Gastrointestinal System
Gastrointestinal Disease
Intestinal Malabsorption
Inflammatory Bowel Disease
• Ulcerative Colitis
• Regional Enteritis
(Crohn’s Disease)
Hepatobiliary Disease
Liver Functions• Synthesis• Billirubin• Protein
–Globulins–Albumin–Prothrombin–Clotting Factors
Liver Functions• Metabolism
–Proteins–Carbohydrates–Lipids
• Biochemical Functions–Coagulation–Drug Metabolism
Liver
Disease
Bleeding Disorders
Digestive Problems
Infections
Metabolic Disorders
Altered Drug Metabolism
MEDICAL HISTORY
• Hepatitis
• Liver Disease
• Jaundice
• Hospitalization
• Transfusion
• Alcohol
Hepatic Disease
•Viral Hepatitis
•Cirrhosis
Liver Disease(Etiologic Factors)
• Toxins (alcohol, drugs)
• Infectious (viruses, bacteria, parasite)
• Bile Excretion Disturbance
• Tumors (Primary, Metastatic)
Cirrhosis(liver fibrosis)
•Laennec’s (Alcoholic)
•Biliary
•Post-Necrotic
HEPATOTOXINS
Hepatotoxins• Chloroform• Carbon Tetrachloride• Phosphorous• Mushrooms• Drugs
Alcoholism
Findings
• Jaundice
• Facial Erythema
• Spider Telangiectasia
• Parotid Enlargement
ICTERUS (Jaundice)
Hyperbilirubinemia
>2.5 mgm/100 ml
Normal < 1 mgm/100 ml
Alcoholism(Oral Complications)
• Poor oral hygiene• Periodontal disease• Xerostomia• Caries• Altered drug metabolism• Hemorrhage
Alcoholic Liver Disease(Lannec’s Cirrhosis)
•Bleeding Tendencies
•Drug Metabolism
Laboratory Tests(Liver Function)
• AST – (SGPT)• ALT – (SGOT)• Billirubin – (CB, UCB)• LDH• ALK PHOS
Acquired Hypoprothrombinemias
Vitamin K(Fat Soluble)
&Intestinal Flora
Liver
Prothrombin
Dental Management of the
Liver Failure Patient
Dental Management of Patient with Alcoholic Liver Disease
1. Detection bya. Historyb. Clinical examinationc. Repeated odor on breathd. Information from family members or friends
2. Referral or consultation with a physician toa. Verify historyb. Check current statusc. Check medicationsd. Check laboratory virusese. Obtain suggestions for management
Dental Management of Patient with Alcoholic Liver Disease (cont.)
3. Laboratory screening(if otherwise not available from physician)a. CBC with differentialb. AST, ALT c. Bleeding timed. Thrombin time
4. Minimize drugs metabolized by liver
Dental Management of Patient with Alcoholic Liver Disease (cont.)
5. If screening tests abnormal, for surgical procedure consider using a. Antifibrinolytic agentsb. Fresh frozen plasmac. Vitamin Kd. Platelets
Common Dental Drugs Metabolized Primarily by the Liver
• Local AnestheticsLidocaine (Xylocaine)Mepivacaine (Carbocaine)
• AnalgesicsAcetaminophen (Tylenox, Datril)Acelysalicylic acid (aspirin)Codeine
Meperidine (Demerol)
Common Dental Drugs Metabolized Primarily by Liver (cont.)
• Sedatives–Diazapam (Valium)–Barbiturates
•Chlordiazepoxide• Antibiotics
–Ampicillin–Tetracycline
Hepatitis
(Inflammation of the liver)
Hepatitis(Inflammation of the Liver)
• Primary
–Viral
–Drug Infected
–Toxic
• Secondary
–Mono
–Syphilis (2 °)
–TB
VIRAL HEPATITIS
Viral Hepatitis
A – HAV
B – HBV
C – Non-A, Non-B (Transfusion Related)
D – HDV (Delta)
E – Non-A, Non-B (Enteric Related)
Symptoms of Acute Hepatitis
• Prejaundiced phase–Loss of appetite, nausea, vomiting,
headache, fever, muscle soreness• Jaundiced phase
–Yellow eyes, white or grey stools, brownish urine
Clinical Stages - Hepatitis
•Incubation
•Prodromal
•Ictal
JAUNDICE(Ictal stage)
Ictal phase
• Hepatomegaly• RUQ tenderness• Dark urine• Grey stools• Jaundice
Hepatitis A
Hepatitis A
• Hides in RNA• Infectious/short incubation• Fecal-oral• 2-6 weeks• Rare sequelae• No carriers
DELTA AGENT
Delta Hepatitis(HDD)
• Variant form• Only active if HBSAg Present• Drug abusers more susceptible• More severe diseases• HB vaccine is effective
Non-A, Non-B Hepatitis
•Post Transfusion(HCV)
•Enterically Transmitted(HEV)
Non A – Non B Hepatitis
• Bloodborne (C)–Body fluids
–carrier
• Epidemic (E)
–Oro-fecal
–No carrier
Hepatitis C (HCV)
(Non A – Non B)
Hepatitis C Virus
• 35,000 – 180,000 Infections/yr. In US• 3,000 – 54,000 symptomatic (30%)• > 85% chronic infection• 24,500 – 126,000 chronic liver
disease/yr.• 8,000 – 10,000 deaths/yr.
Source: CDC
HEPATITIS BAND THE
HEALTH-CARE PROFESSIONAL
Hepatitis B Virus
• 140,000 – 320,000 infections/yr. in U.S.
• 70,000 – 160,000 symptomatic• 8,400 – 19,000 hospitalizations• 5,000 – 6,000 deaths in a year.
Source: CDC
HBV Infections(HCW)
• 1983- 17,000/yr(386/100,000)
• 1995- 400 (9.1/100,000)
General Population 50/100.000
Hepatitis B Infections
•USA - 3%
•Endemic Areas - 10-25%
–Southeast Asia
–Sub-Sahara Africa
Dental Management of the Hepatitis B Carrier
The Hepatitis-B Vaccine
Antibody Testing(HCW)
•Post-Immunization•30-60 days
CDC 1998
Responder with 10 SRU or less
(BOOSTER?)
PRECAUTIONS(Hepatitis B Patient)
???
Emergency Dental Care for Patient with Hepatitis
• Consult with patient’s physician to discuss patient’s status and planned dental treatment.
• If surgery is necessary, obtain preoperative prothrombin time and bleeding time, discuss abnormal results with physician
END-STAGELIVER DISEASE
LIVER DISEASE
End Stage
LIVER TRANSPLANT
LiverTransplant
The End
Medical History
LABORATORY TESTS
NON-A, NON-B HEPATITIS