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10.3 Disorders of the Liver and Billiary Tract

Table of Contents

10.3.1 Hepatitis

This is the term referring to inflammation of the liver, which may result from various causes, both infectious i.e. viral, bacterial, fungal, and parasitic organisms and noninfectious e.g. alcohol, drugs, autoimmune and metabolic diseases; this section focuses on viral hepatitis and its sequels.

10.3.1.1 Acute Viral Hepatitis

It is a systemic infection predominantly affecting the liver caused hepatotropic viral agents namely Hepatitis A virus (HAV), Hepatitis B virus (HBV), Hepatitis C virus (HCV),HBV – associated delta agent or Hepatitis D virus (HDV), and Hepatitis E virus (HEV);in most cases leads to a self limiting disease but can take a fulminant course and lead to hepatic failure.

Diagnostic Criteria

  • Fever, anorexia, malaise, jaundice and abdominal pain
  • Enlarged and tender liver
  • Altered consciousness, coma (hepatic encephalopathy), and bleeding stigmata (in fulminant cases). Plus
  • Serological evidence of specific viral antigen/ core antibody tests (HBc IgM or HBc IgG); and biochemical alteration of liver tranaminases (ALT, AST).

Treatment

  • There is no specific treatment to alter the course of acute viral hepatitis.
  • Supportive management including hydration, feeding, control fever and pain if present is required.
  • Fulminant cases may require specific antiviral medications

Note: Refer all suspected and confirmed cases to next level of care with adequate expertise and facility for proper management and disposal.

10.3.1.2. Chronic viral Hepatitis

This is a chronic inflammatory reaction that on going beyond 6months from the acute infection. Most common causative agents are HBV, HCV, and HDV which potentially leads to liver fibrosis, cirrhosis and portal hypertension, hepatocellular carcinoma and hepatic failure.

Diagnostic Criteria

  • Usually asymptomatic
  • Right upper quadrant abdominal pains.
  • Fatigue, malaise, anorexia, low grade fever; jaundice is frequent in severe disease.
  • Ascites, variceal bleeding, encephalopathy, coagulopathy, and hypersplenism.
  • Uticaria, athritis, vasculitis, polyneuropathy, glomerulonephritis, thyroditis PLUS
  • Serological evidence of specific viral antigen/ core antibodies and quantitative PCR assays.

Pharmacological Treatment

HBV

A: Tenofovir (PO) 300mg once daily for life

OR

S: Entecavir (PO) 0.5mg–1mg once daily for life

OR

A: Lamuvidine (PO) 100mg once daily for life

HCV

S: Ledpasvir 90mg in divided doses (PO) for 12–24 weeks

Plus

S: Sufosbuvir 400mg in divided doses (PO) for 12–24 weeks

Plus

S: Ribavirin 600mg–1000mg in divided doses (PO) for 12–24 weeks

Note: Refer cases to the next level care with adequate expertise and facility for proper management

10.3.2 Portal Hypertension

This is high blood pressure in the hepatic portal system which includes the portal veins and its branches which drains from most of the intestines to the liver. It is indicated when the hepatic venous pressure gradient exceeds 7mmHg, while liver cirrhosis remains the most common cause which in our local setting is commonly caused by chronic viral hepatitis followed by heavy alcohol intake.

Diagnostic Criteria

  • Ascites, Splenomegaly
  • Esophageal varices, and hematemesis
  • Swollen veins of the anterior abdomen(caput medusa) and hemorrhoids PLUS
  • Radiological evidence of shrunken liver, with typical features of cirrhosis.

Pharmacological Treatment

Ascites

C: Spironolactone 50mg – 400mg (PO) once daily incrementally till ascites resolves

AND

B: Furosemide 40mg–160 mg (PO) once daily or in divided doses incrementally till ascites resolves

AND

A: Propranolol 40mg–160mg (PO) once daily incrementally until portal venous pressure is stabilizes to normal values

OR

C: Carvedilol 6.25mg–12.5mg (PO) once daily, incrementally till portal pressures stabilizes to normal

AND

S: Albumin 25% infusion (IV) – in refractory ascites and large volume parecentecis. Give 25g stat, repeat at 15–30min interval at max dose of 250g/48 hourly

Bleeding Esophageal Varices

S: Octreotide Inj (SC) 50 µg–100 µg 8 hourly for 3 days

AND

S: Band ligation of beeding esophageal varices (EVL); 3 – 6 shoots per session.

OR

S: Inj sclerotherapy (Histo Acryl Glue Inj 5%; Ethanolamine oleate 5%); given 2mls -5mls per varix up to 20mls per session.

AND

Blood transfusion (PRBC, PLT concentrates and FFP) as appropriate.

Hepatic Encephalopathy

S: L-Ornithine L-Aspartate (Herpemez) granules (PO) 9g/day in divided dose for 4–12 weeks

AND

C: Lactulose 20mls (PO) 12 hourly for bowel ceasing

AND

B: Metronidazole (IV) 400mg 8 hourly for 7days

AND

A: Ceftriaxone (IV) 1g 12 hourly for 7days (if evidence of spontaneous bacterial peritonitis)

Fluid deficit correction and electrolytes replacements as appropriate

Hepatorenal Syndrome

S: Terlipressin (IV) 0.5–2mg 6 hourly for 14 days

Plus

S: Albumin 5% albumin infusion (Dose 1g/kg up to 100g/day) Plus fluid deficit correction.

10.3.3 Cholestatic Jaundice

Cholestasis is a pathologic state of reduced bile formation or flow which can be hepatocellular (Intrahepatic), where an impairment of bile formation occurs or ductular (extra hepatic), where impedance to bile flow occurs after it is formed. Intrahepatic causes of cholestasis include viral hepatitis, alcohol, primary biliary cirrhosis, drug toxicity, Hodgkin’s lymphoma and pregnancy. Extrahepatic causes include choledocholithiasis, carcinoma, and ascariasis of the biliary tree.

Diagnostic criteria

  • Jaundice,
  • Dark urine,
  • Pale stools, and
  • Generalized body itching/pruritis. PLUS
  • Laboratory evidence of elevated serum levels of total bilirubin, direct bilirubin, alkaline phosphatase, gamma-glutamyl transferase, and transaminanses. WITH
  • Supporting radiological evidence of dilated intra or extra hepatic biliary radicles.

Pharmacological Treatment Definitive treatment:

  • Identify and treat specific cause

Supportive treatment:

S: Cholestyramine (PO) 4–16gm/day

OR

S: Ursodeoxycholic acid (PO) 20–30 mg/kg/day

Surgical intervention is indicated for extra hepatic cholestasis.

Note

Refer cases to the next level of care with adequate expertise and facility for proper evaluation and management of prolonged and unresponsive cholestatic jaundice.

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