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© Springer Nature Switzerland AG 2021

R. Reti, D. Findlay (eds.)Oral Board Review for Oral and Maxillofacial Surgerydoi.org/10.1007/978-3-030-48880-2_12

12. Liver Disease

Marc Dentico-Olin1  , Gregory S. Tentindo2 and Maryam Akbari3

University of California San Diego, Plasticand Reconstructive Surgery, San Diego, CA, USA

Oral Facial Surgery Institute, St. Louis, MO, USA

Mount Sinai, Oral and Maxillofacial Surgery, New York, NY, USA
Marc Dentico-Olin

HepatitisCirrhosisNonalcoholic fatty liver disease (NAFLD)Child-Pugh scoreModel for End-Stage Liver Disease (MELD)Autoimmune hepatitisPortal hypertension

Liver Function

  • The liver plays a major role in maintaining homeostatic, immunological, and synthetic processes. Hence, liver dysfunction and liver failure have significant consequences on overall health.


  • There are five forms of viral hepatitis (A, B, C, D, and E).

  • The leading causes of chronic viral hepatitis are chronic hepatitis B and C.

  • The pathophysiology of all viral hepatitis is an inflammatory-mediated process with active hepatocellular damage and necrosis with a lobular inflammatory response.

  • Viral hepatitis is considered acute when inflammation lasts 6 months or less.

  • With chronic viral hepatitis, the longstanding repetition of the inflammation and healing process leads to liver fibrosis.

Hepatitis A

  • RNA virus with an average incubation period of 35–70 days.

  • Typically , it is a self-limiting process leading to acute hepatitis.

  • Clinical illness manifests as malaise, myalgias, arthralgia, anorexia, nausea, vomiting, diarrhea, low-grade fevers, and/or jaundice.

  • Clinical features usually subside over 2–3 weeks.

  • There is no chronic form of hepatitis A.

  • Mode of transmission: fecal-oral, sewage-contaminated shellfish.

  • Prevention: pooled gamma globulin, hepatitis A vaccine.

  • Complications: Hepatitis A can lead to fulminant liver failure. It has <0.2% mortality rate [1].

Treatment: Hepatitis A can be prevented with a vaccine. There is no specific treatment for hepatitis A (treatment is just supportive care). Physical exertion, alcohol, and hepatotoxic agents should be avoided.

Hepatitis B

  • DNA virus with an average incubation period of 60–110 days that has an insidious onset leading to acute hepatitis.

  • Chronic hepatitis develops in 1–5% of immunocompetent adults, a substantial proportion of immunocompromised adults and as high as 90% of infected children [2].

  • After an infection with hepatitis B there are four phases: (1) immune tolerant, (2) immune clearance, (3) inactive HBsAg carrier state, and (4) reactivated chronic hepatitis B.

  • Mode of transmission: vertical transmission (mother to fetus), percutaneous, and sexual.

  • Risk factors: IV drug use, unprotected sex with multiple sexual partners, incarceration, needle sticks, tattoos, body piercings, hemodialysis, and blood transfusions.

  • Prevention: hepatitis B immunoglobulin, hepatitis B vaccine.

  • The clinical features of acute hepatitis B are similar to that of hepatitis A.

  • Complications: The clinical course associated with acute hepatitis B ranges from asymptomatic to fulminant disease and death in a few days. If aminotransferase levels remain elevated for more than 6 months, the patient is considered to have chronic hepatitis B.

  • 20% of chronic hepatitis B cases progress to cirrhosis [2].

  • Hepatocellular carcinoma develops in cirrhotic patients at a rate of 2–4% per year [2].

Treatment: Hepatitis B vaccines are available. Treatment of acute hepatitis B is the same as hepatitis A, supportive care centered. Chronic hepatitis B patients with active viral replication may be treated with nucleoside or nucleotide analogs, with the goal of lowering HBV DNA levels and possible seroconversion.

Hepatitis C

  • RNA virus with an average incubation period is 35–70 days.

  • The clinical illness of acute hepatitis C is often mild and usually asymptomatic. Majority of cases progress to chronic liver disease.

  • Mode of transmission: percutaneous.

  • Risk factors: IV drug use, incarceration, needle stick, tattoos, body piercing, hemodialysis, and blood transfusion.

  • Prevention after exposure: interferon plus ribavirin.

  • Complications: Chronic hepatitis C is clinically indistinguishable from other causes of chronic hepatitis. Cirrhosis occurs in 20% of affected patients after 20 years [3]. Patients are also at risk for developing hepatocellular carcinoma. Hepatitis C has been shown to be associated with mixed cryoglobulinemia and membranoproliferative glomerulonephritis. HCV infection increases a patient’s risk of developing non-Hodgkin lymphoma.

Treatment: Unlike hepatitis A and B there is no vaccine for hepatitis C. Both antiviral medication and interferon plays a role in the treatment of hepatitis C. Use of peginterferon in patients with acute hepatitis C decreases the risk of developing chronic hepatitis C. Ribavirin can be added to the course of peginterferon if HCV RNA does not clear with peginterferon alone. Direct-acting and host-targeting antiviral agents are changing the treatment of chronic hepatitis C. Many patients are now able to clear their chronic hepatitis C infections after a multidrug regimen (e.g., Harvoni ® and Mavyret®). Patient response rates to these treatment regimens depend on the specific genotype of HCV they are infected with. Patients may also be treated with liver transplantation.

Alcoholic Liver Disease (ALD)

  • Excessive alcohol intake leading to a fatty liver, followed by hepatitis and cirrhosis.

  • The consumption of 50 g daily (5 standard drinks) of alcohol for 10 years or more puts individuals at risk for ALD.

  • The clinical course of ALD includes a spectrum of disease: alcoholic steatosis, alcoholic steatohepatitis, cirrhosis, and hepatocellular carcinoma.

  • The pathophysiology of alcoholic liver disease starts with acute or chronic inflammation leading to parenchymal necrosis of the liver. The liver inflammation and hepatocyte degeneration at the level of alcoholic steatosis is reversible with cessation of alcohol use. The dreaded complication of alcoholic liver disease is progression to cirrhosis.

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Jul 23, 2021 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Disease
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