Hepatic insufficiency

Following are the features of hepatic insufficiency:

1. Jaundice: it is usually mild or absent. If occurs, it is mainly due to failure of bilirubin metabolism.

2. Circulatory changes: these changes result from increased peripheral circulation (hyperdynamic circulation) causing the following manifestations: palmar erythema: it is mottled redness of the thenar and hypothenar eminences due to increased peripheral blood flow. Palmar erythema may also be present in normal old person, rheumatoid arthritis, pregnancy, thyrotoxicosis. Spider nevi: these are telangiectasia that result from arteriolar changes and comprise a central arteriole from which small vessels radiate. Spider nevi are confined to the area above the nipple and occurs on the face, necklace area, forearms and dorsum of hands.

3. Endocrine abnormalities:

• gynecomastia (because liver is unable to metabolize estogen, it may also develop as a side effect of diuretic spironolactone that is commonly used in cirrhosis;

• loss of libido;

• impotence and testicular atrophy in man;

• breast atrophy and amenorrhea.

4. Hemorrhagic tendency: it occurs in advanced liver failure and is due to underproduction of coagulation factors. The manifestations of hemorrhagic tendency may be:

• bruising, purpura;

• epistaxis;

• menorrhagia;

• GIT bleeding.

5. Skin changes:

• pigmentation occurs in cirrhosis (especially caused by hemochromatosis) and cirrhosis due to any reason as a result of cholestasis;

• clubbing of fingers and toes may also present.

6. Dupuytren's contracture associated with alcoholic cirrhosis and is very rare.

7. Hepatic encephalopathy. The cerebral disturbance or encephalopathy develops due to the following two factors:

• collateral venous circulation in cirrhosis bypasses the liver and allows nitrogenous substances from the gut to reach the systemic circulation through which they reach to the brain directly and produce cerebral disturbance;

• liver is responsible for detoxification of substances. When there is severe loss of liver function the un-detoxified substances such as ammonia reach to the brain, and produce cerebral dysfunction.

8. Renal failure (hepatorenal syndrome). It presents as low urine output, raised urea and creatinine, hyponatremia, low urinary sodium and hypotension. Kidneys are histologically normal and can work normally if transplanted to non-cirrhotic person. It occurs in advanced cirrhosis mostly with ascites is caused by decreased effective blood volume and hypotension as a result of vasodilatation due to release of nitric oxide from the liver. Details are given in the section of complications of ascites.

9. Hepatopulmonary syndrome. In cirrhosis pulmonary arteriovenous shunts also develop, leading to hypoxia and eventually central cyanosis, this is called hepatopulmonary syndrome.

Literature

1. Internal diseases an introductory course. - Vasilenko V., Grebenev A. - M.: Mir . Publishers, 1990. - 647 p

2. Propedeutics to internal medicine. Part 1.-Vinnytsya: NOVA KNYHA, 2006.- 424 p.

3. Propedeutics to internal medicine. Part 2.-Vinnytsya: NOVA KNYHA, 2007.- 264 p.

4. Introduction to the course of internal diseases. Book 1. Diagnosis: [Textbook/Zh.D. Semidotskaya, O.S. Bilchenko, et al.].-Kharkiv: KSMU, 2005. -312p.

5. Michael Swash Hutchison’s clinical methods / XIX edition. ELBS, 1989. -618p.

6. Mark H., Beers M.D., Robert Berkow The Merck Manual of diagnosis and therapy / XVII edition.- Published by Merk research laboratories, 1999.- 2833 p.

7. Harrison΄s principles off internal medicine / Fauci, Braunwald, Isselbacher and al.-XIV edition. - Vol. 1 and 2. - International edition, 1998.

Topic 13. The Main Symptoms and Syndromes in Renal Disease - Acute and Chronic Glomerulonephritis and Pyelonephritis.

Class lasts: 3 hours

Chronological class structure:

Control of initial standard of knowledges- 20 min.

Teacher′s demonstration of practical skills - 60 min.

Sudents′ independent work: - 30 min.

Control of ultimate standard of knowledges- 15 min.

Sum up of the class, homework- 10 min.

Questions for theoretical preparation: The definition and modern classification of glomerulonephritis and pyelonephritis. The main mechanisms of developing glomerulonephritis and pyelonephritis. Patient’s complaints in kidneys disorders and physical examination data in patients with glomerulonephritis and pyelonephritis. Edematous syndrome and syndrome of arterial hypertension in kidneys disease. The possibilities of instrumental diagnostics of kidneys pathology. Laboratory examination of urine, the analysis and the interpretation of the results of general clinical analysis of urine. The examination of urine by Nechiporenko, Ambjurrhe, Adiskakovsky, Zymnitskyj methods. Urinary, nephritic syndromes in renal diseases. The results of biochemical blood examination in kidneys pathology. The syndromes of renal insufficiency and renal colic.