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