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Liver Diseases

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Treatment of a Patient with HBeAg-negative Chronic Hepatitis B

Ian PUN, MD, Family Physician, Scarborough, Ontario with help from Anthony Vu, 4th Year student, University of Toronto undergraduate life science, Rob Myers, MD, Associate Professor of Medicine, Hepatologist, and Director of the Viral Hepatitis Clinic at the University of Calgary, Calgary, AB.

Abstract
It is estimated that there are 350 million world wide carriers of the hepatitis B virus, mostly coming from Asia (Lai et al., 2005). With immigration of Chinese into Western countries, hepatitis B is now becoming established in countries where it was previously uncommon. Chronic hepatitis B infection is a prevalent disease especially in the Toronto and Vancouver areas where most Asians live. Fortunately, over the past decade effective anti-viral treatments have become available. Chronic hepatitis B is mostly an asymptomatic disease, therefore, serological and imaging tests should be used to identify, follow and treat those considered high risk.
Key Words: HBV DNA (hepatitis B DNA), cirrhosis, anti-viral tenofovir, FibroScan.

Related Terms: Liver Diseases, cirrhosis, HBV DNA (hepatitis B DNA), anti-viral tenofovir, FibroScan

Management of Patients with Ascites

Karen L. Krok, MD, Assistant Professor of Medicine, Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
Andrés Cárdenas, MD, MMSc, Institut de Malalties Digestives i Metaboliques, Hospital Clinic, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.

Ascites is the accumulation of free fluid in the peritoneal cavity. In over 80% of cases, it is a result of cirrhosis. Ascites develops in 60% of patients with cirrhosis within 10 years of the diagnosis of cirrhosis, and its development marks a turning point in the natural history of the disease. The mainstays of treatment are twofold: sodium restriction and diuretics. The development of spontaneous bacterial peritonitis is another ominous sign that requires indefinite antibiotic prophylaxis to prevent future infections. A referral to a transplant centre is essential once ascites or spontaneous bacterial peritonitis develop.
Key words: ascites, portal hypertension, cirrhosis, spontaneous bacterial peritonitis, paracentesis, albumin infusion.

Related Terms: Liver Diseases, albumin infusion, ascites, cirrhosis, paracentesis, portal hypertension, spontaneous bacterial peritonitis

The Aging Liver

David G. Le Couteur, MD, PhD, Professor of Geriatric Medicine, Centre for Education and Research on Ageing and ANZAC Research Institute, University of Sydney and Concord RG Hospital, Sydney, Australia.
Arthur Everitt, PhD, Associate Professor, Centre for Education and Research on Ageing, and Department of Physiology, University of Sydney, Sydney, Australia.
Michel Lebel, PhD, Associate Professor, Centre de Recherche en Cancérologie de l’Université Laval, Hôpital Hôtel-Dieu de Québec, Québec, PQ.

The liver undergoes substantial changes in structure and function in old age. There are age-related changes in liver mass, blood flow, and hepatocyte and sinusoidal cell morphology. These changes are associated with a significant impairment of many hepatic metabolic and detoxification activities, with implications for systemic aging and age-related disease. For example, the age-related impairment of the hepatic metabolism of lipoproteins predisposes to cardiovascular disease. The age-related decline in the hepatic clearance of most medications causes an increased risk of adverse drug reactions. Many of the beneficial effects of caloric restriction and caloric restriction mimetics such as resveratrol are mediated by their effects on the liver. Increasingly, the liver is seen as having a key role in aging.
Key words: liver, aging, hepatocyte, liver sinusoid, drug metabolism.

Related Terms: Liver Diseases, aging, drug metabolism, hepatocyte, liver, liver sinusoid

Managing Abnormal Liver Blood Tests in Older People

James Frith, MB ChB, MRCP, Clinical Research Associate, Biomedical Research Centre in Ageing—Liver Theme and Institute for Ageing and Health, Newcastle University, Newcastle, UK.
Julia L. Newton PhD, FRCP, Professor, Biomedical Research Centre in Ageing—Liver Theme and Institute for Ageing and Health, Newcastle University, Newcastle, UK.

The prevalence of chronic liver disease is increasing in older people. The presentation of these diseases is often asymptomatic or nonspecific, so they easily go undiagnosed. Investigating the older person who has abnormal liver function is important in primary care, and the same vigilance should be applied to an older person as to a young person, even with mild abnormalities. Referral for specialist opinion in appropriate older people provides important diagnostic and prognostic information. Treatment options are similar for all age groups. Morbidity and age-adjusted mortality are often more severe in older people; therefore, early diagnosis and intervention are important.
Key words: chronic liver disease, aging, liver function tests.

Related Terms: Liver Diseases, aging, chronic liver disease, liver function tests

Gallstone Diseases in the Older Adult

Simon Yang, MD, Division of General Surgery, University of Toronto, Toronto, ON.
Calvin Law, MD, MPH, FRCS, Division of General Surgery, University of Toronto; Sunnybrook Health Sciences Centre, Toronto, ON.

The prevalence of gallstones has been increasing among the aging population. Common sequelae of cholelithiasis include asymptomatic gallstones, biliary colic, acute cholecystitis, choledocholithiasis, cholangitis, and gallstone pancreatitis. Among individuals over age 65, gallstone diseases represent an important cause of recurrent abdominal symptoms and surgical admissions. As advanced age is correlated with increased mortality and morbidity in complicated gallstone disease, timely diagnosis and appropriate management are essential to improving disease outcomes.
Key words: older adults, gallstones, cholecystitis, choledocholithiasis.

Related Terms: Liver Diseases, cholecystitis, choledocholithiasis, gallstones, older adults

Liver Disease: Learning and Leading

When I started out in medicine, differentiating between the various causes of hepatobiliary disease was extraordinarily difficult. It is not easy now (what in medicine ever is?), but modern imaging techniques have certainly helped us dramatically. As well, new discoveries have made more disorders treatable, which is wonderful news for our patients. However, for clinicians that means learning more about liver disease so that we can effectively manage our patients’ conditions. The University of Toronto, my home base, has long been a leader in the study of liver disease. One of my clinical teachers, Victor Feinman, was a leader in the field of liver disease and in particular the study of hepatitis B. One of my contemporaries, Jenny Heathcote, is a world leader in the study of primary biliary cirrhosis. Thus I feel I have a personal tie to this issue’s focus on hepatobiliary disease.

At times it seems like almost all of our older patients have gallstones. Which ones require treatment, and which can be managed conservatively? Our continuing medical education article, “Gallstone Diseases in the Older Adult” by Dr. Simon Yang and Dr. Calvin Law should help us tackle how to manage these patients. With so many routine blood tests being performed these days, it is inevitable that we will all come across patients who have abnormal liver tests. The article “Managing Abnormal Liver Blood Tests in Older People” by Drs. James Frith and Julia Newton should help us with this common problem. For those of us in internal medicine, an expanding belly is much more likely to signify ascites than pregnancy (especially for us geriatricians!). Diagnosis is usually much easier than management, so one of our focus articles is on this topic. I am sure you will find the article “Management of Patients with Ascites” by Dr. Karen Krok and Dr. Andrés Cardénas very useful. Our Biology of Aging column this month is related to our focus theme as well, namely “The Aging Liver” by Dr. David le Couteur, Dr. Arthur Everitt, and Dr. Michel Lebel.

Of course, we have our usual collection of excellent articles on varied topics. Our Cardiovascular Disease column is on “Functional Gains for Stroke Survivors in Response to Functional Electrical Stimulation” by Dr. Janis Daly. The issue of behavioural disturbances in demential is so prevalent, so concerning, and so difficult to manage that we like to revisit the topic on a regular basis, and our Dementia column this month is entitled “Approach to the Management of Dementia-Related Behavioural Problems” by Dr. Michael Passmore. Our Caregiving column this month is on the “Clinician’s Role in the Documentation of Elder Mistreatment” by Dr. Elizabeth Pham and Dr. Solomon Liao. I serve on a committee with some police officers who are experts in elder mistreatment, and their stories are very frightening. Our final article on Technology in Medicine is very patient-focused, namely “Information Communication Technology–Enabled Health Care for Older Adults at Home” by Dr. Simon Brownsell, Dr. Elaine Biddiss, and Dr. Mark Hawley.

Enjoy this issue,
Barry Goldlist

Related Terms: Liver Diseases, liver disease

The Impact of Aging on the Liver

David Stell, PhD, FRCS(Gen) and William J. Wall, MD, FRCS(C), Department of Surgery and Multi-Organ Transplant Program, London Health Sciences Centre, London, ON.

The process of aging does not produce changes in the liver that can be described as pathological. The major age-related alterations are a reduction in liver mass and a reduction in total blood flow, neither of which interferes with the liver's normal homeostatic functions. In spite of the liver's resilience, however, the aged liver is more vulnerable to injury from toxins, viruses and ischemia, and its capacity to regenerate is slowed. There also is a decline in liver enzymes with aging that affects metabolic clearance of drugs, a finding that has implications for drug dosing in the elderly.
Key words: liver, aging, function, metabolism, injury.

Related Terms: Liver Diseases, aging, function, injury, liver, metabolism

Portal Hypertensive Complications of Liver Cirrhosis

 

Dr. Faisal M. Sanai, MD, ABIM, Hepatology Fellow, London Health Sciences Centre, University of Western Ontario, London, ON.
Dr. Cameron N. Ghent, MD, FRCP(C), Consultant Hepatologist, Adjunct Professor, University of Western Ontario, London Health Sciences Centre, London, ON.

Cirrhosis of the liver is highlighted essentially by its portal hypertensive complications. The incidence of these complications in elderly cirrhotic individuals has been rising due to better management of this disease in the younger population. Moreover, improved diagnostic techniques have further contributed to this rising incidence. Early recognition of the cirrhotic complications coupled with aggressive intervention has led to reductions in mortality. Special consideration is given to elderly patients in view of the higher incidence of comorbidity and the variability in disease presentation. We present here a review of cirrhosis and its sequelae in this distinct population group with emphasis on recent trends towards diagnosis and management.
Key words: cirrhosis, portal hypertension, ascites, liver.

Related Terms: Liver Diseases, ascites, cirrhosis, liver, portal hypertension

Liver Transplantation in the Elderly: Indications and Outcomes

 

Douglas Thorburn, MD, MRCP and Paul J. Marotta, MD, FRCPC, Multi-Organ Transplant Unit, London Health Sciences Centre, University of Western Ontario, London, ON.

Liver transplantation improves survival for selected patients with chronic liver disease, fulminant hepatic failure and hepatocellular carcinoma. There is no absolute upper age limit for liver transplantation and the proportion of patients undergoing liver transplantation who are older than 60 years is increasing. Although the indications for liver transplantation in elderly patients do not differ from those in younger patients, the prevalence of comorbidities that are contraindications to liver transplantation are higher among the elderly. Outcomes after transplantation for selected patients over 60 years of age with Child-Pugh class B cirrhosis who are well nourished and at home are comparable to those for younger patients.
Key words: liver transplantation, fulminant hepatic failure, hepatocellular carcinoma, indications.

Related Terms: Liver Diseases, fulminant hepatic failure, hepatocellular carcinoma, indications, liver transplantation
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