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Cholestasis PowerPoint Presentation

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Description : medical .pharm D presentation Dr.Nagwan

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Published on : Apr 29, 2018 | Views : 2629 | Downloads : 3

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Cholestasis 1
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Definition a condition where bile cannot flow from the liver to the duodenum 2
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Types The two basic distinctions are 3 an obstructive type of cholestasis metabolic types of cholestasis
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Pathophysiology of the obstructive type the blockage of any duct that carries bile from the liver to the gallbladder or from the gallbladder to the small intestine. This can occur at various levels within the biliary system what happens ? 4
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Pathophysiology of hepatocellular type Intrahepatic cholestasis generally occurs at the level of the hepatocyte or biliary canalicular membrane in hepatocellular disease, interference in the 3 major steps of bilirubin metabolism, ( uptake, conjugation, and excretion what happens ? 5
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A stone in a bile duct Narrowing of a bile duct. Genetic (biliary atresia ) Alcohol Anabolic steroids Birth control pills Chlorpromazine Estradiol Viral Hepatitis Sever bacterial infection Primary biliary cirrhosis Pregnancy jaundice Malignant tumor on liver 7
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Epidemiology Age Mortality Sex 8
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Diagnosis History Screening tests : Evaluation of color change : Yellowish discoloration of sclera and skin Dark color of urine Pale color of stool Lab tests : Increased ALP & GGT Increased conjugated bilirubin 10
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Diagnostic tests Imaging tests: Ultrasonography , CT scan , MRI : To visualize bile ducts and stones ERCP(endoscopic retrograde cholangiopancreatography) & MRCP ( magnetic resonance cholangiopancreatography) Direct visualization of lumen of bile ducts Liver biopsy 11
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Differential diagnosis Hemolytic jaundice CBC : Elevated reticulocyte Decrease in HB + Haptoglobin Increased unconjugated bilirubin Hepatocellular Jaundice Increase in both (conjugated & unconjugated ) bilirubin Increase in AST & ALT 12
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TTT: Depends on the diagnosed cause or underlying problem. Focused on dealing with the symptoms (such as itchiness). Stop using liver toxic substances such as alcohol and certain drugs. 14
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TTT (cont.,): For bile duct blockages, surgery or endoscopy. For blockages within the liver, If a drug is the suspected cause, the doctor stops its use. If acute hepatitis is the cause, cholestasis and jaundice usually disappear. 15
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TTT (cont.,): For itching, Cholestyramine (Cholestran ®) taken by mouth, this drug binds with certain bile products in the intestine, so they cannot be reabsorbed to irritate the skin. 16
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TTT (cont.,): For chronic cholestatic disease: A- Ursodeoxycholic acid (Ursofalk®) Dose: 20-30 mg/kg/d MOA: 1- Increase bile formation 2- Antagonizes the effect of hydrophobic bile acids on biological membranes. 17
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TTT (cont.,): B- Phenobarbital Dose: 5 mg/kg/d May be useful in some children with chronic cholestasis. 18
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TTT (cont.,): 19
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TTT (cont.,): 20
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Case presentation 21
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Case presentation M.A is a 32 years old female 65 kg weight admitted to Tanta University Hospital , ICU on 5-11-2017 shocked , suffering from fever , vomiting , fatigue , dysnea from one week ago Past medical history : Normocytic normochromic anemia (blood transfusion) 22
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Soap analysis 23
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Subjective data Vomiting Fever Fatigue Blurred vision headache 24
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Objective data Physical examinations Anemic mainfestation Jaundice ( yellow color of sclera & inner surface of lower lip palm of hand , dark urine) olive green color skin Confused (shocked) 25
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Objective data Physical examinations Vital signs: BP : 90/60 mmHg P : 80 b/m T : 39 ° C Extremities : - Mild lower limb edema 26
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Objective data Physical examinations Abdominal Ultra Sound Normal , with mild spleenomegaly Echo Normal Virology test HCV –ve HAV –ve HBsAG –ve 27
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Objective data Laboratory investigation 28
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Objective data Laboratory investigation Serum alkaline phosphatase levels → elevated serum gamma- glutamyl transferase(GGT)→ elevated LDH, Corrected ratic count → mild elevation Blood culture Coomb`s test → - ve 29
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Objective data Laboratory investigation (cont.) 30
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Objective data Laboratory investigation (cont.) Arterial blood gases( ABG) & hemoglobin 31
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Objective data Lab. Results Electrolyte disturbance (hypokalemia) Acid base disturbance (Low PCO2 &Low HCO3) Mild hypo-albuminemia Low hemoglobin, mild increase in LDH, Corrected ratic count High BUN and Sr Cr Direct hyper-bilirubinemia 32
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Assessment Patient with Cholestatic Liver Disease Normocytic normochromic anemia Infection (fever) 33
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Assessment (cont.) The patient developed metabolic acidosis caused by dehydration after vomiting By measuring ABG Normal pH Pa CO2 < 35 mm hg HCO3 < 22 mm hg It was compensated by the body by increasing alveolar ventilation so no need for therapy 34
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Plan pharmacological plan Fluid resuscitation & Electrolyte replacement Panamin G (A.A. for intravenous nutrition) With monitoring of fluid intake & output Ringer solution + potassium (q 12 hr ) Glucose 5% (q 8 hrs ) 35
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Plan pharmacological plan Choleretic agents ursodeoxycholic acid (ursofalk®) Shown to promote bile flow in cholestatic conditions associated with a patent extrahepatic biliary system. Decreases the cholesterol content of bile and therefore reduces bile stone and sludge formation Dose : 2 tab q 12 hr 36
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Plan pharmacological plan Bile salt resins Cholestyramine (cholestran ® ) Bile acid–binding resins form a non-absorbable complex with bile acids in the intestine inhibits enterohepatic reuptake of intestinal bile salts and thereby increases the fecal losses of bile salt–bound low-density lipoprotein cholesterol. Dose : q 8 hr 37
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Plan pharmacological plan N-acetyl cysteine (q 8 hr ) Protective kidney from bilirubin nephropathy 38
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Plan pharmacological plan Fever & infection management Perfalgan ® (q 8 hr ) Meronem ® 500 mg q 8 hr (Empirical) Acyclovir for HSV Mouth wash (500 cm saline+ 1amp xylocaine+Na-bicarbonate) 39
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Plan pharmacological plan RBCs transfusion is recommended to keep an acceptable hemoglobin level parenteral iron supplement should be added Fat-soluble vitamins A, D, E, and K must be administered as individual supplements to assure proper absorption 40
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Monitoring plan Monitor INR and prothrombin activity Monitor electrolyte levels Monitor body weight Monitor liver function test 41
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Conclusion Cholestasis is a liver disease. It occurs when the flow of bile from your liver is reduced or blocked There are two types of cholestasis: intrahepatic cholestasis and extrahepatic cholestasis The causes of cholestasis are divided into two groups those originating within the liver and those originating outside the liver Jaundice, dark urine, light-colored stools, and generalized itchiness are characteristic symptoms of cholestasis 42
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Ultrasonography and ERCP are used to diagnose cholestasis . TTT depends on the diagnosed cause or underlying problem either inside the liver or outside it . 43
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Any 44
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Reference Marrelli D, Caruso S, Pedrazzani C, et al. CA19-9 serum levels in obstructive jaundice: clinical value in benign and malignant conditions. Am J Surg. 2009 Apr 16 Satrom K, Gourley G. Cholestasis in Preterm Infants. Clin Perinatol. 2016 Jun. 43 (2):355-73. Afdhal NH. Diseases of the gallbladder and bile ducts. In: Goldman L, Ausiello D, eds. Goldman’s Cecil Medicine . 24th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 158. Beuers U, Boberg KM, Chapman RW, et al. EASL clinical practice guidelines: clinical presentation of cholestatic liver diseases. J Hepatol. 2009;51(2):237-267. PMID: 19501929 www.ncbi.nlm.nih.gov/pubmed/19501929. Ahmed A, Cheung RC, Keeffe EB. Management of gallstones and their complications. Am Fam Physician. 2000 Mar 15. 61(6):1673-80 46