Diseases of the Liver in Children: Evaluation and Management

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The special characteristics of dental management of cirrhotic patients must be understood to minimize possible complications in the treatment of patients with liver disease. These complications are mainly due to alterations in haemostasis, drug metabolism, and the greater predisposition to infection found in these patients..

Our main objective was to establish evidence-based therapeutic action protocols that can serve as an approach to outpatient dental management of the cirrhotic patient. To that end, we performed a literature review: firstly, to study the main systemic abnormalities related with cirrhosis that might affect dental management of these patients risk of haemorrhage, infection and altered drug metabolism ; and secondly, to review the recommendations and measures reported in the literature to prevent the onset of undesired events during and after outpatient dental treatment in the cirrhotic patient..

A total of articles were found. As an exception, 1 article in French was included, as it was considered relevant for the review. A total of 19 articles were eventually included.. The presence of oral manifestations in patients with cirrhosis, such as the appearance of haemorrhages, petechiae, haematomas, jaundiced mucosa, gingival bleeding, glossitis and sialadenosis, may be concomitant with the appearance of other signs and symptoms of liver dysfunction, and could indicate decompensation of the cirrhosis.

The likelihood of infections is higher in cirrhotic patients because their immunosuppressed state which will vary depending on the stage of the disease increases their susceptibility to systemic infections. In a healthy body, these small bacteraemias are neutralized by components of the immune system, but in cirrhosis, clearance of circulating endotoxins, bacteria and inflammatory mediators is compromised due to hepatic dysfunction. The effect of oral infections on the progression of cirrhosis has been extensively studied in the last decade. The need for dental treatment apical periodontitis, pockets larger than 6 mm, root fragments or large loss of bone support has been positively correlated in some patients with the more advanced stages of cirrhosis, greater urgency for liver transplant, and alcoholic cirrhosis, 6,7 although a cause—effect relationship between the severity of the dental and liver disease has not been demonstrated.

Alcohol in turn is a substance that interferes with protein metabolism and tissue healing, both processes related with periodontal disease. Moreover, serum cytokines, also implicated in the process of periodontal inflammation and destruction, are elevated in patients with cirrhosis especially alcoholic cirrhosis , which could increase the prevalence and severity of periodontitis in these patients. Patients with cirrhosis should undergo regular dental checkups to maintain good oral hygiene, thereby preventing oral infections and avoiding invasive treatments.

Dental treatment in cirrhotic patients, particularly interventions involving bleeding, should not be undertaken before considering the stage of the disease and the need for antibiotic prophylaxis to reduce the complications derived from the spread of infection, especially in patients with advanced cirrhosis.

This justifies the need for antibiotics prior to surgery, 5 although there is no clear evidence to recommend administration of mg of clindamycin in the case of allergy to penicillin 1 h before the procedure. The most widely used antibiotic groups in dentistry include the penicillins-cephalosporins, clindamycin, macrolides and quinolones.. Penicillins and their derivatives very rarely cause liver damage, and it is usually asymptomatic.

Penicillin G, penicillin V, ampicillin and amoxicillin are drugs in which very few cases of hepatotoxicity have been described. The liver damage caused by this component can appear up to 2 weeks after completing treatment 11 ; it is therefore advisable to avoid the use of beta-lactamase inhibitors due to their risk of causing liver damage.. Cephalosporins have been occasionally implicated in cases of cholestatic hepatitis, assuming a hypersensitivity mechanism similar to that of the penicillins.

Macrolides have also been implicated in liver damage. Cases of hepatotoxicity with erythromycin have been described, 11 sometimes occurring up to 2 weeks after completing treatment. Azithromycin has been considered responsible for some cases of cholestasis, 11 as has clarithromycin, especially in high doses. For these reasons, the use of macrolides should be avoided in patients with advanced cirrhosis. Liver damage secondary to clindamycin is exceptional. Despite this, clindamycin is the antibiotic of choice in the prophylaxis of cirrhotic patients who are allergic to penicillin single dose of mg of clindamycin in case of allergy to penicillin, 1 h before the procedure 6,9, Few cases of hepatotoxicity have been caused by quinolones, 12 although ciprofloxacin has been associated with isolated cases of high serum transaminases with hepatocellular damage, cholestasis and acute liver failure resulting in death.

How is cirrhosis of the liver diagnosed and evaluated?

Furthermore, dose adjustment for cirrhosis is not usually required, 13 although it should be adjusted in cases of renal failure.. Preoperative management involves analysis of the patient's medical record and evaluation of the dental treatment to be performed; a history of bleeding in other previous procedures must also be assessed, as this is an important indicator of coagulation disorders.

Cirrhosis can result in low plasma levels of coagulation factors due to poor absorption and utilization of vitamin K, which affects the synthesis of factors II, VII, IX and X. This should include a complete blood count with platelet count, prothrombin time, activated partial thromboplastin time, international normalized ratio INR and liver function test transaminases, bilirubin and albumin levels.

The INR alone does not always accurately predict the risk of postoperative bleeding, nor do the aforementioned laboratory tests.

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However, it is associated with the degree and progression of liver dysfunction.. Thrombocytopenia or platelet dysfunction suggests an increased risk of postoperative bleeding, more so if found together with elevated INR. Anti-fibrinolytic agents, such as epsilon aminocaproic acid EACA or tranexamic acid, inhibit fibrinolysis.

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Depending on the type of surgery and bleeding risk, anti-fibrinolytics can be used preoperatively in oral form or postoperatively in mouthwashes. It is important to bear in mind that the higher bleeding risk in the cirrhotic patient is also due to the presence of ectasias and varicosities in the gastro-oesophageal mucosa, pharynx and oral mucosa, 16 and that certain invasive procedures on these areas can cause profuse bleeding, especially if the patient's haemostatic parameters are still significantly compromised.

For this reason, it is important to minimize soft tissue trauma. American Society of Anesthesiologists ASA III compensated cirrhotic patients can usually be seen on an outpatient basis, providing that the foregoing criteria are met and haemostatic parameters are within the above-mentioned ranges, and that the dental procedures can be performed in these conditions. However, dental treatment in a hospital setting is advisable in ASA III or ASA IV cirrhotic patients with severe haemostatic alterations that coexist with other conditions, or with a high risk of complications derived from a complex dental treatment.

Although there is no reliable liver function parameter for adjusting drug doses, 17,18 recommendations are usually based on the Child—Pugh classification and model for end-stage liver disease MELD scores, which correlate the cirrhosis-related degree of dysfunction and survival. Complications following administration of drugs in cirrhotic patients include: acute liver failure, hepatic encephalopathy, acute renal failure and gastrointestinal bleeding.

Local anaesthetics should be administered with caution, as amides are metabolized in the liver and can cause toxic reactions at lower than expected doses.

Since they are less dependent on liver metabolism, these drugs should cause fewer toxic effects. With respect to analgesic drugs, most dental procedures require drugs recommended for the first and second steps of the World Health Organization analgesic ladder, i. The use of strong opioids third step on the WHO analgesic ladder or coadjuvants is not usually required. If they are needed, they should not be used before consulting with a specialist.. Paracetamol can be safely prescribed in cirrhotic patients in small doses of 2 or 3 g per day, even for long periods, due to the absence of sedation and nephrotoxicity.

Although they can be tolerated in patients with moderate liver disease, 17 NSAIDs should be avoided or used with extreme caution in the cirrhotic patient, 13 as the combination of their antiplatelet action with the haemostatic alterations and thrombocytopenia frequently found in these patients increases the risk of gastrointestinal bleeding.

What is cirrhosis of the liver?

This risk is even further aggravated in patients with gastric-oesophageal varices and ectasias or portal hypertension. There is still little experience in the use of coxibs in these patients. They seem to be effective in pain control, and could be better tolerated, as they do not interfere in platelet and renal metabolism, although they should also be used with caution. Weak opioids should also be used with caution, since their toxicity increases in cases of hypoalbuminaemia associated with cirrhosis. They should also be administered concomitantly with laxatives to prevent constipation and the development of encephalopathy.

Erratic analgesic power has also been described in codeine and tramadol, 13,17,18 since the biotransformation of these drugs to active metabolites is affected by the first-pass effect. Nevertheless, low-dose tramadol can be considered a second-line analgesic in the management of pain in the cirrhotic patient when paracetamol is insufficient to control the pain.

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Outpatient dental treatment of the cirrhotic patient requires extraordinary measures to be taken in order to avoid the onset of complications as a result of chronic hepatic dysfunction. Haemostasis, the risk of infection, and drug metabolism must be considered and studied individually in patients with cirrhosis, given the difficulty of achieving correct homeostasis in these situations.


Preoperative Evaluation and Management of Patients with Liver Disease

Therefore, we conclude that: — There is a higher risk of systemic infection and bacterial endocarditis derived from oral infectious foci in the cirrhotic patient. As a result, it is advisable to administer antibiotic prophylaxis, although there is no protocol to recommend this at present..

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Haemostatic alterations can lead to excessive bleeding in dental surgery, so a detailed case study should be made, following an appropriate action protocol Appendix Drug metabolism may be affected, according to the degree of hepatic dysfunction. To prevent the appearance of undesirable effects, the safest drugs can be prescribed.

In advanced stages, and when recommended by a specialist, lower, less frequent doses should be given. The protocols include the most common clinical situations and the drugs recommended for each of these in the outpatient dental treatment of the cirrhotic patient Appendix The authors declare that they have no conflict of interests.. Gastroenterol Hepatol. ISSN: Previous article Next article.

Issue 3. This content does not have an English version. This content does not have an Arabic version. Make an appointment. Visit now. Explore now. Choose a degree. Get updates. Give today. Request Appointment. It is least common among African American children. Certain conditions also make children more likely to develop fatty liver disease.

For many children, the only symptoms are feeling tired or having discomfort in the upper right abdomen. They do know that it is more common in children with certain conditions. These conditions include:. Our team of pediatric liver doctors, dieticians, nurses and administrative staff is dedicated to the care of children with confirmed or suspected fatty liver disease.

We use specialized non-invasive imaging tests, like the FibroScan to help estimate the degree of scarring and fat in the liver to help manage the fatty liver disease. This includes the , offered within the Division of Gastroenterology, Hepatology and Nutrition , which takes a multidisciplinary approach to the evaluation and management of fatty liver disease. Patient Resources Patient Story Two life-threatening conditions.

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