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Liver Disease

Diseases Liver

Liver is the largest internal organ of the body which is present on the right side of abdomen. It is a fleshy and rubbery organ, brown in colour, has an ability to regenerate and is responsible to control over 500 vital functions. It is responsible for exocrine, endocrine, absorptive functions, postabsorbative and immunological clotting functions [1]. Liver helps in metabolizing nutrients from small intestine, it detoxifies harmful substances from bloodstream like drugs and alcohol. The organ produces proteins and stores nutrients, it secrets bile and helps in the metabolism of drugs. Any of the factors affecting the vital functions of liver can result in liver disease.


Presentation

Most common liver diseases are fibrosis, cirrhosis and liver inflammation due to infections. Liver cirrhosis occurs due to scar tissue replacing normal liver cells because of chronic liver pathology. Symptoms of liver disease include weakness, fatigue, nausea, vomiting, weight loss, yellow discoloration of skin, yellow urine, pruritis, abdominal discomfort and pain, loss of appetite and inability to digest fatty food.

In cases of liver failure the symptoms are much worse and the patient may become confused, disoriented, and fatigued. This can lead to coma and sudden death [6]. If liver diseases are treated at the very initial phase, then there is a good chance of the person recovering well. Biliary tract obstruction, cholelithiasis and cholecystitis are biliary tract problems which can predispose to metabolic disorders.

Recurrent Bacterial Infection
  • Abstract Common variable immunodeficiency (CVID) is the most common form of primary immunodeficiency characterized by antibody deficiency, recurrent bacterial infections, and autoimmunity.[ncbi.nlm.nih.gov]
Short Stature
  • Abstract Noonan Syndrome (NS) is characterized by short stature, typical facial dysmorphology and congenital heart defects. The incidence of NS is estimated to be between 1:1000 and 1:2500 live births.[ncbi.nlm.nih.gov]
Easy Bruising
  • Kidney disease or failure Easy bruising and severe bleeding. This happens when the liver stops making proteins that are needed for your blood to clot. Type 2 diabetes.[hopkinsmedicine.org]
  • […] symptoms may include: Fluid buildup of the legs (edema) and in the abdomen ( ascites ) Yellow color in the skin, mucous membranes, or eyes ( jaundice ) Redness on the palms of the hands In men, impotence, shrinking of the testicles, and breast swelling Easy[nlm.nih.gov]
  • Symptoms of liver cancer may include any of the following: Abdominal pain or tenderness, especially in the upper-right part Easy bruising or bleeding Enlarged abdomen ( ascites ) Yellow skin or eyes ( jaundice ) Unexplained weight loss Treatment depends[nlm.nih.gov]
Vomiting
  • Abstract A 56-year-old white female presented to the emergency room (ER) with acute onset of right upper quadrant abdominal pain, nausea, and vomiting, and she was found to have a sudden drop in hemoglobin.[ncbi.nlm.nih.gov]
  • […] blood, or blood in the urine Shortness of breath Vomiting more than once a day Yellowing skin or eyes (jaundice) that is new or gets worse quickly Talk openly to your provider about your alcohol intake.[nlm.nih.gov]
  • In 2016, the patient was admitted with compensated cirrhosis and splenomegaly for a ligature of esophageal varices which was complicated by vomiting of blood followed by severe coagulopathy and hemorrhagic shock.[ncbi.nlm.nih.gov]
  • […] the skin and rashes – for autoimmune hepatitis Anorexia – for drug-induced hepatitis Fluid accumulation – for alcohol-induced hepatitis Cirrhosis symptoms include: Foot and abdominal swelling Nighttime sleep difficulty and increased daytime sleeping Vomiting[houstonmethodist.org]
Nausea
  • Abstract A 56-year-old white female presented to the emergency room (ER) with acute onset of right upper quadrant abdominal pain, nausea, and vomiting, and she was found to have a sudden drop in hemoglobin.[ncbi.nlm.nih.gov]
  • Symptoms: Symptoms may include nausea, vomiting, loss of apetitie, weight loss due to portal hypertension, distension of abdominal veins, confusion, disorientation.[symptoma.com]
  • Symptoms of liver disease can also include nausea, loss of appetite, fatigue and diarrhea. As liver failure progresses, one may experience a swollen abdomen, confusion, sleepiness, bleeding easily and coma.[beyondceliac.org]
  • Nonalcoholic fatty liver disease Poisons and drugs Infections Heart disease Genetic diseases Autoimmune disorders Medications Symptoms Many liver disease symptoms include: Fatigue Appetite loss Skin yellowing (jaundice) Fever Abdominal pain and swelling Nausea[houstonmethodist.org]
Loss of Appetite
  • See a GP if you have symptoms of cirrhosis, such as: feeling very tired and weak all the time loss of appetite – which may lead to weight loss loss of sex drive (libido) yellow skin and whites of the eyes ( jaundice ) Other symptoms may include itchy[nhs.uk]
  • Symptoms of liver disease can also include nausea, loss of appetite, fatigue and diarrhea. As liver failure progresses, one may experience a swollen abdomen, confusion, sleepiness, bleeding easily and coma.[beyondceliac.org]
  • Early symptoms include: Nausea Loss of appetite Fatigue Diarrhea However, as liver failure progresses, the symptoms become more serious, requiring urgent care.[webmd.com]
Abdominal Pain
  • Abstract A 56-year-old white female presented to the emergency room (ER) with acute onset of right upper quadrant abdominal pain, nausea, and vomiting, and she was found to have a sudden drop in hemoglobin.[ncbi.nlm.nih.gov]
  • She was readmitted for acute abdominal pain with elevated blood pressure at 29 weeks of gestation. An emergency cesarean delivery was performed for severe preeclampsia. Her neonate was noted to have a distended abdomen.[ncbi.nlm.nih.gov]
  • pain and swelling Nausea and vomiting Dark urine Clay-colored stool Muscle and joint aches Weight loss Other symptoms include: Confusion – for hepatitis D and cirrhosis Abnormal blood vessels on the skin and rashes – for autoimmune hepatitis Anorexia[houstonmethodist.org]
  • Children may exhibit symptoms such as abdominal pain, which may be in the center or the right upper part of the abdomen, and sometimes fatigue. However, other causes of abdominal pain and fatigue should be considered.[patients.gi.org]
  • Seek immediate medical attention if you have abdominal pain that is so severe that you can't stay still. Causes Liver disease has many causes. Infection Parasites and viruses can infect the liver, causing inflammation that reduces liver function.[mayoclinic.org]
Upper Abdominal Pain
  • Later symptoms may include upper abdominal pain, fever, chills, night sweats, enlarged liver or spleen, weight loss or jaundice.[memorialhermann.org]
  • A person with gallstones may experience right upper abdominal pain and vomiting after eating a greasy (fatty) meal. If the gallbladder becomes infected, fever may occur.[medicinenet.com]
Jaundice
  • We present the case of a patient without any prior liver disease who developed obstructive jaundice and a liver abscess due to peribiliary cysts.[ncbi.nlm.nih.gov]
  • […] and weight loss Nausea Belly pain Small, red spider-like blood vessels on the skin As liver function worsens, symptoms may include: Fluid buildup of the legs (edema) and in the abdomen ( ascites ) Yellow color in the skin, mucous membranes, or eyes ( jaundice[nlm.nih.gov]
  • Evaluations of her jaundice revealed chronic parenchymal liver disease with multiple nodules in the liver with early portal hypertension.[ncbi.nlm.nih.gov]
  • Jaundice, or yellowing of the skin, can be one sign of liver disease.[niddk.nih.gov]
Hepatomegaly
  • CONCLUSIONS LAL-D should be included in the differential diagnosis of lipid metabolism disorder, hepatomegaly, and non-alcoholic fatty liver disease with fibrosis or cirrhosis.[ncbi.nlm.nih.gov]
  • Abdominal ultrasound revealed pronounced hepatomegaly, with inhomogeneous, slightly hyperechoic parenchyma without attenuation. The well-known metastasis could not be delineated easily.[ncbi.nlm.nih.gov]
  • Diarrhea Hepatomegaly Hepatic cirrhosis No change or slower progression of liver failure. Right-upper quadrant pain Resolution or marked improvement.[web.archive.org]
  • Characteristics of liver disease are jaundice, anorexia, hepatomegaly, ascites, and impaired consciousness. The exact diagnosis of liver disease is made through a combination of laboratory tests and clinical findings.[medical-dictionary.thefreedictionary.com]
  • Hepatomegaly and splenomegaly but not invariably. Cerebral oedema with increased intracranial pressure (ICP), may produce papilloedema, hypertension, and bradycardia. Liver palms are red and an hepatic flap, also called asterixis, may be present.[patient.info]
Asterixis
  • Constructional apraxia Patients cannot reproduce simple designs (e.g. a star of David) Drowsiness and confusion Parotid gland enlargement Spider angiomas Icterus Bilateral parotid swelling ( Credit ) Diminished axillary hair Spider angioma Gynecomastia in a male Asterixis[stanfordmedicine25.stanford.edu]
  • Abnormal findings suggestive of cirrhosis include: Jaundice Spider angiomata Palmar erythema Caput medusa Palpable left lobe of the liver Splenomegaly Ascites Clubbing Asterixis Gynecomastia Testicular atrophy Temporal wasting Hypertrophic osteoarthropathy[hiv.va.gov]
  • Hand tremor (asterixis). Jaundice (yellowing of skin and eyes). Weight loss. Nausea. Fatigue. Abdomen swelling (peritoneal ascites). Swelling of limbs (peripheral edema). Generalized edema (anasarca). Itching.[drugabuse.com]
  • Liver palms are red and an hepatic flap, also called asterixis, may be present. Hyperextend the fingers and wrist, gently pushing back and a slow clonic movement is the liver flap.[patient.info]
Hepatic Mass
  • We can learn that various possibilities must be considered before diagnosing and treating a hepatic mass.[ncbi.nlm.nih.gov]
  • Within a week after partial hepatectomy, which, in typical experimental settings entails surgical removal of two-thirds of the liver, hepatic mass is back essentially to what it was prior to surgery.[scitechnol.com]
  • AFP measurement is recommended if a focal hepatic mass is detected with ultrasound or other abdominal imaging. AFP level does not correlate well with other clinical features of HCC, such as size, stage, or prognosis.[hiv.va.gov]
Liver Palms
  • Liver palms are red and an hepatic flap, also called asterixis, may be present. Hyperextend the fingers and wrist, gently pushing back and a slow clonic movement is the liver flap.[patient.info]
  • Liver palms are red and an hepatic flap, also called asterixis, may be present: Hyperextend the fingers and wrist, gently pushing back and a slow clonic movement is the liver flap.[patient.info]
Quickening
  • The liver computational models might quicken the pace toward assessing personalized disease progression and treatment options.[ncbi.nlm.nih.gov]
Dark Urine
  • […] disease Poisons and drugs Infections Heart disease Genetic diseases Autoimmune disorders Medications Symptoms Many liver disease symptoms include: Fatigue Appetite loss Skin yellowing (jaundice) Fever Abdominal pain and swelling Nausea and vomiting Dark[houstonmethodist.org]
  • Symptoms Signs and symptoms of liver disease include: Skin and eyes that appear yellowish (jaundice) Abdominal pain and swelling Swelling in the legs and ankles Itchy skin Dark urine color Pale stool color, or bloody or tar-colored stool Chronic fatigue[mayoclinic.org]
  • Signs of liver disease that are more prominent are jaundice or yellowing of the eyes and skin, dark urine, very pale or light colored stool, bleeding from the GI tract, mental confusion, and retention of fluids in the abdomen or belly.[uihc.org]
  • In acute liver disease, symptoms related to problems processing bilirubin , including yellow skin and eyes ( jaundice ), dark urine, and light stools, along with loss of appetite, nausea, vomiting, and diarrhea are most common.[labtestsonline.org]
  • In acute liver disease, symptoms related to problems processing bilirubin, including yellow skin and eyes ( jaundice ), dark urine, and light stools, along with loss of appetite, nausea, vomiting, and diarrhea are most common.[labtestsonline.org]

Workup

The various investigations of liver dysfunction include complete blood count (CBC), liver function tests, ferritin, hepatic enzymes, bilirubin, ammonia, lactate, blood gases, creatinine, free copper, phosphate, viral markers and drug screening. Biopsy, CT scan and MRI may also be useful to diagnose liver diseases.

Gastric Varices
  • With BRTO, an interventional radiologist makes a small incision in the groin and, using live x-rays, maneuvers a catheter through a large vein in the body (the inferior vena cava) into the veins in the stomach (gastric varices), typically next to the[sirweb.org]
  • These veins—called varicose veins of the esophagus (esophageal varices) or stomach (gastric varices)—are fragile and prone to bleeding (see Gastrointestinal Bleeding ).[merckmanuals.com]
Hypercholesterolemia
  • KEYWORDS: Hypercholesterolemia; Lipoprotein x; Primary sclerosing cholangitis; Type 1 hyperlipoproteinemia; Xanthomas[ncbi.nlm.nih.gov]
  • N Engl J Med 2018; 378:e26 A 49-year-old man with severe hypercholesterolemia and a history of biliary cirrhosis presented with painful xanthoma striatum palmare, which abated after weekly low-density lipoprotein apheresis.[nejm.org]
Hepatocellular Carcinoma
  • Abstract Nonalcoholic fatty liver disease (NAFLD) represents a spectrum of disorders from simple steatosis to inflammation leading to fibrosis, cirrhosis, and even hepatocellular carcinoma.[ncbi.nlm.nih.gov]
  • Today is a certainty that fatty liver can complicate with cirrhosis and hepatocellular carcinoma; moreover, nonalcoholic fatty liver disease is the main cause of cryptogenic cirrhosis and the second cause of liver transplantation.[ncbi.nlm.nih.gov]
  • carcinoma in unusual clinical settings.[ncbi.nlm.nih.gov]
  • After the patient expired due to hepatic failure, an autopsy revealed poorly differentiated hepatocellular carcinoma (HCC) surrounded by multiple hepatic cysts.[ncbi.nlm.nih.gov]

Treatment

Patients with acute liver failure develop circulatory dysfunction. Fluid and hemodynamic support should be provided to these patients. Noting down and keeping a record of metabolic parameters, infection control, proper nutrition, and observation of gastrointestinal bleeding if any are steps of management of various liver diseases. Clotting factors, complete blood cell count, and liver functions should be measured time to time [7]. Serum aminotransferases and bilirubin are recorded daily to follow the pattern of the disease.

Antibiotics are given if liver disease due to infection. Penincillamine and zinc therapy are used in patients with metabolic diseases. Prednisone and azathioprine are given to suppress the immune system. Spironolactone and furesimide diuretics are used in patients with ascites. Lactulose and neomycin are employed to treat encephalopathy. Appropiate doses of vitamins help in the absorption of fat thus preventing fatty liver [8].

Prognosis

Prognosis of liver diseases is good in early detection of disease. Diet control and treating the underlying causes can help prevent liver dysfunction. Chronic cases like congenital anomalies, chronic liver failure and liver cirrhosis have a poor prognosis, where only intensive care can be provided to the patient by keeping a check over his liver functions and trying to improve the condition by supportive medication.

Etiology

Cytomegalovirus is the major cause of liver infections in most cases of acute liver disease. Hepatitis is the major causes of chronic diseases of liver. Azathioprine is responsible for acute cholestasis, but could not be identified as a direct cause of chronic disease.

Other viruses and diseases affecting liver are adenoviruses, coxsackie virus, rubella, yellow fever, arena viruses and ebola virus disease. Bacterial, fungal, spirochetal infections, rickettsial infections and vascular disorders like arteriosclerosis, amyloidosis, aneurysms, infarcts, eclampsia may also affect the liver function. Drug induced liver injury, portal vein thrombosis, veno-occlusive diseases, congenital disorders, right and left heart failure are some of the abnormalities possibly affecting the liver. Graft-versus-Host reaction, hepatic autograft rejection, autoimmune cholangitis and idiopathic adulthood ductopenia may lead to liver function disorders [3].

Epidemiology

The true reason for the liver disease precipitation is unknown; there can be many causes both external and internal that can induce liver diseases. Alcoholic liver diseases are common, which can cause liver cirrhosis and liver failure. Epidemiological studies vary quite a lot all over the world with respect to the prevalence and incidence of liver diseases. No predisposition in a particular population is found for liver diseases, but hepatitis B has an overall higher prevalence rate than hepatitis A and C in causing liver functional disorders [4].

Sex distribution
Age distribution

Pathophysiology

General pathology of liver diseases include cellular changes, reaction to any injury, inflammation, repair, fibrosis, tissue changes and cholestasis. Liver pathology is seen in two basic patterns, one is dystrophy and the second is necrosis. If broadly classified, the different pathological presentation of liver in different conditions is as follows:

In liver cirrhosis, autoimmune cells are present comprising predominantly of T lymphocytes, bile duct damage and vanished bile ducts. Accumulation of lymphocytes, plasma cells and histolytic are seen in the portal area.

Hepatitis, folic acid deficiency and hypovitaminosis may cause fatty liver. Hypoxia is an important factor in fatty liver infiltration. In long standing cases, fatty dystrophy of liver may follow.

When copper gets deposited in the hepatocytes it results in Wilson’s disease, it also affects central nervous system and joints. Urea synthesis disorder can lead to the accumulation of urea and hepatic encephalopathy. Hepatocerebral coma may be a result of hepatic disease, toxic liver dystrophy and cirrhosis.

Disorders of bile production can lead to jaundice, steatorrohea and cholemia. In cholelithiasis, there is an obstruction of bile duct and elevated levels of conjugated bilirubin, predisposing to clay like stools and black colored urine.

Alcoholic liver disease is characterized by hepatocyte swelling and necrosis, Mallory body formation, fibrosis and neutrophilic reaction. Portal hypertension is characterized by caput medusa (varicose veins of abdomen), ascites and splenomegaly [5].

Prevention

Stopping intake of alcohol and drug overuse can prevent progression of liver pathology. Vaccines should be administered in order to prevent occurrence of various types of hepatitis. Obesity and diabetes may cause fatty liver. Medicines should be used wisely. Contact should be avoided with people with infected blood and body fluids. Increase in body weight should be kept under check [9].

Summary

Classification of liver disease can be based on many types. Liver disease can be induced by variety of agents ranging from alcohol, drugs, infections, and hereditary causes. Infections may result from virus, bacteria and other pathogens.

Viral hepatitis (A, B, C, D and E) is a disease of major concern. Toxic agents like alcohol, drugs and environmental pollutants may also result in liver diseases. Autoimmune diseases and biliary cirrhosis cause liver injury. Autoimmune disease include Wilson's disease, Budd–Chairi syndrome, Chyle fistula, hemochromatosis, inborn error of metabolism, Antitrypsin 1 deficiency, and autoimmune hepatitis.

Hepatic cysts and hepatic hemangiomas are conditions which may result in liver malfunction. Benign neoplasm, malignant conditions, like hepatocellular carcinoma and adenoma, can also affect liver resulting in liver failure [2].

Patient Information

Definition: Liver disease is the dysfunction of any of the liver functions related to nutrition, absorption, digestion, blood clotting and toxin elimination. Any problem in the metabolic activities of liver relating to the vital functions of metabolism, clotting and immunogenicity may predispose to liver disease.

Cause: Causes of the liver disease can be alcohol overuse, drug misuse, obesity, diabetes, deficiency of multivitamins and obstruction of bile duct. Reasons of predisposition of liver disease can be hereditary which may include diseases like Wilson’s disease, Gilbert’s syndrome and antitrypsin deficiency. Other reasons are viral, bacterial and fungal infections.

Symptoms: Symptoms may include nausea, vomiting, loss of apetitie, weight loss due to portal hypertension, distension of abdominal veins, confusion, disorientation.

Diagnosis: Diagnosis may be made by presenting symptoms like itching, yellow discoloration of skin. Liver function tests and other diagnostic measurements are used in diagnosing liver diseases. Some conditions may require liver biopsy and imaging studies.

Treatment: Antibiotics are given commonly in liver disease. Treatment with diuretics, and other drugs is according to the disease condition [10]. Rifampin, naloxone, acetaminophen, azathioprine and multivitamins are other common drugs given in liver malfunction.

References

Article

  1. Previsani N, Lavanchy D. World Health Organization. Hepatitis B (WHO/CDS/CSR/LYO/2002.2). 2002
  2. Gray H, Lewis WH. Gray's Anatomy of the Human Body. 20th Ed. New York, NY: Bartleby; 2000
  3. Nelson PK, Mathers BM, Cowie B, Hagan H, Des Jarlais D, Horyniak D, et al. Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: results of systematic reviews. Lancet. Aug 13 2011;378(9791):571-83.
  4. Calmus Y, Gane P, Rouger P, et al. Hepatic expression of class I and class II major histocompatibility complex molecules in primary biliary cirrhosis: effect of ursodeoxycholic acid. Hepatology. Jan 1990;11(1):12-5.
  5. Telem DA, Schiano T, Goldstone R, Han DK, Buch KE, Chin EH. Factors that predict outcome of abdominal operations in patients with advanced cirrhosis. Clin Gastroenterol Hepatol. May 2010;8(5):451-7, quiz e58.
  6. Costa-Pinho A, Melo RB, Graca L, Lopes JM, Costa-Maia J. Multiple Hepatic Inflammatory Pseudotumours Diagnosed after Laparoscopic Excisional Biopsy. J Clin Diagn Res. Aug 2013;7(8):1730-1731.
  7. D'Albuquerque LA, de Miranda MP, Genzini T, Copstein JL, de Oliveira e Silva A. Laparoscopic cholecystectomy in cirrhotic patients. Surg Laparosc Endosc. Aug 1995;5(4):272-6.
  8. Pronovost P, Dorman T, Sadovnikoff N, Garrett E, Breslow M, Rosenfeld B. The association between preoperative patient characteristics and both clinical and economic outcomes after abdominal aortic surgery. J Cardiothorac Vasc Anesth. Oct 1999;13(5):549-54.
  9. Testino G, Sumberaz A, Ancarani AO, Borro P, Ravetti G, Ansaldi F, et al. Influence of body mass index, cholesterol, triglycerides and steatosis on pegylated interferon alfa-2a and ribavirin treatment for recurrent hepatitis C in patients transplanted for HCV and alcoholic cirrhosis. Hepatogastroenterology. Mar-Apr 2009;56(90):501-3.
  10. Phillips M, Curtis H, Portmann B, Donaldson N, Bomford A, O'Grady J. Antioxidants versus corticosteroids in the treatment of severe alcoholic hepatitis- A randomized clinical trial. J Hepatol. Apr 2006;44:784-90.

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Last updated: 2018-06-22 12:13