LIVER DISEASE

LEARNING OBJECTIVES :

KNOWLEDGE - Students should know:

1. Develop an approach to the patient with clinical jaundice.
2. Recognize the five serologic types of hepatitis (A,B,C,D,and E), their serologic markers for active, acute and chornic disease, their primary mode of transmission, that only B, C and D can culminate in chronic hepatitis, and that liver biopsy is essential in establishing the diagnosis of chronic disease.
3. Recognize that active and passive immunization is available for hepatitis A and B only.
4. Recognize that treatment of chronic B and C disease is available with interferon and several oral agents.
5. Recognize some of the indications for hepatic transplantation.
6. Define and describe the symptoms, signs and complications of portal hypertension.
7. Define and describe the pathophysiology and common causes of ascites.
8. Identify causes of portal hypertension unrelated to liver disease.
9. Complete an abdominal exam, including evaluation for presence of ascites.
10. Define and describe the pathophysiologic manifestations, symptoms, signs, treatment, prognosis, and complications of alcohol-induced liver disease including but not limited to:
    1. Spontaneous bacterial peritonitis
    2. Hepatic encephalopathy
    3. Hepatorenal syndrome
11. Define and describe the analysis of ascitis fluid and its use in the diagnostic evaluation of liver disease including analysis of the serum to ascites albumin gradient (SAAG).
12. Define and describe the epidemiology, pathophysiology, symptoms, signs, and typical clinical course of cholelithiasis and cholecystitis.
13. Define and describe the clinical syndrome of "ascending cholangitis" including its common causes and typical clinical course.
14. Understand pathophysiology of conjugated and unconjugated hyperbilirubinemia (Overlap with Liver Function Tests).
15. Describe the common types of liver diseases and their risk factors (including inherited and acquired).
16. Know when to order laboratory tests for evaluation of liver disease and when a liver biopsy might be indicated (Overlap with Liver Function Tests).
17. Define and describe genetic considerations in liver disease (i.e., hemochromatosis, Wilson's disease, alpha-1 antitrypsin deficiency, Gilbert's syndrome).
18. Discuss the CAGE screening tool for alcohol abuse.

SKILLS - Students should be able to:

1. Obtain and record an accurate history in the patient with suspected liver disease.
2. Perform an accurate physical examination in the patient with suspected liver disease; palpate for hepatosplenomegaly and appreciate the extrahepatic findings in chronic liver disease such as spider angiomata, gynecomastia, ascites, testicular atrophy, etc.
3. Generate a differential diagnosis in the jaundiced patient.
4. Develop a treatment plan for patients with chronic liver disease.

ATTITUDES AND PROFESSIONAL BEHAVIORS:

• Students should be able to recognize the impact of chronic liver disease on the patient's life and the need for close follow up so that complications can be recognized and treated promptly.    

RECOMMENDED READINGS :

1. Yamada, Tadataka.   Handbook of Gastroenterology . 2000, Chap 16 (The Medicine Education Office, 7604, has a copy of this reference.)
2. Screening for Hepatitis C Virus Infe c tion : Re c ommendations from the U.S. Preventive Servi c es Task For c e   Ann Intern Med , Mar 2004; 140: I-62.
3. Steven K. Herrine   Approa c h to the Patient with C hroni c Hepatitis C Virus Infe c tion
   Ann Intern Med , May 2002; 136: 747 - 757.