192255260 pendekatan klinis pasien dengan penyakit hati 2010

Pe n d e k a ta n k lin is p a s ie n d e n g a n p e n ya k it h e p a to b ilie r

Blok hepato-bilierFK UNTAR – RSSW

SMF Ilmu Penyakit DalamDr. Syarif Hidayat, SpPD

p e n d a h u lu a n• Diagnosis penyakit Hepato-Bilier sekitar 50 %

sudah dapat ditegakkan berdasarkan anamnesis yang akurat, dan pemeriksaan fisik.

• Pemeriksaan laboratorium , dan Pemeriksaan penunjang lainnya dapat membantu diagnosis penyakit hepatobiler. Menjadi lebih jelas.

• Pemeriksaan biopsi hati merupakan "gold standard" untuk mengevaluasi kelainan di hati .

• Pemeriksaan biopsi hati sedikit penggunaannya untuk diagnosis.

S truktur Ha ti da n fung s inya

• Hati merupakan organ terbesar di tubuh dengan berat 1 – 1,5 kg &1,5 - 2.5 % seluruh berat badan.

• Ukuran dan bentuk bervariasi.

Fu n g s i h a ti

Blo o d s u p p ly to th e liv e r

R e g ula tio n o f b lo o d nutrie nts .• Blood sugar levels are regulated by the

hepatocytes.• Salts as above can affect the osmotic

concentration of the blood and are controlled for the same reason.

• Amino acids as with sugar can affect the osmotic concentration of blood.

• Vitamins & Minerals diet is crucial for enzyme function, skeletal development, vision along with a variety of other essential functions.

S to re d nutrie nts .

P la s m a pro te ins a nd c ho le s te ro l s ynthe s is .

• The liver has a role in the synthesis of plasma proteins (blood proteins). Such proteins have a wide variety of functions

• Cholesterol is also synthesised in the liver and has a variety of functions including being a component of cell membranes.

De to x ific a tio n

B re a kdo w n o f ha e m o g lo b in a nd b ile fo rm a tio n

The evaluation of the jaundiced patient. CT, computedtomography; EUS, endoscopic ultrasound; ERCP, endoscopicretrograde cholangiopancreatography; MRCP, magnetic resonancecholangiopancreatography; MRI, magnetic resonance imaging;PTC, percutaneous transhepatic cholangiography.

C o m m o n s ym pto m s a nd s ig ns in live r dis e a s e .

Some Major Features of Liver Disease Feature Description

Jaundice A yellowish discoloration of the skin and whites of the eyes

Hepatomegaly Liver enlargementAscites Fluid in the abdominal cavityHepatic encephalopathy Confusion caused by deterioration of brain function due

to buildup of toxic substances in the blood

Gastrointestinal bleeding Bleeding from large, tortuous veins (varices) in the esophagus and stomach

Portal hypertension Abnormally high blood pressure in the veins that bring blood from the intestine to the liver (branches of the portal vein)

Skin symptoms Spiderlike blood vessels on the face and chest Red palms Bright red complexion Itching

Some Major Features of Liver Disease Feature Description

Blood abnormalities Decreased number of red blood cells (anemia)Decreased number of white blood cells (leukopenia)Decreased number of platelets (thrombocytopenia)A tendency to bleed (coagulopathy)

Hormonal abnormalities High levels of insulin Some Trade Names HUMULINNOVOLINbut a poor response to it, leading to high blood sugar levels Cessation of menstrual periods and decreased fertility in women Erectile dysfunction and feminization in men

Heart and blood vessel abnormalities

Increased heart rate and amount of blood pumped Low blood pressure (hypotension)

General symptoms FatigueWeaknessWeight lossPoor appetiteNauseaFeverAbdominal pain

Ro u tin e b io c h e m ic a l te s ts in th e p a tie n t w ith id e a liz e d h e p a to b ilia ry d is e a s e

Test Hepatocellular necrosis

Cholestasis Infiltrative process

Aminotransferase ++ to +++ 0 to + 0 to +

Alkaline phosphatase

0 to + ++ to +++ ++ to +++

Total/direct bilirubin

0 to +++ 0 to +++ 0 to +

Prothrombin time Prolonged Prolonged; responsive to vitamin K

Normal

Albumin Decreased in chronic disorders

Normal Normal

0, normal; + to +++, increasing degrees of abnormality.

No n h e p a tic c a u s e s o f a b n o rm a l liv e r c h e m is trie s

Test Nonhepatic causes Discriminating testsAlbumin Protein-losing enteropathy

Nephrotic syndromeMalnutritionCongestive heart failure

Serum globulins, a1-antitrypsin clearanceUrinalysis, 24-h urinary proteinClinical settingClinical setting

Alkaline phosphatase

Bone diseasePregnancyMalignant disease

GGT, SLAP, 5′-NTGGT, 5′-NTAlkaline phosphatase electrophoresis

Serum aspartate aminotransferase

Myocardial infarctionMuscle disorders

MB-CPKCreatine kinase, aldolase

No n h e p a tic c a u s e s o f a b n o rm a l liv e r c h e m is trie s

Test Nonhepatic causes Discriminating testsBilirubin Hemolysis

SepsisIneffective erythropoiesis

“Shunt” hyperbilirubinemia

Reticulocyte count, peripheral smear, urine bilirubinClinical setting, culturesPeripheral smear, urine bilirubin, hemoglobinelectrophoresis, bone marrow examinationClinical setting

GGT Alcohol, drugs History

Ferritin Systemic disease, chronic inflammation

Clinical setting

Prothrombin time

Antibiotic and anticoagulant use, steatorrhea,dietary deficiency of vitamin K (rare)

Response to vitamin K, clinical setting

GGT, g-glutamyltransferase; MB-CPK, MB isoenzyme of creatine phosphokinase; 5′-NT, 5′-nucleotidase; SLAP, serum leucine aminopeptidase.

C AUS E S OF MIL D AL T OR AS T E L E V AT ION S Hepatic: Predominantly ALT• Chronic hepatitis C• Chronic hepatitis B• Acute viral hepatitis (A to E,

EBV, CMV)• Steatosis/steatohepatitis• Hemochromatosis• Medications/toxins• Autoimmune hepatitis• α1-antitrypsin deficiency• Wilson's disease• Celiac disease

Hepatic: Predominantly AST• Alcohol-related liver injury• Steatosis/steatohepatitis• Cirrhosis

Nonhepatic• Hemolysis• Myopathy• Thyroid disease• Strenuous exercise• Macro-AST

Adapted from Green R, Flamm S. AGA technical review on the evaluation of liver chemistry tests.Gastroenterology. 2002; 123:1367-1384.

C AU S E S O F AC U T E HE P AT IT IS

C la s s ific a tio n o f J a undic e• Unconjugated hyperbilirubinemia (predominant indirect-

acting bilirubin)

C la s s ific a tio n o f J a undic e

• Conjugated hyperbilirubinemia (predominant direct-acting bilirubin)

Adapted, with permission, from Tierney LM et al. Current Medical Diagnosis & Treatment, 44th ed. New York: McGraw-Hill, 2005:630.

Differential diagnosis of the jaundiced patient.

C L IN IC AL F E AT UR E S AN D L AB AB N OR MAIT IE S IN C IR R HOS IS

* Muehrcke’s nails: white bands separated by normal appearing nails; Terry’s nail: proximal part two third of the nail is white while the distal third is normal color. Both of these are nonspecific and are tought to result from periods of hypoalbuminemia.** Cruveilhier Baumgarten’s sign: venous hum heard best over the epigastrium due to portosystemic collaterals between the portal vein and umbilical vein.

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