Hepatologi 1 (CMP)
Hepatologi 1 (CMP)
Hepatologi 1 (CMP)
Ummi Maimunah
Div. Gastroentero-Hepatologi
Dep-SMF Ilmu Penyakit Dalam
FKUA / RSUD Dr Soetomo
THE LIVER
• FUNCTIONS OF THE LIVER:
– MAKES PROTEIN: NEEDED FOR
BLOOD CLOTTING
– STORES: VITAMINS, IRON AND
GLYCOGEN
– METABOLIZES / produce energy :
SUGAR, PROTEIN AND FAT
TO PRODUCE ENERGY
– DETOXIFICATION
2
THE LIVER
• ENZYMES (PROTEINS) FROM
LIVER (CALLED LFT’S – LIVER
FUNCTION TESTS) eg:
– ALT (SGPT)
• ALANINE
AMINOTRANSFERASE
(Serum Glutamic Pyruvat
Transaminase/
– AST (SGOT)
• ASPARTATE
AMINOTRANSFERASE
(Serum Glutamic
Oxsaloacetic transaminase)
3
Tests based on detoxification &
excretory functions :
• Serum bilirubin (measured by Van Den
Bergh method)
• Urine bilirubin
• Blood ammonia
• Serum enzymes : AST, ALT, GGT (gama
glutamic transpeptidase), 5’Nucleotidase
(5NT)
Tests that measure Biosynthetic
function of liver :
Serum Albumin, Serum Globulins, PT & INR
6
Acute Viral Hepatitis
I. Definition:
Diffuse liver inflammation lasting less than
6 months
II. Causes:
Hepatitis A Hepatitis B Hepatitis Hepatitis C Hepatitis E
HAV HBV D HCV HEV
Infective serum HDV Post Epidemic/
hepatitis hepatitis transfusion Entral
hepatitis
virus RNA DNA Incomplete RNA flavi firus RNA
Hepa virus RNA+HBsAg
HBV DNA Most sensitive indication for viral replication & chronicity (Dan particle)
It is detected by PCR
VI. Treatment:
Rest: Bed rest till LFT normal
Diet : CHO, Protein, Lipid
Drugs: vitamin
VII. Prophylaxis:
• Screening: of blood for hepatitis Ag , disposable syringes,
avoid sharing razors or tooth brush
• Passive prophylaxis:
Hepatitis A : serum gamma globulin
Hepatitis B: HBIG
• Active prophylaxis (Vaccin):
Hepatitis A:
Inactivated HAV 0.5 – 1 ml IM to be repeated
after 6 -12m
Hepatitis B:
Recombinant HBV vaccine (Heptavax) IM in
3 doses at 0 - 1 - 6 m
Hepatitis Kronis
Hepatitis B Kronis
HBV: Penyebab Signifikan Morbiditas dan
Mortalitas di Dunia
• Prevalensi: > 2 miliar terinfeksi[1]
• insiden: 4 juta kasus akut / tahun[1]]
1. WHO. Hepatitis B. 2002. 2. Maynard JE, et al. In: Viral Hepatitis and Liver Disease. New York: Alan R.
Liss, Inc. 1988. 3. CDC. Epidemiology & prevention of vaccine-preventable diseases. The Pink Book. 8th
ed. 4. CDC. MMWR. 2001;50:RR-11.
Distribusi HBV di Dunia
Prevalensi HBsAg
High ≥ 8%
Intermediate 2% to 7%
Low < 2%
Centers for Disease Control and Prevention. CDC Health Information for International Travel 2010.
Dampak infeksi jangka
panjang
Sirosis
Sembuh Karier Tanpa Gejala yg Jelas
15 – 30 Tahun
Diagnosis Hepatitis B
Pemeriksaan Lab/penunjang
• Biokimia :
• ALT meningkat, IgM anti HBc sudah (-)
• HBV DNA
• Petanda kuantitatif dari replikasi virus dan khronisitas
• Serologi :
• HBeAg dan anti-HBe
• HBsAg dan anti-HBs
• Histologi :
• Menunjukkan aktifitas fibrosis dan nekroinflamasi
• USG, CT Scan
• Fibroscan.
Infeksi kronis
• Persistensi HBsAg, anti HBc,
• & serum HBV DNA terdeteksi > 6 bulan
GEJALA
- asimtomatis
- komplikasi
- Flare/ reaktivasi.
Tujuan Terapi Hepatitis B:
Sasaran (tujuan langsung):
Supresi persisten HBVDNA
Serokonversi HBeAg
Perbaikan histopatologi hati
Normalisasi ALT
Tujuan akhir :
Pencegahan progresivitas sirosis hati &
kanker hati
Peningkatan kualitas hidup
Perpanjangan kesintasan
KELOMPOK RISIKO TINGGI
• Pengguna Narkoba Suntik
• Sex aktif
• Laki-laki yang berhubungan sex sesama jenis
• Anak-anak yang berasal dari daerah endemik
• Sosial ekonomi rendah
• Kontak seksual dengan penderita Hepatitis B
• Bayi dengan ibu terinfeksi virus Hepatitis B
• Pekerja di sektor kesehatan
• Pasien Hemodialisa
MENCEGAH :
Transmisi virus
Hepatitis B akut
Penyakit hati kronik dan
cirrhosis
komplikasinya
liver cancer
TERAPI
• 1. Interferon α ( IFN - α ) / Pegylated interveron
α-2a / α-2b
• 2. Nucleosida analog:
Lamivudine, Telbivudine, Tenovovir,
Adefovir dipivoxil, Entecavir.
• 3. Thymosin alfa I
Hepatitis C Kronis
Introduction
• It is 130–210 million
individuals
• 6 HCV genotypes: 1, 2, 3, 4,
55&6
Natural History of Disease
Prevention of HCV transmission
• Blood screening
• universal precaution
• condom for sexual partner
• Decrease drug injection (only is needed)
Transmission
• Contaminated blood most infectious (transfusions prior to
1992, now needle-sharing, intranasal cocaine)
Cirrhosis is defined
histologically as a diffuse hepatic
process characterized by fibrosis
and the conversion of normal liver
architecture into structurally
abnormal nodules (diffuse
process with fibrosis and
nodule formation).
Type: micronoduler
macronoduler
mixed
• Alcohol
Autoimmune Hepatitis
Cryptogenic
Clinical Manifestations of the Liver
Clinical Manifestations of the Liver
GEJALA KLINIS
Asimtomatis
Kullit kuning
Capai
Lemah
Nafsu makan menurun
Gatal
Mual
Berat badan menurun
Nyeri perut
Mudah berdarah
GEJALA KLINIS
akibat komplikasi
Ikterus
asites
Perdarahan varises
Ensefalopati
Caput Medusae Ascites Palmar erythema
jaundice Esophageal varices
DIAGNOSIS
ANAMNESIS PEMERIKSAAN FISIK
1. Konsumsi 1. Splenomegali
alkohol jangka 2. Spider telangiectasias
panjang 3. Ikterus atau jaundice
2. Narkotik 4. Asites
suntikan
5. Edema
3. Penyakit hati
menahun
4. Hepatitis virus
B atau C
DIAGNOSIS
Laboratorium Endoskopi
1. ↑abnormal enzim Varises esofagus
transaminase (AST
CT scan (CAT) atau
dan ALT)→tanda
peradangan atau MRI dan USG
kerusakan hati. Ditemukan :
2. ↓ albumin dan faktor nodul dalam hati,
pembeku darah splenomegali, cairan dalam
3. Ditemukan abdomen
Autoantibodi: Pungsi Asites
ANA,ASMA,AMA
Mengetahui penyebab asites
KOMPLIKASI EDEMA dan
SBP
(Spontaneous
SIROSIS HATI ASITES Bacterial
Peritonitis)
(SH)
Perdarahan Ensefalopati
Varises Esofagus Hepatik
Sindroma Sindroma
Hepatorenal Hepatopulmoner
Kanker Hati
Hipersplenisme (hepatocellular
carcinoma)
PENGOBATAN
Sirosis Hati (SH)
Mencegah Mengobati Mencegah Transplant
Kerusakan komplikasi kanker hati asi hati
hati lebih sirosis dan deteksi
lanjut dini
Ascites
Cirrhosis : 85 %
Malignancy : 10 %
Tuberculous
Cardiac cirrhosis
Examination
Complications - Infection
• SBP
• Positive AF culture
• AF absolute PMN count (≥ 250cells/mm3)
• Absence of intraabdominal surgically
treatable source of infection
Treatment
Five days of parenteral 3rd generation cephalosporin
such as Cefotaxime / Amoxicillin – Clavulanic acid
• 2 Types:
Type 1 HRS : progressive Rapidly (< 2 weeks )
Type 2 HRS : do not progressive
Ensefalopati Hepatik
• Hepatitis C
• Cirrhosis
- 70% of HCC arise on top of cirrhosis
• Autoimmune hepatitis
• States of insulin resistance- Overweight in males
Diabetes mellitus
Diagnosis
what investigations are required to make a
definite diagnosis
2) Imaging:
- focal lesion in the liver of a patient with cirrhosis is highly likely
to be HCC
- Spiral CT of the liver
- MRI with contrast enhancement