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 by a. History b. Clinical examination c. Repeated odor on breath d. Information from family members or friends 2.Referral or consultation with a physician to a. Verify history b. Check current status c. Check medications d. Check laboratory viruses e. 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 differential b. AST, ALT c. Bleeding time d. 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 agents b. Fresh frozen plasma c. Vitamin K d. Platelets

Common Dental Drugs Metabolized Primarily by the Liver Local Anesthetics Lidocaine (Xylocaine) Mepivacaine (Carbocaine) Analgesics Acetaminophen (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

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 HB S Ag 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 B AND 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) ,000/yr (386/100,000) (9.1/100,000) General Population 50/

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 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-STAGE LIVER DISEASE

LIVER DISEASE End Stage LIVER TRANSPLANT

Liver Transplant

The End

Medical History

LABORATORY TESTS

NON-A, NON-B HEPATITIS