KONSEP TERKINI

NON-ALCOHOLIC STEATO HEPATITIS

(NASH)

Bagian Ilmu Penyakit Dalam

RSUD Dr. Adhyatma
Semarang

 Ludwig (1980) Non Alcoholic Steato

Hepatitis (NASH)
Istilah Lain: - Diabetic Hepatitis
- Fatty Liver Hepatitis
- Alcohol Like Liver Disease
Istilah sekarang: Non Alcoholic Fatty Liver
Disease (NAFLD).
NAFLD (Primer) harus dibedakan dari
steatosis dengan atau tanpa hepatitis
akibat kausa lain (NAFLD Sekunder).

NAFLD
Steatosis
Steato Hepatitis
Fibrosis
?
Cirrhosis

Implikasi Klinik NAFLD

Di Amerika merupakan penyakit hati
menahun yang banyak ditemukan
dalam praktek sehari-hari.
Kausa tersering dari kenaikan
transaminase .
Dapat berkembang menjadi sirosis hati
dan karsinoma hepatoseluler.

Epidemiologi

Faktor Risiko
Obesitas (30-50%)
DM Tipe 2 (10-75%)
Hiperlipidemia (20-92%)
Hypertension

Patogenesis
Two Hit Hypothesis (Day & James 1998)
First Hit:

Steatosis
[ Steatotic Liver ]

Second Hit: Steato Hepatitis

Fibrosis
Cirrhosis

Harisson S.A., dkk 2002

Gambaran Klinik dan Laboratorium

Asimptomatik
Hepatomegali
SGPT & SGOT

Gamma-GT dan Fosfatase alkali

Hipoalbuminemia
Waktu protrombin memanjang

Sirosis

Pencitraan
Infiltrasi lemak Bright liver pada
ultrasound
US
Kadang-kadang
CT
Focal Fatty Liver

Penemuan Histologi

Steatosis
Mixed Inflammatory Cell Infiltration
Hepatocyte Ballooning and Necrosis
Glycogen Nuclei
Fibrosis

Harisson S.A., dkk 2002

Terapi

Belum ada obat yang dapat mengurangi atau

memperbaiki kelainan histologi
Memperbaiki kondisi yang berhubungan dengan
NAFLD
Penurunan berat badan
Penanganan diabetes
Penanganan hiperlipidemia

Modalitas Farmakoterapi yang menjanjikan

Vitamin E
Ursodeoxycholic acid
Betaine
Thiazolidinedione: troglitazone
Metformin
Gemfibrozil

Ringkasan
NAFLD mempunyai implikasi klinik yaitu dapat
berkembang menjadi sirosis
Resistensi insulin dan stress oxidatif
mempunyai peranan penting dalam patogenesis
NAFLD
Biopsi hati tetap merupakan modalitas yang
paling sensitif untuk informasi diagnosis dan
prognosis
Pengobatan yang efektif belum ada walaupun
beberapa farmakoterapi menjanjikan
Transplantasi hati merupakan terapi alternatif
untuk stadium akhir NAFLD

Petunjuk Praktis
Pasien dengan observasi kenaikan ALT tanpa
petanda virus dan riwayat obat hepatotoksik
serta disertai obesitas+/- DM tipe 2 +/Dislipidemia perlu dipikirkan NAFLD.
Terapi meliputi mengatasi kondisi yang
menyertai serta farmakoterapi yang terbukti
aman seperti UDCA dan Vitamin E.
Penggunaan obat untuk mengatasi resistensi
Insulin dan anti oksidan lain masih memerlukan
studi lanjutan.

Liver Abscess in Children

and Young Adults
Presented by
Zulfachmi Wahab, MD-FINASIM

Introduction
Two characters:
Common in developing countries.
Unique set of predisposing factors.

Predisposing causes of Liver

abscesses

These include:
Parasitic Infestations.
Genetic Disorders.
Skin infections.
Protein Calorie malnutrition.
Abdominal infections.
Post trauma.

Parasitic Infestations
Parasitic infestations are thought to predispose to pyogenic
liver abscesses.
These include:
Ascariasis.
Schistosomiasis
Fascioliasis
Trichuris
Necator.
Ancylostoma.
Toxocara.

Genetic Disorders
1) Papillon-Leferve syndrome:

Autosomal recessive disease.

Palmoplantar keratoderma .
Periodontitis.
Pyogenic liver abscess

 2) Chronic Grannulomatous Disease:

Primary immunodeficiency disease.
Can be complicated with life threatening infections
including liver abscesses.
Fever is the most common presenting symptom.
These abscesses are often recurrent, multiple and
difficult to treat.

 Mean age of first abscesses is often mid teens.

Commonest micro-organism is staphylococus
though gram negative rods, nocardia and fungal
infections are also reported.
Often surgical resection is better than percutaneous
drainage.

 3) Infections and liver abscess has been reported in

children with deficiencies in C1 complement.

Skin infections
Skin infections are common in children. These
provide a source of bacteremia and inoculation of
infection in liver and a resultant pyogenic liver
abscess.
Predominant organism is Staphylococcus aureus.

Protein Calorie malnutrition

There is a co-relation between liver abscesses and
malnutrition in children. Liver abscesses in children
are rare in developed countries whereas they are
common in developing countries.

Abdominal infections
Previous portal vein catheterization predispose to
portal pyaemia and liver abscesses.
Choledochal cysts can predispose to recurrent
cholangitis and liver abscesses.
Similarly congenital hepatic fibrosis can predispose
to cholangitis and liver abscesses

Post trauma
Trauma predisposes to liver abscesses both by direct
injury to liver or by providing habitat for proliferation
of organisms elsewhere.

Microbiology of Liver
abscesses

 Staphylococcus is the leading cause.

Anaerobes : up to 30% of organisms.
Gram negative rods like E. coli and klebsiella.

 Unusual infections :
Fungal hepatic microabscesses.
Tubercular liver abscesses.
Typhoid fever can be associated hepatic abscesses.
Cat scratch disease.
Brucella liver abscesses.

Location and number of Liver

abscesses
(1) Mainly: right lobe of liver
Left lobe abscesses are frequently associated with
complications like rupture into peritoneum and
pericardium.
Left sided liver abscesses require drainage far more
often (85% cases) when compared to right sided
lesions.

 (2) Mainly: solitary.

With multiple liver abscesses, mortality may be
almost twice that in solitary cases.

Clinical Presentation

 Fever often with chills.

Abdominal pain specially in right upper quadrant.
Tender hepatomegaly
Anorexia, nausea and vomiting.
Unexplained anemia.
Afebrile presentations still can happen.
On the other hand, liver abscesses may present as
fulminant sepsis or acute abdomen.

Investigations

 CBC: Anemia, leucocytosis and raised ESR.

LFT: Altered liver enzymes specially alkaline
phosphatase and may be prolonged prothrombin
time.
Blood cultures must be sent but they have lower
sensitivity than pus aspirate cultures.
Negative amebic serology points strongly to a
pyogenic source of infection.

Imaging
Role of CXR:
May show:
Elevation of right
hemidiaphragm
Blunting of Right
costophrenic angle
Fluid levels below
diaphragm in case
of gas forming
organisms

 Role of Ultrasonography:
U/S is the imaging of first choice.
Hypoechoic lesion but may have heterogenous
echotexture. Majority of the abscesses have a well
defined wall.
U/S may reveal an intra-abdominal precipitating
cause for liver abscess.

 Role of CT :
CT is more sensitive in detecting even small abscesses
in liver.
Expensive with risk of contrast nephropathy.
Image: A hypodense lesion with low attenuation areas
and an enhancing rim.

 Role of MRI:
Image: hypo intense on T1 weighted and hyper
intense in T2 weighted sequences.
On gadolinium enhanced sequences: there is early
and continued enhancement of wall which persists on
delayed images. There is increased peri-abscess tissue
enhancement in immediate post-gadolinium images.

Resolution and follow up of

abscess on imaging :
U/S is the best for follow up.
The abscess cavity takes many months to finally resolve
and lags behind clinical resolution by months.
Resolution
time
depends
hypoalbuminemia and anemia.

on

abscess

size,

Recurrences are observed mostly within 3 months of

treatment. There may be an underlying problem like
CGD predisposing recurrence.

Treatment

Medical therapy
A combination of anti-staphylococcal drug like
cloxacillin, an anti-anerobic and an aminoglycoside
or cephalosporin for gram negative bacilli is a good
initial choice, and modified according to results of
cultures.
Therapeutic drainage is needed in 80-90% of cases.
Medical antibiotic cover is additionally required for a
period of 3-4 weeks.

Role of aspiration
Aspiration is indicated in solitary, unilocular lesions.
Multiloculated liver abscesses can be managed with
aggressive percutaneous techniques that include
disruption of loculations and placement of large bore
catheters.

 Failure is mostly due to technical causes like

(a) Inappropriate approach into a non- dependant
portion of cavity.
(b) Failure to recognize and respond to septation.
(c) Premature withdrawal of drains. Catheters should
be withdrawn once there is negligible(<10 ml) pus
drain per day and when patient is apyrexic.

Role of surgery
Surgical drainage is for :
(a) Patients with failed percutaneous drainage.
(b) Patients who need additional management for an
underlying abdominal problem.
(c) Patients with multiple macroscopic abscesses.
(d Patients on steroids.
(e) Patients with ascites.

Morbidity and Mortality

Complications :
Pleuro-pulmonary complications: pleural effusion,
empyema, pneumonitis, and hepatopleural or hepatobronchial fistula.
Intraperitoneal rupture of abscess, peritonitis and
ascites.
Intrapericardial rupture and pericardial effusion.
Septic shock.
Hemobilia and Jaundice.
Perforations into a hollow viscus like colon, stomach
and duodenum.

Mortality
Facility of rapid diagnosis with imaging,
percutaneous drainage, and better antibiotics have
improved survival.
With modern management : mortality less than 15%