Liver and its clinical

implications

Aziz .H.Pahadwala
1st MDS
ORAL AND
MAXILLOFACIAL
SURGERY
15-7-2014

Contents
1.
2.
3.
4.
5.
6.

Introduction.
Anatomy of liver.
Functions of liver.
Liver function test.
Liver diseases.
Dental management of patients
with liver disease.
7. Risk assessment in liver disease.
8. Conclusion.
9. References.

Introduction
o
o
o

Liver is the largest internal organ in

the human body.
It approximately weighs 4% of total
body weight.
Liver is mainly responsible for
metabolism, synthesis, digestion,
hemostasis and excretion.

Any disorder of liver will lead to imbalance

in the above mentioned functions.
As an oral and maxillofacial surgeon, it is
very much essential to have a knowledge
of anatomy, physiology, diseases and
modifications of dental management.

Anatomy of
liver

1. The liver lies mostly under cover

of the thoracic bony cage and is
covered by the diaphragm.
2. On the right side, it extends
superior to the inferior border of
the lung and causes dullness
there on percussion.
3. The liver moves with respiration,
and its position varies with the
diaphragm and with body type.

 Situated

in
the right
upper
quadrant of
the
abdominal
cavity.
Shape-- like a
cone,
Colour-- dark
reddish-brown
Weight--

The liver
occupies the
whole of the
right
hypochondriu
m, the greater
part of
epigastrium
and extends
into left
hypochondriu
m.

Lobes
Major:
Left
Right
Minor:
Caudate
Quadrate

Gallbladder
Thin-walled

green
muscular sac
On the inferior
surface of the liver
Stores bile that is
not immediately
needed for
digestion
When the
muscular wall of
the gallbladder
contracts bile is
expelled into the
bile duct

Blood supply

There are 2 sources of blood supply

1. Portal vein
2. Hepatic artery

Portal vein supplies 80% of the nutrient

rich blood.

Hepatic artery, a branch of the celiac

trunk supplies oxygen rich blood

Venous drainage
Right
hepati
c vein

Hepatic
Sinusoids

Middle
Hepati
c vein

Left
hepati
c vein

Central vein
Interlobular
veins
Hepatic veins
Inferior
Venacava

Nerve Supply

The

liver receives its nerve

supply from the hepatic plexus
which contains both sympathetic
and parasympathetic fibres.

Functions of liver
Synthesis
Regulation
Conversion
Processing
Metabolism
Storage
Excretion

Functions
Synthesis-

1) Production of bile, which helps

carry away waste and break down
fats in the small intestine during
digestion
2) Production of certain proteins for
blood plasma (protein C, protein S)
3) Production of cholesterol and special
proteins to help carry fats through
the body

4) Production of coagulation

factors such as I(fibrinogen), II

(prothrombin), V, VII, IX, X and
XI, as well as protein C protein S
and antithrombin
5) Kupffer cells (Macrophages )
filter out the antigens and thus
helps in maintaining healthy
immunity.

 Regulation-

1) The liver regulates most

chemical levels in the blood and
excretes a product called bile,
which helps carry away waste
products from the liver
2) Regulation of blood levels of amino
acids, which forms the building blocks
of proteins

 Conversion-

1) Conversion of excess glucose

into glycogen for storage
(glycogen can later be converted
back to glucose for energy)
2) Conversion of ammonia to urea (urea is
an end product of protein metabolism and
is excreted in the urine)

Processing

Breaks down RBCs

Iron,Bile.

Heme

Metabolism

It

metabolizes the nutrients and

drugs and breaks them into the
forms that are easier to use for
the rest of the body.

Storage

Iron
Copper
Vit A
Vit D
Vit B12
Vit K

Excretion
Drugs

including sulfonamides,
penicillin, ampicillin and
erythromycin

Hormones

including thyroxine,
estrogen, cortisol and
aldosterone

What is meant by a function

test!!!
A

number of laboratory tests

performed to assess the
functional status of an organ is
termed as FUNCTION TEST
( LFT,RFT,PFT)

Liver

is an important organ
where assessment of its overall
function is determined by

LIVER FUNCTION TESTS

In

view of multiplicity and complexity

of the liver functions, it is obvious
that no single test can establish the
disturbance in liver function

Thus

a group of tests are required to

diagnose, to assess the severity of
damage, to judge prognosis and to
evaluate therapy

1. Tests for assessment of

bile
2. Serum enzyme assays
3. Tests for metabolic
functions
4. Immunologic tests

Tests for
assessment of bile
Bilirubin

pigment can be detected in

serum, faeces, and urine

Normal

value :-

Total bilirubin ---- 0.3 1.1mg/dl

(conjugated and unconjugated)
Direct

bilirubin---- 0.1 0.4mg/dl

Indirect

bilirubin---- 0.2 0.7mg/dl

Bilirubin elevated in
Congenital Bilirubinemia
Conjugated Bilirubinemia
Hepato-biliary Diseases
Cholestatic / Obstructive
Diseases
Co-infection with HIV, HBV
Alcohol & Drug Abuse

Serum enzyme
assays
1 Transaminases
Serum aspartate transaminase (AST
OR SGOT) Serum Glutamic
Oxaloacetic Transaminase(SGOT) Normal value :- 10- 40U/ml.
Serum alanine transaminase (ALT
OR SGPT) Serum Glutamic Pyruvate
Transaminase(SGPT) - Normal value
:- 6-35 mU/ml.

Serum enzyme
assays
2 Alkaline phosphatase
Normal value :- 1.5 4.5 U/ml

Serum enzyme elevated in

Transaminases ( SGOT/SGPT)
Hepatitis, Hepatocellular
Damage

Alkaline phosphatase
Cholestatic / Biliary Obstruction

TYPES OF LIVER DISEASES

A. Parenchymal / Hepatocellular

B. Cholestatic / Obstructive

A. Parenchymal /
Hepatocellular

Acute Viral Hepatitis

Chronic Viral Hepatitis
Chronic Alcohol Cirrhosis
B. Cholestatic / Obstructive

Extra-hepatic Obstructive
Primary Biliary Cirrhosis

CAUSES OF LIVER
DISEASES
Infectious, Non-infectious
Alcohol
Drugs
Genetics
Stone
Tumour
Cyst

HEPATITIS B VIRUS (HBV)

HBV

has been found in blood, saliva,

semen, and vaginal secretions and
can be transmitted through mucous
membranes and breaks in the skin.

HBV is also transferred from carrier

mothers to their babies.

HBV

has a long incubation period. It

replicates in the liver and remains in
the serum for relatively long periods,
allowing transmission of the virus.

Clinical
manifestations(contd)
Clinically,

the disease closely

resembles hepatitis A, but the
incubation period is much longer (1 to
6 months).

Signs and symptoms of hepatitis B

may be insidious and variable. Fever
and respiratory symptoms are rare;
some patients have arthralgias and
rashes.

The

patient may have loss of appetite,

dyspepsia, abdominal pain, generalized
aching, malaise, and weakness.

Assessment and Diagnostic

Findings
HBV is a DNA virus composed of the
following antigenic particles:
HBcAghepatitis B core antigen (antigenic
material in an inner core)
HBsAghepatitis B surface antigen
(antigenic material on surface of HBV)
HBeAgan independent protein circulating
in the blood
HBxAggene product of X gene of
HBV/DNA

 HBsAg

appears in the circulation

in 80% to 90% of infected
patients 1 to 10 weeks after
exposure to HBV and 2 to 8
weeks before the onset of
symptoms or an increase in
transferase (transaminase)
levels

Patients

with HBsAg that persists

for 6 or more months after acute

DRUG-INDUCED HEPATITIS
Drug-induced

hepatitis is responsible for 20%

to 25% of cases of acute hepatic failure.

Manifestations

of sensitivity to a medication
may occur on the first day of its use or not
until several months later, depending on the
medication.

Usually

the onset is abrupt, with chills, fever,

rash, pruritus, arthralgia, anorexia, and
nausea. Later, there may be jaundice and
dark urine and an enlarged and tender liver.
39

 Whatever

may be the reason for

liver affection the end result is-

Blood

coagulation is affected
Drug metabolism is disturbed
Increased destruction of RBCs
Immune system is affected

Laboratory investigations

Liver function
tests

Test

Normal range

Albumin

3.5 5.5g/dl

Bilirubin

0.3 1.1mg/dl

Unconjugated B (Indirect)

0.2 0.7mg/dl

Conjugated B (Direct)

0.1 0.4mg/dl

SGOT

10- 40U/ml

SGPT

5 35U/ml

Alkaline phosphatase

10 30 U/ml

Bleeding assessment tests

Tests

Results

Prothrombin time

11-13 seconds

Partial Thromboplastin
time
Bleeding time

60-70 seconds

Clotting time

4 9 mins

International normalized
ratio (INR)

0.8-1.1

2 5 mins

 Prothrombin

time and partial

thromboplastin time reflect the
presence and activities of
various clotting factors. (factors
I, II, V, VII, and X)

Prothrombin

time is dependent
upon both hepatic synthesis of
clotting factors and intestinal
uptake of vitamin K (fat soluble
vitamin)

 The

prothrombin time is also

prolonged by anticoagulant,
such as heparin.

Another test, the activated

partial thromboplastin time
(APTT) test, is a better test to
find out if the right dose of
heparin is being used

Prothrombin time
Prolonged :
vitamin K deficiency
(malnutrition,
malabsorption, antibiotics)
massive transfusion
congenital disease
liver disease
warfarin

THE INTERNATIONAL NORMALIZED

RATIO (INR)

Since laboratories use thromboplastins

produced by several methods and
originating from different sources, PTs
performed on the same specimen in
different labs vary significantly.
To standardize the results, the World
Health Organization (WHO) devised a
formula that uses the ratio of the patients
PT results and the mean of the normal
range:
ISI
INR = [PT
/MNPT]
patient

THE INTERNATIONAL NORMALIZED RATIO

(INR)

Measures the speed of a particular pathway of

coagulation, comparing it to normal.

If

the INR is increased, it means it is taking

longer than usual for blood to clot.

The

INR will only be increased if the liver is so

damaged that synthesis of Vitamin Kdependent coagulation
factors( Prothrombin, Factor VII, Factor
IX, Factor X ) have been impaired.

It is very important to
normalize the INR before
operating on people with liver
problems.

It is usually done by
transfusion of blood plasma
containing the deficient factors .

 Hepatitis

B Immunoglobulin

(HBIG)
HBIG provides passive immunity
and is indicated along with
Hepatitis B vaccine in management
of
perinatal/occupational/sexual
exposures to Hepatitis B in
susceptible individuals. The dose of
HBIG in adults is 0.06 ml/kg and in
neonates/infants 0.5 ml.

Risk assessment in liver disease

Child-Turcotte-Pugh(CTP)Classificationof Severity ofLiver

Disease

Criterion

1 point
each

2 points
each

3 points
each

Ascites

none

Controlled Poorly
with
controlled
diuretics

Encephalopathy

none

Grade 1-2

Grade 3-4

Total bilirubin
<34
mol/L
Normal=17.1mol/ 0-2
L or 1.0mg/dl
mg/dl

34-50

>50

2-3 mg/dl

>3mg/dl

Albumin, g/l

>3.5g/dl

2.5-3.5
g/dl

<2.5 g/dl

INR

<1.7

1.7-2.2

>2.2

Patients with CTP class

A disease are estimated
to have a 10% mortality
rate after surgery. That
mortality rate increases
to 30-31% for CTP class
B and 76-82% for CTP
class C

Drugs metabolized mainly in the liver

Local anesthetics Lidocaine
Prilocaine
Mepivacaine
Bupivacaine
Analgesics

Aspirin
Ibuprofen
Codeine
Meperidine

Sedatives

Diazepam
Barbiturates

Antibiotics

Erythromycin
Clindamycin
Tetracycline

Antifungals

Ketoconazole
Fluconazole

Drugs contraindicated and alternatives in

patients with liver diseases
Contraindicated

Use instead

Analgesics

Aspirin, Codiene,
Mefenamic acid, Opioids,
Indomethacin

Paracetamol

Antibiotics

Tetracyclines, Erythromycin
Estolate, Talampicillin

Penicillin,
Erythromycin
stearate,
Amoxycillin

Anaethetics

Methohexitone,
Thiopentone, Halothane

Isoflurane,
Desflurane,
Sevoflurane,
Prilocaine, Articaine

Muscle
relaxants

Suxamethonium

Tubocurarine

Corticosteroids

Prednisone

Prednisolone

Control of haemorrhage
Consult Haematologist
It is very important to normalize the INR
before operating on people with liver
problems.
In addition to local measures like use of Ab
gel/ Surgicel, Tranexamic acid (Pause)

Vitamin K-10mg [phytomendione] IM

Inadequate response of PT:
Fresh Blood/ Plasma, Cryoprecipitate

Dental management of patients with

liver disease

Comprehensive and current medical and dental histories

Consultation with and/or referral to treating physician(s)
prior to dental treatment
Appropriate laboratory investigations
Complete blood count with differential (erythrocyte count,
leukocyte count, hemoglobin, hematocrit, platelet count)
Prothrombin time
Partial thromboplastin time
International normalized ratio
Bleeding time
Liver function tests
Others as needed

Judicious use or avoidance of prophylactic and therapeutic

dental medications that are metabolized in the liver and/or
impair hemostasis
Analgesics (acetaminophen, non-steroidal
anti-inflammatory agents, opioids)
Anesthetics
Local (amides)
General (halothane)
Antibiotics (ampicillin, tetracycline)
Antiplatelets (aspirin)
Sedatives (long-acting benzodiazepines, barbiturates)
Minimization of soft tissue trauma during dental procedures
Consideration of hospital setting for advanced surgical
procedures or severely coagulopathic patients

References
Grays Anatomy
DAVIDSONs
HARRISONs
CAWSON & SCULLY- Medical Problems in
Dentistry; 4th edition
K D TRIPATHI- Essentials of Medical
Pharmacology- 5th edition

THANK YOU