<TITLE: Abdominal Complaints 2
ACADEMIC DOMAIN: medicine
DISCIPLINE: internal medicine
EVENT TYPE: seminar discussion
FILE ID: USEMD080
NOTES: USEMD070 is part of the same course

RECORDING DURATION: 53 min 48 sec

RECORDING DATE: 8.10.2004

NUMBER OF PARTICIPANTS: 7

NUMBER OF SPEAKERS: 6

S2: NATIVE-SPEAKER STATUS: Finnish; ACADEMIC ROLE: masters student; GENDER: female; AGE: 17-23

S3: NATIVE-SPEAKER STATUS: Finnish; ACADEMIC ROLE: masters student; GENDER: female; AGE: 24-30

S4: NATIVE-SPEAKER STATUS: Finnish; ACADEMIC ROLE: undergraduate; GENDER: female; AGE: 17-23

S5: NATIVE-SPEAKER STATUS: Italian; ACADEMIC ROLE: masters student; GENDER: male; AGE: 17-23

S6: NATIVE-SPEAKER STATUS: Finnish; ACADEMIC ROLE: masters student; GENDER: male; AGE: 24-30

S7: NATIVE-SPEAKER STATUS: Finnish; ACADEMIC ROLE: senior staff; GENDER: female; AGE: 31-50

SU: unidentified speaker

SS: several simultaneous speakers>


<S7> so the group group is here nobody [else] <S6> [yes] yes </S6> okay </S7>
<S6> okay okay let's start let's start , i hap- i'm happy to [see you] </S6>
<S7> [before] before we start , you did not see this CT picture </S7>
<S6> no i didn't </S6>
<S7> from acute pancreatitis that's why i took it here </S7>
<S6> oh that's very kind of you </S6>
<S7> now because the others now know . what you can see here in this picture this is case C </S7>
<HANDOUTS BEING PASSED AROUND, P:05>
<S6> yes thank you thank you </S6>
<P:06>
<S7> the diagrams can be seen here </S7>
<S6> little little bit enlarged or </S6>
<S7> this is (xx) the legs are here and the head is over there <S6> yes </S6> so this is liver liver and it's co- the picture's coming further down here liver getting smaller smaller , and what can you see here </S7>
<S6> the pancreas </S6>
<S7> yes this is the pancreas which is swollen and this picture is very good there's two big necrosis spots in the pancreas that's swollen and <S6> mhm-hm </S6> this is necrotising pancreatitis , it's typical picture and when the picture comes down , further the pancreas disappears (xx) this is the be- best <S6> okay </S6> this is very typical . okay <S6> [okay] </S6> [you are] the chairman of of the next case <S6> okay [okay] </S6> [our] last case </S7>
<SS> @@ </SS>
<S6> so this is the last case and i happy to h- see you all here not all but er <SS> [@@] </SS> [you anyway] , so this was the case of this er middle-aged man who , who had some liver problems , and we can start of these liver-function tests but w- which are the most important and , where should they be taken , please help </S6>
<S7> <NAME S5> </S7>
<S6> [@yeah@] </S6>
<SS> [@@] </SS>
<S5> erm the transaminase </S5>
<S6> yeah transaminase [and wh- wh- yeah] </S6>
<S5> [transaminase is important] for to they can tell you if there was erm erm er a problem with the liver in a sense that er er it was injured say it was er , @okay@ er </S5>
<S6> yeah , er what er what which transaminase </S6>
<S5> er E-S-T and E-L-T <S6> yes </S6> erm , <S6> and [er] </S6> [they] tell you liver di- dimension they show liver dimension in this case it's er just we had just the er the E- E-L-T er that was elevated not the (xx) i don't know mhm the other one , you know , i don't know </S5>
<P:05>
<S2> i think it was interesting it's er here in the book er that er if er ALAT is less than 200 it could be caused by obesity and er use of alcohol so you don't necessarily have to be an alcoholic or have some kind of liver disease <S6> mhm </S6> so this could be normal for this patient </S2>
<S6> yes yes , yes er it was also said that er normally er the ALAT is the more important erm so you don't have to take the ASAT if you don't want to compare <S2> [yeah] </S2> [them] like in the alcoholic diseases you must compare the ratio . and if if the ratio is like two then it's above alcoholic , alcohol syndrome <COUGH> <P:07> and yeah it was interesting that the you know where the these transaminases are located in the cell it was also said in the book . like ALAT is in the cy- cytoplasm and the ASAT is all in the cytoplasm and in mitochondria so <S5> [yeah] </S5> [that's why] the ALAT rises more easily </S6>
<S3> and is more specific </S3>
<S6> yeah more specific that's right , <COUGH> </S6>
<S5> and then there are the serum albumin and protein (xx) to to see to see the capacity of the liver to to <SIC> synthetise </SIC> proteins and so you you see how it work <S6> [yes] </S6> [it] worked </S5>
<S2> it also said here in the book that er you don't need this gamma-GT very often because it doesn't really give any additional information if <S6> [yeah] </S6> [you have] taken the ALAT , but i think they do it like quite a lot [gamma-GT] </S2>
<S6> [yeah yeah] i think so too maybe too often waste of money <S2> @yeah@ </S2> waste of money and <COUGH> . and then there was this , what the the alcohol-specific test maybe you were telling about it one time , the C what was the </S6>
<SU-4> [the CD- yeah] </SU-4>
<S3> [(xx) transferrin] </S3>
<S5> yeah it was for </S5>
<S3> CDT </S3>
<S6> yeah [CDT] <S5> [CDT] yeah </S5> , what was the problem with that was it expensive or why don't they use it , [so often] </S6>
<S5> [i think] somewhere they use also for alcohol test something like that <S6> [mhm] </S6> [but] , er </S5>
<S6> yeah it's very specific </S6>
<S5> yeah it is specific and more erm there are other ways to control the alcohol <S6> mhm </S6> <SIC> addictation </SIC> @do you say@ </S5>
<S6> yes yes , it will go down in two or three weeks [when you s- when] </S6>
<S2> [so what was the] thing you said , [C-] </S2>
<S6> [CD-] </S6>
<SS> CDT </SS>
<S6> it's a c- carbohydrate deficient transaminase or something CDT </S6>
<S2> where did you hear about it </S2>
<S6> [it was in] </S6>
<S2> [it's not] in the @book@ </S2>
<S6> yes it [is in the in the book] </S6>
<S4> [yes yeah] </S4>
<S2> [oh] </S2>
<S6> it is in the <S2> [okay] </S2> [book] , you must read more precisely <SS> [@@] <S2> [@yeah@] </S2> </SS> okay then we had this </S6>
<S7> what about i'm interested in CDT how quickly does it go up </S7>
<S6> it goes up </S6>
<S7> after heavy drinking </S7>
<S5> er was it the transferrin or </S5>
<S6> no no this [CDT] </S6>
<S5> [no] uh-huh CDT yeah </S5>
<S6> h- do you do you know how how fast it goes up . i think it was said here , nobody knows . nobody knows , nobody knows </S6>
<S7> but one m- one must be sober for three week </S7>
<S6> yes two to three weeks then it it's normal <S7> okay </S7> , yes . okay what else , then we have this galactose which is like shows the function how it how how the liver functions it can be used in some cases <P:06> good what else <P:10> so what are the indications for biopsy , like in this our case w- they didn't take the biopsy </S6>
<P:05>
<PHONE RINGS, S7 ANSWERS>
<S5> (xx) because (xx) is used to drink and we see that that that drinking alcohol make you erm there is a passage from fatty liver then you have alcohol hepatitis and then cirrhosis and it's er and it's a progress <S6> [mhm] </S6> [to] to that so , sometimes biopsy is is good to to see how is the the liver er er which state is the liver which liver is liver er , but in this case i don't know if maybe he's not so er er usef- used to to to drinking er to <S6> mhm </S6> erm , and you don't have erm to use er indication of er liver dimension , maybe . if you not do the [biopsy yeah] </S5>
<S6> [yeah] because it's also , it's not er there's maybe some risks also which one you take <S5> yeah </S5> , [comp- complications] </S6>
<S7> [what could be the] what could be @the risks@ </S7>
<SS> bleeding </SS>
<S7> it's terrible if they go go from here <S5> mhm </S5> they usually go they can er the ar- intercostal artery can be involved and the bleeding can be very large <S6> yes </S6> several litres i have seen a thoracotomy a- after liver biopsy </S7>
<S2> so the blood doesn't come from the liver it comes from the [(xx)] </S2>
<S7> [yes intercostal] artery <S6> oh </S6> <S5> @mhm@ </S5> especially if the patient has cirrhosis so the the clotting <S6> [yeah] </S6> [(is defected)] it's it might be dangerous </S7>
<P:05>
<S6> er yeah what are the contraindications for , er they are said there (like er) <P:16> well if the if the liver is too bad there's usually the if the thrombocytes are less than 60 , that's something else then yes yes good <COUGH> </S6>
<S2> er what does it mean it says here that extra-hepatic er jaundice is contra- <FOREIGN> vasta- vai mikä se oli </FOREIGN> </S2>
<S6> [contraindication] </S6>
<S3> [contraindication] </S3>
<S2> @contraindication@ what does it mean , <S7> mhm </S7> <S6> uh </S6> , i mean how can you have er jaundice which is not extra-hepatic </S2>
<S6> which is not extra-hepatic if it's intra-hepatic </S6>
<SS> @@ </SS>
<S2> @how can you see it@ </S2>
<S6> i don't know . maybe from er , <S7> [the st-] </S7> [ult-] ultrasound or </S6>
<S7> yes the stone in the in the m- main bile duct it's the extra-hepatic </S7>
<S6> mhm </S6>
<S2> oh i thought they meant like <S7> no </S7> @(xx)@ okay </S2>
<S7> all the bil- all bilirubin come from liver </S7>
<P:13>
<S6> [and the] </S6>
<S5> [of course] i think i think about the biopsy it's th- y- on the liver so you have to decide where to do the biopsy and if you have focal lesion you could ruin the biopsy not and and this patient doesn't have focal le- lesions just er enlarged bright liver <S6> [mhm] </S6> [so] so so you can do it but you don't know what er you are going to to find and it's it's @difficult@ , this case (xx) case @but@ but i think it's er a good er reason to to have biopsy and </S5>
<P:05>
<S6> mhm <S5> @mhm@ </S5> i didn't quite understand but </S6>
<S5> @well@ </S5>
<SS> [@@] </SS>
<S6> [or i didn't understand the] </S6>
<S5> [no that's er] on this on the sorry on the ultrasound <S6> [mhm] </S6> [they] didn't find any focal lesion <S6> yes </S6> so the biopsy er it's er if you have er focal lesion you <S6> [mhm] </S6> [b- the] you do the biopsy there and you try to <S6> [mhm] </S6> [to see] how is the tissue [and er] <SS> [mhm] mhm </SS> if not er er it's not a good idea to do the biopsy </S5>
<S6> if there's not focal </S6>
<S5> focal i think or er </S5>
<S6> but if there's but there [may be] </S6>
<S5> [in this case] no focal lesion </S5>
<S6> but there may be some cirrhosis or some parenchyma like if the full liver the whole liver is , is er [diseased] <S5> [no] no </S5> then the biopsy may give some information <S5> yeah yeah </S5> of the [status] </S6>
<S5> [yeah] yes mhm-hm (xx) because of the the sizes and mhm @i don't know@ </S5>
<S6> well anyway <P:07> <COUGH> what else </S6>
<S5> then there is the se- serum iron and transferrin saturation to to see if there there was hemochromatosis [(xx)] </S5>
<S6> [yes] yes </S6>
<S7> i'm very interested in hemochromatosis <S6> okay </S6> what happens [in hemochromatosis] </S7>
<S6> [so who who wants] to give us information </S6>
<S5> well it's er increasing er intestinal circulation and submission of <S6> yes </S6> iron <S6> [what] </S6> [and] that er cause an deposition of iron , and er </S5>
<S6> and what are the w- what is the reason for the [er what was] </S6>
<S5> [i think there is] er a genetical one <S6> mhm </S6> er er i think a secondary one er . (xx) iron-loading anaemia one had (xx) anaemia and (xx) <P:05> and there is a specific er genetical test to to see <S6> [mhm] </S6> [if it is] a genetical one and er . they made the serum iron transferrin saturation to understand if w- if it could be er hemochromatosis but it was known so . and it c- it can cause er failure of the tissue in <S6> [yeah] </S6> [this case of] of the liver <S6> [yeah] </S6> [and] deposit on parenchymal cell cells and they don't work <S6> yeah </S6> (er) because (if you should) (xx) impaired functions and </S5>
<S6> yes yes and it may also the iron may accumulate to other organs like in the heart <S5> [yeah] </S5> [and] and er joints , <S5> yeah </S5> and what else some- something else </S6>
<S5> it can [(xx)] </S5>
<S3> [the skin] </S3>
<S6> skin yeah yeah </S6>
<S5> it can cause er (xx) arthritis and hypogona er <S6> [hypogonadi] </S6> [dotrophic] @@ hy- hypogonadotrophic <S6> yes </S6> hypogonadi </S5>
<S6> yeah yeah er it affects the hypothalamus <S5> yeah </S5> hypophysis . good good what is the treatment for hemochromatosis <P:05> it's the or it was the vene- venesection or i don't know <S3> yeah </S3> you take blood out <S5> yeah and you </S5> very much blood out </S6>
<S5> [yeah] </S5>
<S3> [was it] every week you take </S3>
<S6> it was er </S6>
<SU-4> i don't think so </SU-4>
<S6> it was uh </S6>
<S5> i think there was two ways one of er to , er <COUGH> not not take all the blood you </S5>
<S6> no not all blood </S6>
<S5> you take blood out and you clean how you say you take out [the iron] <S6> [yeah] mhm </S6> and then there was another way i think er , something like er the molecule that bind er <S6> mhm </S6> bind the iron or make it erm increase the er the number of iron that you lost with <S6> yes yes </S6> [just a] </S5>
<S6> [but i] think it was said that er the taking blood out it's it's better (xx) better , i think it was in the beginning when you find the disease you must take quite a lot of blood . and and then w- when the when you have taken the storage iron out then you you don't have to take blood so much anymore like once per year or something , i don't remember but not not so often anymore </S6>
<S2> and do this patient have like high haemoglobin or is it normal <S4> [yeah] </S4> [before] they have been treated </S2>
<S4> not necessarily </S4>
<S7> this is not polycythemia </S7>
<S2> so what happens when they take , like you don't let blood every week does it drop </S2>
<S7> haemoglobin </S7>
<S2> yeah </S2>
<S6> yeah maybe it it drops </S6>
<S7> it drops of course , that's like donadi- donating blood the haemoglobin goes down a bit , i'm very interested , which are more often diseased men or women . concerning hemochromati- chromathosis </S7>
<S3> i think men </S3>
<S6> yeah , yeah but maybe because women lose more [iron] </S6>
<S7> [yes] </S7>
<SS> yeah </SS>
<S6> they have this disease </S6>
<SS> [@@] </SS>
<SU-3> [@this chronic disease@] </SU-3>
<P:06>
<S6> and then we had also these other metabolic liver diseases like wilson's disease and alpha-antitrypsin i don't know anything about those , they can they can cause liver disease , liver malfunction </S6>
<S7> what is the mechanism behind wilson's disease </S7>
<S6> it is the what is it </S6>
<S3> there is a copper accumulation <S6> yes </S6> not the iron </S3>
<S6> yeah </S6>
<S2> is that the disease where you can see the ring in the , <S7> yes </S7> eye yeah </S2>
<S7> i have seen two patients with di- wilson wilson's disease er before liver transplantation <S6> [oh] </S6> [they] had that typical sign in the in the eyes what is that what is that call called </S7>
<S2> er it says here that er kayser-fleischer ring </S2>
<S7> kayser-fleischer ring </S7>
<SS> @@ </SS>
<S2> it also says something about er sunflower cataract <S7> yeah </S7> i don't know what that is </S2>
<S7> erm in the te- terminal phase of the wilson's disease the patients they also get the encephalopathy they are absolutely mad before they get the the new liver which which is totally destroyed by the copper </S7>
<S6> oh okay . is it is it same kind of encephalopathy as a as in cirrhosis or other liver diseases <S7> yes </S7> yes <P:11> then </S6>
<S4> was the encephalopathy due to the fact that liver doesn't er metabolise any more of those toxins and they go to the brain </S4>
<SS> yeah </SS>
<S2> so it's not really about the copper or </S2>
<S7> in wilson disease the copper is the most (p- profund) in the aetiology of encephalopathy but in in the terminal phase of cirrhosis whatever is the cause they get encephalopathy and they can they can be even unconscious your brain <S6> [yeah] </S6> [gets] swollen . i have seen it very many times , and they die due to herniation of the , small brain because the brain gets so swollen </S7>
<P:07>
<S6> alright , then , what about er fatty liver <P:05> i think it was the case </S6>
<S2> well there's fat in the liver @cells@ </S2>
<P:11>
<S5> er and (xx) increased er the , er in the , ALAT is metabolised in er (xx) w- which is er er hepatotoxic and they they decrease the number of er er lipoprotein er made from the tri- triglycerides glycerides <S6> mhm </S6> so there is a combination of er fat er , do we say er <S6> [mhm] </S6> [fatty] acids in the in in the liver <COUGH> , er fatty acids and triglycerides </S5>
<S6> and it also </S6>
<S5> and it's irreversible </S5>
<S6> yeah it's irrev- yes , <S5> okay </S5> yeah and then there were some other mechanisms of o- of alcohol how how the alcohol makes fatty liver . it also affects the , the cell wall or cell surface and makes it more more makes it more easy for the fatty acids to go inside <S5> [(enter mhm)] </S5> [cells] , and it also er alcohol also releases fatty acids from the fat tissue which was the , liver </S6>
<S5> you have the (empatomy) er (xx) and the transaminase are increased (xx) elevated and then i saw that it suggests er a liver @biopsy@ b- er because er you can see diffuse er cen- centro-lobular fat erm occupy the muscle <S6> mhm </S6> (xx) and so @@ this biopsy i don't know </S5>
<S6> so does it make any different t- where the fat is is it centro-lobular or or <S5> [mhm] </S5> [panlobular] is there is there any significance , if you take the biopsy and you see , does it tell you something , <S5> mhm </S5> i don't know . do you know about this microvesicular and mac- macrovesicular types , i didn't really understand it it was in the book but , have you have you heard of it , no </S6>
<S5> micro (xx) </S5>
<S6> micro and er micro and macrovesicular , it was something that the the fat drops they they can be like like very small vesicules or or then they can be large vesicules and in some depending on the aetiology of the fatty liver it can be either micro or <S5> mhm </S5> macrovesicular </S6>
<P:05>
<S7> how the fatty liver gets cirrhotic . all alcoholics first have fatty liver <P:12> i guess that the the fat gets cirrhotic <SS> mhm </SS> , it must be the mechanism . i don't know how many [(xx)] </S7>
<S6> [or is] it er because the portal hypertension , mhm if it has some- something to do </S6>
<S7> the pressure in the portal vein gets up , in cirrhosis and fibrosis but not with the fatty liver </S7>
<S6> oh </S6>
<S5> after because of the fibrosis [(xx)] </S5>
<S7> [yes] , the pressure i- the intrahepatic pressure gets , increases because it's totally fibrotic <S5> yeah </S5> and the tissue is tissue is </S7>
<S6> so is it is it never the hyp- portal hypertension associated with the fatty liver [only] </S6>
<S7> [i don't] think so <S6> no </S6> i'm not sure </S7>
<S6> okay , okay <P:06> so it's fi- first the fatty liver and then the , the cirrhosis develops maybe [sometimes] </S6>
<S5> [mhm (xx)] for alcohol hepatitis and then cirrhosis yeah </S5>
<S6> yes , and then there can be some complications of the , what are the complications , in cirrhosis </S6>
<S5> mhm </S5>
<S2> haemorrhoids </S2>
<S6> haemorrhoids yes yes </S6>
<S5> a h- a heart is inju- injured </S5>
<S6> good </S6>
<S7> have you , <S5> mhm </S5> how is a cirrhotic looking like </S7>
<S5> how [is] </S5>
<S6> [cirrhotic] person </S6>
<S7> yes you can see the cirrhosis when you look at the patient . how are they , their [appearance] </S7>
<S6> [they] they are tired [er] </S6>
<SU-4> [(haemorrhoids)] </SU-4>
<S7> they can be absolutely [normal] </S7>
<S6> [yeah] okay </S6>
<S5> i think er jaundice <SU> mhm-hm </SU> jaundice </S5>
<S6> jaundi- and they may have these <S5> spider [(angiomas)] </S5> [spiders] </S6>
<S3> and caput medusae </S3>
<S5> yeah </S5>
<S6> caput medusae yeah </S6>
<S2> scratching marks </S2>
<S6> scratching marks </S6>
<S4> ascites </S4>
<SS> [@@] </SS>
<S6> [ascites , ascites] </S6>
<S7> where does the ascites come from . when you're big like this </S7>
<P:05>
<S2> i think it's the same thing when you're having hypertension so you have er s- your legs are swollen because the fluid goes to extra , cellular space </S2>
<S6> but is it the is the same mechanism because i've been thinking about this </S6>
<SS> @@ </SS>
<S2> @i don't know [i just thought that]@ </S2>
<S6> [because i mean] when when the legs are swollen er is it isn't it because of the protein [lack of protein prot- lack of] </S6>
<S5> [yeah well probably it was] in this case because albu- albumin <S6> yes </S6> is going is increasing <S6> mhm </S6> so probably a lot of liquids are [going out] </S5>
<S6> [mhm] but is it is it same with the ascites [is it the pro-] </S6>
<S7> [why do the] cirrhotic cirrhotics have ascites if if the your patient has the , heart failure , the legs can be swollen but the belly is nor- normal why why comes where comes the ascites from </S7>
<S5> from blood (xx) </S5>
<S7> they can have seven litres of fluid in the abdominal cavity </S7>
<S6> yeah but is it because of the portal hypertension </S6>
<S7> yes , and there's a huge lymphoid tissue in the centrum of of the liver and the when the portal gets hypertensive the lymphoid tissue takes the extra fluid off , but when the pressure is high enough the lymphoid tissue is unable to re- remove it because the amount of fluid is so mu- big , so that's that is spillover of fluid of abdominal fluid </S7>
<P:11>
<S6> okay </S6>
<S7> so that's local spillover of fluid and it's in the liver and the fluid goes into the free abdominal cavity </S7>
<S2> is it so that because of the pressure in the <S7> yes </S7> er so the fluid is coming away from the <S7> yes </S7> the vessels okay </S2>
<S7> from portal port- portal vein , the normal liver transplantation starts first they open the abdomen and then they take seven litres of fluid out and then they start to remove the the si- diseased liver and put the new one in </S7>
<P:05>
<S6> do you know how long the procedure takes </S6>
<S7> yes i i have done it for 15 years </S7>
<SS> @@ </SS>
<S7> they always come the new liver comes at 11 o'clock in the evening and the operation is ready at six o'clock in the morning </S7>
<S6> d- why why do they work during the night </S6>
<S7> because the diagnosis of brain death it always happens in the afternoon in the intensive care unit and so the donor is ready in the afternoon and they , the transplantation group goes late afternoon to the donor takes the donated liver off and then they travel with the liver to helsinki and the operation starts in the evening </S7>
<S6> so so they are the same surgeries s- same person who takes it out <S7> [no no no] </S7> [and put no no they have to be] different okay </S6>
<S2> when you take the er old liver away how do you do er you have the portal vein <S7> yes </S7> it's bleeding very much how do you </S2>
<S7> they have four forceps first they fi- first they clamp the portal vein and then they clamp the superior cava so the the old liver is , is separated from the circulation and then they clamp the vein vena cava in two places er and of course the hepatic artery , hepatic artery portal vein and then superior vena cava up and down four forceps and then they took it away take it away and put it to the basket </S7>
<SS> @@ </SS>
<S5> do they put something in it or just er some solution (at the end) </S5>
<S7> yes it's wisconsin solution or in the new liver is is it's it's in solution <S5> mhm </S5> w- water and electrolytes and it er the new liver can be stored in that solution for eight hours and that's maximum if if the new liver waits more than eight hours they get difficulties the the new li- liver function doesn't start very quickly , so they they are important hours when the new liver is in the package they they must be very fast </S7>
<S2> what do you do if the donator is in sodankylä do you </S2>
<S7> they fly </S7>
<SS> @@ </SS>
<S6> [(xx)] </S6>
<S5> [with the heart] [with the heart transplants they're flying too] </S5>
<S7> [no they go they go to rova-] rovaniemi </S7>
<S2> okay </S2>
<S5> there er with the heart transplant is er is [less time so] </S5>
<S7> [that] yes that the heart can wait for four hours <S5> four hours yes </S5> it's even even more busy but the kidneys can wait for 36 hours they are not so resistant for anopsia <S5> mhm </S5> . that's very interesting work , you can see the patient before liver transplantation , after two weeks of of transplantation the patient is totally different , good humour walking eating , ha- having normal life </S7>
<S2> can you if you the donator is a small child can you use the small liver <S7> yes </S7> to adult </S2>
<S7> yes but w- we see very very seldom we see paediatric donors </S7>
<S6> @@ what about o- other way can you give a b- large [(liver)] </S6>
<S7> [they can] they can cut the an adult liver and give the the rest , two two pieces of the liver for two patients <S6> oh </S6> . and the paediatric kidneys they can be that small and when they are p- when these kind of kidneys they are put t- into an adult patient they grow up in an adult in the adult and after one year they have grown up for nor- to normal <S6> @mhm@ </S6> , that's very interesting and <S5> amazing </S5> the paediatric kidneys are excellent they always work and they always function for years and longer times than don- er kidneys from adult donors . perfect perfect kidneys </S7>
<P:06>
<S6> in the textbook they said it said that nowadays they give livers even from for alcoholics <S7> yes </S7> do what do you think about it is it ethically right </S6>
<S7> i have seen a liver transplantation where an alcoholic , received a new liver from an alcoholic , i think it was good <SS> @@ </SS> the alcoholic liver was fatty liver and it recovered <S5> oh </S5> , but of course the total survival with a new fatty liver is not not as the same the same <S5> [yeah] </S5> [as] as healthy liver , they get difficulties infections bleeding , complications are more (obvious) </S7>
<S2> what if er you're an alcoholic and you get one liver and you drink so much that you need another liver do they give it to you </S2>
<S7> not in finland , erm in finland they have a rules , you you must show that you can live without alcohol for six months , thereafter you get a new liver , and you must have a social contacts that an alcoholic can tolerate the immunosuppression and medication and take and take care of her- herself or himself . and the transplanted liver does not tolerate alcohol as good as the own liver , it gets it gets more easily destroyed with alcohol , so if you get a new liver because of alcohol you must stop drinking absolutely <P:08> and they do it . and they are in very tight control those alcoholics . but in USA you can have a second liver , with money </S7>
<S2> it was this actor er er <S7> yes </S7> larry hagman </S2>
<S7> J R </S7>
<SS> [@@] </SS>
<S2> [@yeah he's had many livers@] </S2>
<S7> yes , dallas </S7>
<S2> do you have to control like er take these gamma-GT or some blood tests [afterwards] </S2>
<S7> [C- CDT] is quite good <S2> okay </S2> they take it very often </S7>
<S5> what about rejection er re- rejection <S7> yes </S7> it's er it is not usual on the liver [rejection] </S5>
<S7> [yes] the rejection starts immediately and it's on the worst during the first week of transplantation but it's not a v- very big problem in liver transplantation , sometimes <S5> mhm </S5> the liver gets totally rejected , and it must be ta- taken off and made a new tra- second transplantation <P:06> they have done about 500 liver trans- transplantations in finland , and 80 per cent of the patients are living <P:08> i have written down here a word chronic liver diseases </S7>
<P:18>
<S6> but w- we have just been discussing </S6>
<SS> @@ </SS>
<S7> discuss more <P:08> there are two weird tests your colleague took , I-G-A I-G-G I-G-N </S7>
<P:18>
<S2> is it because of the suspicion of hepatitis or </S2>
<P:08>
<S6> er but er he also took hepatitis C and B (separately) </S6>
<S2> yeah maybe he was too careful </S2>
<S6> @yeah@ . or are they immunoglobulin like the function tests , more like a fu- you measure the function of the liver , i don't know </S6>
<S5> we need to see er was there vasculitis er vasculitis yeah vasculitis there </S5>
<P:08>
<S6> do do they these immunoglobulin show vasculitis or what </S6>
<P:10>
<S5> erm they can er if they can but (it would be anaemia) hyper @(xx)@ </S5>
<P:24>
<S7> what about the ch- cholesterol </S7>
<P:13>
<S6> it was it was a little bit elevated , but then it went to normal </S6>
<S4> but in cirrhosis it can be decreased </S4>
<S6> yes </S6>
<S7> in cirrhosis we can see values about three very low <S6> yes </S6> and it doesn't mean that the patient could not have atherosclerosis or choles- cholesterol diseases , the synthesis is decreased in cirrhosis </S7>
<S6> but is there in the in the blood is there still cholesterol in the blood <S7> no </S7> no <S7> no </S7> but er what about the the cholesterol that comes from the diet , where where does it go , how does it work or er does it get abs- absorbed [at all no] </S6>
<S7> [no i don't think] so , i'm not sure . however the cholesterol synthe- synthesis is decreased in cirrhosis <S6> yeah </S6> , so cholesterol is sy- synthesised from fatty acids . so the synthesis is decreased , not the breakdown of fatty acids </S7>
<S6> mhm-hm </S6>
<P:08>
<S5> i was i was thinking er in cirrhosis er is increasing the the production of protein or something of a of a </S5>
<S6> is it it it's decreasing </S6>
<SU-2> [yeah] </SU-2>
<S5> [decreasing] sorry @decreasing@ so probably also the lipoprotein are going to decrease <S6> mhm </S6> so maybe in the blood the cholesterol is going to increase because of the free cholesterol because there are <S6> yeah like m- </S6> proteins that bind the cholesterol but i don't know very well i think [there er there aren't enough there aren't so] </S5>
<S2> [is there , yeah] </S2>
<S3> [there is no free cholesterol in the cell] i think so [i think s- they are] </S3>
<S2> [these er] <S5> yeah </S5> LDL and HDL they are all <S5> [yeah] </S5> [proteins] i think </S2>
<S6> [mhm] </S6>
<S5> [yeah] so er so , <SS> @@ </SS> i don't know about the mechanism , if they there are low proteins what happen </S5>
<S6> then the cholesterol cannot travel </S6>
<S5> [uh-huh so] </S5>
<S2> [yeah] there's no proteins there's no cholesterol </S2>
<S5> yeah </S5>
<S6> yeah and also the dietary cholesterol maybe it it cannot be absorbed <SS> mhm yeah </SS> because , because there are no proteins to take it in , @@ maybe because what was the big protein that takes it in the intestine , the not not VLDL but <S5> H er </S5> not HDL but </S6>
<S5> NDL @i don't know@ (xx) </S5>
<S6> it's the protein complex that takes in the in the first phase takes take the cholesterol and then it goes to the , mhm er </S6>
<S3> do you mean the kilo- <S6> yeah </S6> @micrones@ </S3>
<SS> [@@] </SS>
<S6> [micrones] yeah [kilomicrones] </S6>
<S3> [but i] but i think is there any protein in [those particles] </S3>
<S2> [yeah i think that it] just like goes to the without any </S2>
<S3> i think it's just pure fat @@ </S3>
<S6> kilomicrones </S6>
<S2> [yeah] </S2>
<S3> [yes] but i'm not sure </S3>
<S6> okay [but i think that there is also some protein in the kilomicrones] </S6>
<SS> [@@] </SS>
<S7> carrying protein you mean <S6> yes </S6> , i don't remember do you , what says the book </S7>
<S6> i don't know </S6>
<S2> i don't think there's anything about that </S2>
<S3> wait a second </S3>
<S6> because i remember that the heaviest er er proteins were , was it that HDL is the heaviest and the lightest is kilomicron , of the carrier proteins , carrier (xx) er somehow i think that there is some [proteins involved] </S6>
<SS> [@@] </SS>
<S5> about chronic hepatitis it says here i think that <COUGH> it's it's difficult to to catch it because the (xx) and usually it's caused by hepatitis B and C or there is also a autoimmune hepatitis <S6> mhm </S6> and in this case er you have inflammation , fibrosis and hypergamma globulinanaemia so maybe it's that the reason you you go to see the [(doctor)] </S5>
<S6> [mhm] er in autoimmune hepatitis [yeah auto- auto-] </S6>
<S5> [auto- auto-] autoimmune </S5>
<S6> okay so that's why they took it </S6>
<S5> maybe yes maybe that's the reason </S5>
<S7> there is typical autoimmune hepat- hepatitis which cause mhm w- which is going to cirrhosis in in women , primary biliary cirrhosis , and in that disease the mitochondrial antibodies are elevated </S7>
<P:10>
<S2> oh i'm a bit confused about this hepatitis thing so you can have virus hepatitis and this autoimmune can you have hepatitis which is caused by alcohol if there's no , <S7> yes </S7> no bacterial viruses </S2>
<S7> yes you can have <S2> okay </S2> i i have seen quite many and they are they are acute hepati- -titis and almost almost all of them they die , and the the prognosis ve- is very bad the liver gets necrotic <S2> [is it] </S2> [but] they they drink heavily </S7>
<S2> okay er is it a com- common disease <S7> no </S7> so that if you drink a lot you are most likely to get er pancreatitis [and] </S2>
<S7> [no] you are most like- er most likely you have to have fatty liver <S2> okay </S2> , and the alcohol is er it's different for different people some gets brain disease wernicke encephalopathy , some get pancreatitis some get fatty liver and some patients get very easily cirrhosis </S7>
<S6> but i think i i read in the book that er that in finland the most hepatitises are are of alcohol are from alcohol and it was like 80 per cent of the of the <S3> [or nine] </S3> [hepatitises] is due to alcohol </S6>
<S3> yeah well yeah maybe 80 <S6> 80 </S6> yeah </S3>
<S6> and but in italy it was 50 , because [in italy] </S6>
<S5> [due to] alcohol </S5>
<SS> [@@] </SS>
<S6> [yeah 50 50 per cent of their hepatitises] is due to alcohol <S5> oh </S5> and [er] </S6>
<S3> [and] cirrhosis also </S3>
<S6> yeah and the the rest is beca- because of the vi- virus because you have [so much more virus aetiology] </S6>
<S5> [that is , yes] because of the transfusion </S5>
<S6> yes because of the transfusion </S6>
<S5> they didn't control the the blood so </S5>
<P:07>
<S2> is it possible that er an alcoholic that if he doesn't get any of these diseases that he lives like 120 years </S2>
<S7> yes i have seen people who have been drunk for 20 years <SS> @@ </SS> , some are lucky some are not </S7>
<SS> @@ </SS>
<P:22>
<S7> okay <S6> good </S6> are we ready <SS> yeah @@ </SS> i thank you you have been a very good group i have enjoyed these sessions and what do you say about the last case is this , they [were good] </S7>
<S2> [it was] okay </S2>
<S7> okay </S7>
<S3> it's alright </S3>
<S7> thank you </S7>
<S6> thank you and thank you </S6>
