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Liver diseases
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Here are key points to consider
when managing these patients:
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Laboratory Tests: Assess liver function tests (LFTs), complete blood count (CBC), prothrombin
time (PT), and international normalized ratio (INR)
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0 and platelet count is above 50,000/mm³ before
proceeding with the extraction
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Local Hemostatic Measures: Use local hemostatic agents like oxidized cellulose, gelatin sponge,
or topical thrombin
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Medications: Avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) due to their
anticoagulant effects
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Prophylactic antibiotics may be considered, especially in cases of advanced liver
disease or immunocompromise
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Avoid drugs extensively metabolized by the liver
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Drug Considerations
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Anesthetics: Local anesthetics without epinephrine are generally preferred to avoid potential
cardiovascular complications
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Analgesics: Prefer acetaminophen over NSAIDs
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Sedatives: Avoid benzodiazepines if possible, due to the risk of hepatic encephalopathy and
prolonged sedation
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Post-Operative Care

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Monitoring: Close monitoring for signs of excessive bleeding or infection is essential
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Follow-Up: Ensure regular follow-up appointments to monitor healing and manage any
complications promptly
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Multidisciplinary Approach
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Consultation: Work closely with the patient’s hepatologist or primary care physician to optimize
medical management before and after the extraction
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Here are some analgesics considered safer options:
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Mechanism of Action: It primarily acts centrally to reduce pain and fever, rather than exerting
significant effects on the liver
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Monitoring: Regular monitoring of liver function tests is advisable in patients using
acetaminophen chronically or at higher doses
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Tramadol
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Safety Profile: Tramadol, an opioid analgesic, is considered relatively safe for patients with mild
to moderate liver impairment
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Dosing Adjustments: However, dosage adjustments may be necessary in patients with severe
liver disease to prevent accumulation of active metabolites
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Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
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Selective COX-2 Inhibitors: Selective COX-2 inhibitors like Celecoxib may be considered in
patients with liver disease, as they are less likely to cause gastrointestinal bleeding and may
have a lower risk of exacerbating liver damage compared to non-selective NSAIDs
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Short-Term Use: If necessary, short-term use of NSAIDs may be considered in patients with
compensated liver disease and close monitoring of liver function tests
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Opioid Analgesics
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Caution Required: Opioid analgesics should be used cautiously in patients with liver disease due
to the potential for respiratory depression, hepatic encephalopathy, and drug interactions
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Summary
In summary, acetaminophen is often the preferred choice for analgesia in patients with liver disease
when used judiciously within recommended dosages
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Non-selective NSAIDs and certain
opioid analgesics should be used cautiously or avoided, particularly in patients with advanced liver
disease or compromised liver function
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Close monitoring of liver
function tests and symptoms is crucial during analgesic therapy in patients with liver disease
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Its pathogenesis involves multiple factors that contribute to liver damage and dysfunction
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Ethanol Metabolism:
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Ethanol Consumption: Alcohol is primarily metabolized in the liver
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Oxidative Metabolism: Ethanol is primarily metabolized by two main pathways: alcohol
dehydrogenase (ADH) and cytochrome P450 2E1 (CYP2E1)
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Mitochondrial Dysfunction: ROS production leads to mitochondrial dysfunction, impairing
energy production and promoting cell injury
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Hepatic Inflammation: These cytokines promote hepatic inflammation, recruiting immune cells
such as neutrophils and monocytes to the liver, exacerbating tissue injury and inflammation
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Steatosis (Fatty Liver):
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Imbalance in Lipid Metabolism: Chronic alcohol consumption disrupts lipid metabolism, leading
to the accumulation of triglycerides within hepatocytes, resulting in steatosis or fatty liver
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Endoplasmic Reticulum (ER) Stress: Ethanol-induced ER stress contributes to hepatocyte
apoptosis and liver injury
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Progression to Cirrhosis: Progressive fibrosis can lead to the development of cirrhosis,
characterized by extensive scarring and nodular regeneration of liver tissue, impairing liver
function
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Chronic and excessive alcohol
consumption disrupts various metabolic and signaling pathways in the liver, ultimately leading to

progressive liver damage, fibrosis, and cirrhosis
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Here are some key roles of the liver:
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Lipid Metabolism: It synthesizes and metabolizes fats, regulates cholesterol levels, and
produces lipoproteins for lipid transport
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It also converts ammonia to urea for excretion
(urea cycle)
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Detoxification and Excretion:
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Detoxification: The liver metabolizes and detoxifies drugs, hormones, and toxins by enzymatic
processes, converting them into less harmful or more easily excretable forms
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Bile also facilitates the excretion of
bilirubin, cholesterol, and other waste products
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Storage and Regulation:
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Glycogen Storage: The liver stores excess glucose as glycogen, which can be quickly mobilized to
maintain blood glucose levels between meals or during fasting
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Regulation of Hormones: The liver metabolizes and regulates circulating hormones, including
insulin, glucagon, and thyroid hormones
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Immune Function:
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Immune Surveillance: Kupffer cells, specialized macrophages in the liver sinusoids, phagocytose
pathogens, damaged cells, and foreign particles, contributing to immune surveillance and
defense
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