Carsil (dragee) 1-2 dragee 3 times a dayCarsil (dragee) 1-2 dragee 3 times a day Hepabene 1-2 dragee 3 times a dayHepabene 1-2 dragee 3 times a day Thiotriazolinum 1 tabl. 3 times a dayThiotriazolinum 1 tabl. 3 times a day Chophytol 1-2 tabl. 3 times a dayChophytol 1-2 tabl. 3 times a day

Antioxidants (aevitum, tocopheroli Antioxidants (aevitum, tocopheroli acetatis)acetatis)

Enterosortion (enterosgel)Enterosortion (enterosgel) Probiotics (linex, bifiform, bactisuptil) Probiotics (linex, bifiform, bactisuptil)

Blind Duodenal intubation

with magnesii sulfatis 33 % with magnesii sulfatis 33 % xylitol or sorbitol 10 % xylitol or sorbitol 10 %

Chronic cholecystitis and cholecystocholangitis

Chronic recurrent inflammatory process Chronic recurrent inflammatory process of gallbladder and intrahepatic bile ducts, of gallbladder and intrahepatic bile ducts, accompanied with bile ducts motor accompanied with bile ducts motor disorders disorders

Clinical manifestation

Pain syndromePain syndrome Dyspeptic syndromeDyspeptic syndrome Intoxication syndromeIntoxication syndrome Cholestasis Cholestasis Inflammatory syndromeInflammatory syndrome Dyscholia Dyscholia Ph of bile is acidic Ph of bile is acidic USEUSE

Duodenal intubation

Portion Color pH Epithelium Leucocytes Lamblia mu

cus

A green 6.2 8-10 6-8 ++ ++

B Brown-green

4.5 40-50 55-60 - -

C yellow 7.2 10-16 9-16 - -

Treatment of hypotonic-hypokinetic dyskinesia

1.1. Diet N 5Diet N 5

2.2. Prokinetic: motilium, domperidone (tabl. 0.01 g) 1 Prokinetic: motilium, domperidone (tabl. 0.01 g) 1 mg/kg/day mg/kg/day

3.3. Choleretic and cholekinetic drugsCholeretic and cholekinetic drugs:: cholagoncholagon allocholum allocholum cholenzynumcholenzynum galstenagalstena hepabenehepabene chophytolchophytol

Hepatoprotectors

Essentiale (cap., amp.) 1-2 cap. 3 times a Essentiale (cap., amp.) 1-2 cap. 3 times a dayday

Carsil (dragee) 1-2 dragee 3 times a dayCarsil (dragee) 1-2 dragee 3 times a day Hepabene 1-2 dragee 3 times a dayHepabene 1-2 dragee 3 times a day Thiotriazolinum 1 tabl. 3 times a dayThiotriazolinum 1 tabl. 3 times a day Chophytol 1-2 tabl. 3 times a dayChophytol 1-2 tabl. 3 times a day

Treatment of lambliasis, girardiasis

Furasolidone 8-10 mg/kg 4 times a day-Furasolidone 8-10 mg/kg 4 times a day-10 days (tabl. 0.05)10 days (tabl. 0.05)

Tinidazole 50-60 mg/kg/day (tab. 0.5, Tinidazole 50-60 mg/kg/day (tab. 0.5, 0.15)0.15)

Metronidazolum 15-20 mg/kg for 5 days Metronidazolum 15-20 mg/kg for 5 days (tabl. 0.5)(tabl. 0.5)

Blind Duodenal intubation

with magnesii sulfatis 33 % with magnesii sulfatis 33 % xylitol or sorbitol 10 % xylitol or sorbitol 10 %

Definition of the chronic hepatitis

a continuing hepatic inflammatory process a continuing hepatic inflammatory process manifested by elevated hepatic transaminase manifested by elevated hepatic transaminase level, lasting 6 mo or more and accompanied level, lasting 6 mo or more and accompanied with pain, dyspeptic, intoxication and with pain, dyspeptic, intoxication and cholestatic syndromescholestatic syndromes

Chronic hepatitis can be caused by persistent viral infection, Chronic hepatitis can be caused by persistent viral infection, drugs, and autoimmune or unknown factors. Approximately drugs, and autoimmune or unknown factors. Approximately 15–20 % of cases are associated with hepatitis B infection; in 15–20 % of cases are associated with hepatitis B infection; in this group of patients, unusually severe disease may be this group of patients, unusually severe disease may be caused by superimposed infection with hepatitis D (a caused by superimposed infection with hepatitis D (a defective RNA virus that is dependent on replicating defective RNA virus that is dependent on replicating hepatitis B virus). More than 90 % of infants infected during hepatitis B virus). More than 90 % of infants infected during the 1st year of life experience chronic hepatitis B infection the 1st year of life experience chronic hepatitis B infection compared with a rate of 5–10 % among older children and compared with a rate of 5–10 % among older children and adults. Chronic hepatitis may also follow 30–50 % of adults. Chronic hepatitis may also follow 30–50 % of hepatitis C virus infections. Patients receiving blood hepatitis C virus infections. Patients receiving blood products or who have had massive transfusions are at products or who have had massive transfusions are at increased risk. Hepatitis A virus does not cause chronic increased risk. Hepatitis A virus does not cause chronic hepatitis. Drugs commonly used in children that may cause hepatitis. Drugs commonly used in children that may cause chronic liver injury include isoniazid, methyldopa, chronic liver injury include isoniazid, methyldopa, nitrofurantoin, dantrolene, and the sulfonamides.nitrofurantoin, dantrolene, and the sulfonamides.

Classification of the hepatitis

Forms of chronic hepatitisForms of chronic hepatitis::

1. 1. Chronic viral hepatitis (В, С, DВ, С, D))

2. 2. Autoimmune hepatitisAutoimmune hepatitis

3.3. Drug-induced hepatitis Drug-induced hepatitis

4. 4. Toxic hepatitisToxic hepatitis

5. 5. Cryptogenic Cryptogenic

The activity of the chronic hepatitis

1.1. Active periodActive period::

а) а) mild activity mild activity ((elevationelevation of ALTof ALT << 3 3 timestimes););

б) б) moderate activity moderate activity ((elevationelevation of ALTof ALT << 10 10 timestimes););

в) в) severe activity severe activity ((elevationelevation of ALTof ALT >>1010 timestimes). ).

2.2. Inactive period Inactive period

Stages of chronic hepatitis

0- 0- fibrosis is absentfibrosis is absent;;

1- 1- mild fibrosismild fibrosis;;

2- 2- moderate fibrosismoderate fibrosis;;

3- 3- severe fibrosissevere fibrosis;;

4- 4- cirrhosiscirrhosis..

Example of the diagnosis

Chronic viral hepatitis B, active period, mild Chronic viral hepatitis B, active period, mild activity, without fibrosis activity, without fibrosis

Clinical manifestation

Pain syndromePain syndrome Dyspeptic syndromeDyspeptic syndrome Intoxication syndromeIntoxication syndrome

Objective examination shows

Inadequate weight gain or failure to thriveInadequate weight gain or failure to thrive Sexual delaySexual delay JaundiceJaundice Pruritus Pruritus Hyperpigmentation or hypopigmentation of Hyperpigmentation or hypopigmentation of

the skin the skin Symptoms of hypovitaminosis Symptoms of hypovitaminosis Telangiectasias (spider angiomas)Telangiectasias (spider angiomas) Palmar erythema Palmar erythema Clubbing fingers Clubbing fingers

Jaundice

Jaundice

Objective examination shows

Hepatic smellHepatic smell HepatomegalyHepatomegaly Symptoms of portal hypertension Symptoms of portal hypertension

SplenomegalySplenomegaly AscitesAscites Collateral circulation Collateral circulation

Splenism Splenism Hemorrhagic syndromeHemorrhagic syndrome Encephalopathy Encephalopathy

Hepato-spleno-megaly

Collateral circulation in case of biliary cirrhosis

Plan examination Fool blood count Fool blood count Biochemical test of bloodBiochemical test of blood

Serum aminotransferareSerum aminotransferare Serum bilirubin (predominantly the direct reacting Serum bilirubin (predominantly the direct reacting

fraction)fraction) Serum alkaline phosphataseSerum alkaline phosphatase Serum Serum γγ--globulin levels globulin levels Albumin and globulin levelAlbumin and globulin level The prothrombin time The prothrombin time serum iron and serum ferritin serum iron and serum ferritin

Stool test Stool test USE of the abdominal cavity USE of the abdominal cavity

Tests in case viral hepatitis

ELISA test ELISA test PCR examination PCR examination Quantitative PCRQuantitative PCR Viral genotyping Viral genotyping

HBV serum markers

HBsAg HBsAg HBsAb (recovering)HBsAb (recovering) HBeAgHBeAg HBeAbHBeAb HBcAb Ig MHBcAb Ig M HBc Ab Ig G (recovering)HBc Ab Ig G (recovering) HBV DNAHBV DNA

HCV serum markers

HCV Ab Ig GHCV Ab Ig G HCV Ab Ig MHCV Ab Ig M HCV RNAHCV RNA

HDV serum markers

HDV Ab Ig G HDV Ab Ig G HDV Ab Ig MHDV Ab Ig M HDV RNAHDV RNA HBsAg HBsAg

Autoimmune hepatitis Hypergammaglobulinemia. Hypergammaglobulinemia. Serum IgG levels usually exceed 16 g/L. Serum IgG levels usually exceed 16 g/L. Serum antiactin (smooth muscle), antinuclear, Serum antiactin (smooth muscle), antinuclear,

and antimitochondrial antibodies. and antimitochondrial antibodies. Additional less common autoantibodies Additional less common autoantibodies

include rheumatoid factor, anti-parietal cell include rheumatoid factor, anti-parietal cell antibodies, and antithyroid antibodies. antibodies, and antithyroid antibodies.

A Coombs-positive hemolytic anemia may be A Coombs-positive hemolytic anemia may be present.present.

Treatment of the viral hepatitis

Regime Diet 5Diet 5 Interferon-therapy: (α-Interferon).

Diet 5 Exclude heavy fats (like pork), spices, fried Exclude heavy fats (like pork), spices, fried

foods, "fast food"”; avoid stimulators of foods, "fast food"”; avoid stimulators of gastrointestinal secretions, the diet must be rich gastrointestinal secretions, the diet must be rich by metionine, lecithin, and choline to stimulate by metionine, lecithin, and choline to stimulate synthesis of proteins and enzymes in the liver. synthesis of proteins and enzymes in the liver. Diet with normal value of proteins and vitamins, Diet with normal value of proteins and vitamins, with restriction of fats and carbohydrates is with restriction of fats and carbohydrates is administered, also restrict salt. administered, also restrict salt.

Foods boiled, steamed and baked are Foods boiled, steamed and baked are recommended; food taking 5 times dailyrecommended; food taking 5 times daily

Interferon-therapy:

1.1. IntronIntron А ( А (αα2b2b--Interferon), ),

Form of production - vial withForm of production - vial with 3 3 andand 5 М 5 М units units

2.2. Viferon (Viferon (αα22- - Interferon+ vit. E and C)

Form of production rectal suppository Form of production rectal suppository

Viferon 1 -Viferon 1 - 150000 150000 unitsunits

ViferonViferon 2 2 -- 500000 500000 unitsunits

ViferonViferon 3 – 1000000 3 – 1000000 unitsunits

ViferonViferon 4 – 2000000 4 – 2000000 unitsunits..n Pegasis Pegasis ( (peginterferonpeginterferon αα-2а) -2а)

Form of production syrette with Form of production syrette with 135 135 mcgmcg andand 180 180 mcgmcg

Intron А-therapy:

Etiology Etiology DosesDoses Way of Way of injection injection

Duration of Duration of treatmenttreatment

HBVHBV 55 М М units units/м/м22 3 3 times a times a weekweek

i/mi/m, , s/cs/c 6 6 momo..

HCVHCV 33 М М units units/м/м22 3 3--7 7 times times a weeka week

i/mi/m, , s/cs/c 12-18 12-18 momo..

Modern treatment of viral hepatitis

HBVHBV: : Interferon++LamivudineLamivudine..

the doses of Lamivudine is 3 mg/kg (up to 100 the doses of Lamivudine is 3 mg/kg (up to 100 mg) once per daymg) once per day

HHССVV: : Interferon+Ribavirin

the doses of the doses of Ribavirin is 1000-1200 mg once is 1000-1200 mg once per dayper day

Autoimmune hepatitis Prednisone is given at an initial dose of 1–2 Prednisone is given at an initial dose of 1–2

mg/kg/day and continued until aminotransferase mg/kg/day and continued until aminotransferase values return to less than twice the upper limit of values return to less than twice the upper limit of normal. normal.

The dose should then be lowered in 5-mg decrements The dose should then be lowered in 5-mg decrements over a 4- to 6-wk period, until a maintenance dose of over a 4- to 6-wk period, until a maintenance dose of less than 20 mg/day is achieved. less than 20 mg/day is achieved.

In patients who respond poorly, who experience In patients who respond poorly, who experience severe side effects, or who cannot be maintained on severe side effects, or who cannot be maintained on low-dose steroids, azathioprine (1.5 mg/kg/day, up to low-dose steroids, azathioprine (1.5 mg/kg/day, up to 100 mg/day) may be added, with frequent monitoring 100 mg/day) may be added, with frequent monitoring for bone marrow suppression. for bone marrow suppression.

Hepatoprotectors

Heptral (tabl.- 0.4 g, amp.- 0.4 g) 1-2 tabl. 3 Heptral (tabl.- 0.4 g, amp.- 0.4 g) 1-2 tabl. 3 times a day (20-25 mg/kg/day)times a day (20-25 mg/kg/day)

Ursophalk (cap. 250 mg) 8-10 mg/kg/day Ursophalk (cap. 250 mg) 8-10 mg/kg/day Essentiale (cap., amp.) 1-2 cap. 3 times a dayEssentiale (cap., amp.) 1-2 cap. 3 times a day Carsil (dragee) 1-2 dragee 3 times a dayCarsil (dragee) 1-2 dragee 3 times a day Hepabene 1-2 dragee 3 times a dayHepabene 1-2 dragee 3 times a day Thiotriazolinum 1 tabl. 3 times a dayThiotriazolinum 1 tabl. 3 times a day Chophytol 1-2 tabl. 3 times a dayChophytol 1-2 tabl. 3 times a day

Antioxidants (aevitum, tocopheroli acetatis)Antioxidants (aevitum, tocopheroli acetatis) Enterosortion (enterosgel)Enterosortion (enterosgel) Probiotics (linex, bifiform, bactisuptil) Probiotics (linex, bifiform, bactisuptil)