Medicine
The last 18 months have been an exciting time in the study of autoimmune rheumatic disease. Translational research based on a more detailed understanding of the aetiopathogenesis of disease is now leading to tangible results, with the introduction of new therapies for many of these diseases. This update highlights some of the major studies that have elucidated the pathogenesis of disease and have...
Antiphospholipid syndrome (APS) is characterized by venous and/or arterial thrombosis and recurrent fetal loss associated with persistent production of antiphospholipid antibodies (aPL), a group of autoantibodies directed against cell membrane phospholipids and their associated proteins. Additional features, particularly thrombocytopenia, are variably present. In the laboratory, the following types...
The new millennium has already proved to be an exciting time in hepatobiliary disease. In the developed world, the epidemic of obesity leading to metabolic syndrome has aroused academic and commercial interest in non-alcoholic fatty liver disease (NAFLD). This update covers some of the most recent developments in hepatology. Author Biography Rebecca Saich MRCP, Centre for Hepatology, Royal Free and...
Biluribin is a degradation product of haemoglobin that reaches the liver in its unconjugated form tightly bound to albumin and so is not excreted into urine. In the liver, it is taken up by active transport and conjugated within the hepatocytes to form bilirubin monoglucuronides and diglucuronides. These are water soluble, are excreted into bile and are further metabolized by gut bacteria into urobilinogen...
The new millennium has already proved to be an exciting time in hepatobiliary disease. In the developed world, the epidemic of obesity leading to metabolic syndrome has aroused academic and commercial interest in non-alcoholic fatty liver disease (NAFLD). This update covers some of the most recent developments in hepatology. Author Biography Rebecca Saich MRCP, Centre for Hepatology, Royal Free and...
Hepatitis C virus (HCV) infection is an important worldwide public health problem. Population prevalence data are unavailable for many countries, but it is believed that 2–3% of the world's population are persistently infected with HCV. In some countries in the Middle East, particularly Egypt, the prevalence is as high as 14%. Worldwide, up to 170 million individuals may be infected, and are at risk...
Pyogenic liver abscesses are common in tropical countries. They are usually part of septicaemia secondary to portal pyaemia, which may accompany: • bowel sepsis (appendicitis, diverticulitis, cholecystitis, pelvic sepsis) • cholangitis following obstruction of the common bile duct by stone or tumour. In such infective conditions, portal phlebitis leads to formation of multiple small abscesses...
Despite considerable advances in the evaluation of liver dysfunction by non-invasive methods, histopathological assessments continue to have an important role in diagnosis and management in patients with liver disease. In some conditions (e.g. liver allograft rejection), histopathology is still regarded as the diagnostic gold standard. In other circumstances, when a diagnosis has been made by other...
Alcohol is the most common cause of liver injury in the developed world. In 1999, alcoholic liver disease was the most common indication for transplantation in UK and Europe. A regional centre in the UK sees, on average, more than 400 patients with alcoholic liver disease each year. As highlighted in the recent Chief Medical Officer's report (2002), deaths from alcoholic cirrhosis in the UK are increasing;...
The pharmacokinetics and dynamics of many drugs may be altered in patients with liver disease. In the UK, the British National Formulary includes a list of drugs to be avoided or used with caution in such patients; similar information is available in other countries. When in doubt, check whether prescription of any particular drug is likely to be problematic.
There is now a wide range of investigative modalities that contribute to the understanding of liver structure and function. In the clinical context, it is crucial that the choice of tests is focused to answer a clinical problem – investigations should not be applied in a ‘blunderbuss’ manner. They can be divided into: • tests that indicate some form of liver dysfunction but are generally nonspecific...
Patients with liver disease often require drug treatment, either for their liver disease and its complications, or for other concomitant conditions. Liver disease has major effects on drug response of which the prescriber should be aware to ensure safe and effective therapy.
Drugs that damage the liver account for 9.5% of all suspected adverse drug reactions (ADRs), are the main cause of fatal ADRs and are the most common reason for withdrawal of drugs from the market. Pre-market surveillance detects common ADRs, but those seen in clinical practice are rare (1/10,000–100,000 prescriptions). Their description depends on post-market surveillance; in the UK, the Yellow Card...
Hepatitis B virus (HBV) infection is parenterally transmitted; it occurs in babies born to HBV-infected mothers, and after transfusion of blood and blood products, intravenous drug use or sexual contact. It is not transmitted through intact skin. Hepatitis D virus (HDV) infection occurs only in HBV-infected individuals. The outcome of HBV infection depends on age and on genetic factors determining...
Hepatitis A and E are enterically transmitted diseases with several common features. • The aetiological agents (hepatitis A virus (HAV) and hepatitis E virus (HEV)) are RNA viruses. • The route of transmission is mainly faecal–oral. • The clinical course is acute, self-limiting hepatitis with no progression to chronic liver disease. Clinically, HAV and HEV infections are indistinguishable...
Liver disease is increasingly common in the UK, probably reflecting an increase in the per capita intake of alcohol that has occurred over the last decade, and the impact of hepatitis C virus (HCV) infection. There are 5000 deaths from cirrhosis each year in the UK. Most patients present with cirrhosis or decompensated cirrhosis, and there is a clear need to identify disease at as early a stage as...
Ascites is defined as the accumulation of fluid in the peritoneal cavity. Many primary disorders of the peritoneum and visceral organs may produce ascites. Liver cirrhosis is the most common cause in Europe and North America (Figure 1).
Wilson's disease is an inherited disorder of hepatic copper disposition caused by mutations in the gene ATP7B on chromosome 13; the pattern of inheritance is autosomal recessive. It is found worldwide; the average prevalence is 30/million population. The carrier rate is about 1/90. The disease is relatively uncommon and may be difficult to diagnose; however, treatment is usually effective and life-saving...
Interventional endoscopy of the liver principally comprises endoscopic sphincterotomy for stone removal and stent insertion across strictures or leaks. Collaboration between surgeon, endoscopist and interventional radiologist is essential for the optimum management of patients with hepatobiliary disease.
The term ‘cholestasis’ refers to impairment of, or reduction in, bile flow. This can arise from blockage within the biliary tree or through impairment in bile secretion by hepa-tocytes into the bile canaliculi. Chronic cholestasis leads to problems resulting from: • complications of the predisposing cholestatic disease • complications associated with chronic liver disease resulting from the...