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Common Liver Problems |
Jaundice¨ This does not necessarily imply liver disease e.g. bile duct obstruction due to gallstones or malignant disease may also cause jaundice. ¨ Jaundice at birth is common and is usually of no significance. ¨ Normally, bilirubin (a breakdown product of haemoglobin) is conjugated in the liver where it becomes water soluble and is excreted in the bile, which colours the faeces. If the bilirubin is not conjugated e.g. due to parenchymal liver disease, it colours the skin and mucous membrane ('jaundice'). ¨ In obstructive jaundice, bile does not reach the gut leading to pale faeces but there is increased urinary bilirubin, the urine therefore is dark. Dark urine and pale faeces are a hallmark of obstructive jaundice.
Bleeding TendencyIt is important to suspect and enquire about any bleeding tendency (and testing of clotting is required). Poor absorption of fat soluble vitamin K occurs with its attendant effects on clotting and there is also decreased synthesis of clotting factors.
Obstruction to blood flow in the liver (portal circulation) leads to an increase in portal blood pressure with formation of enlarged blood vessels (varices) at the base of the oesophagus (one place where systemic and portal circulations meet) with consequent risk of gastrointestinal haemorrhage. Chronic bleeding may lead to anaemia.
Liver CirrhosisIn cirrhosis of the liver, the architecture is irreversibly destroyed by fibrosis and regenerating nodules of hepatocytes. The cause is often unknown but a quarter of cases are alcohol related. Hepatitis B or C, and the chemotherapy drug methotrexate can all be implicated. Primary biliary cirrhosis (PBC) is a disease primarily of females thought to be autoimmune in origin. It can be associated with Sjogren's Syndrome or oral lichen planus.
Liver TumoursThe most common liver tumours are metastases. These signal advanced disease and the outlook depends on the extent and nature of the primary tumour. Recent advances in surgery have meant that in certain situations resection of metastases is possible and chemotherapy may be appropriate. Jaundice, if present at all, is a late sign. Hepatocellular cancer may occur after hepatitis B or C infection and cirrhosis of the primary biliary type.
Reaction to MedicationsThe patient may give a history of liver problems after certain medications. Likely to be of interest to the dentist are aspirin, carbamazepine, erythromycin estolate, tetracycline and halothane. Aspirin is not indicated in children due to the risk of Reye's Syndrome, which comprises liver damage and encephalopathy occurring after aspirin ingestion.
Liver TransplantPatients may be encountered who have undergone a liver transplant - the most common indication for which is end-stage liver disease.
Genetic DisordersFamilial conditions may occur e.g. Gilbert's Syndrome in which the bilirubin level increases but is not conjugated and therefore does not enter the urine. It generally presents as mild jaundice. Many patients have no symptoms but some have episodes of malaise, anorexia and upper abdominal pain with jaundice. These episodes may be related to infection, fatigue or fasting.
Ref: British Dental Journal 26 July 2003; Volume 195, No. 2
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