A Simple Guide of Liver Cirrhosis II

A Simple Guide of Liver Cirrhosis II
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What are the complications of Liver Cirrhosis?
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Complications may develop with progression of the cirrhosis.

1.Bruising and bleeding due to decreased production of coagulation factors.

2.Jaundice due to decreased processing of bilirubin

3.Itching (pruritis due to bile products deposited in the skin).

4.Hepatic encephalopathy - the liver does not clear ammonia and related nitrogenous substances from the blood, which are carried to the brain, affecting cerebral functioning:

a.neglect of personal appearance,
b.unresponsiveness,
c.forgetfulness,
d.trouble concentrating,
e.changes in sleep habits.
f.Sensitivity to medication due to decreased metabolism of the active compounds.

5.Hepatocellular carcinoma is primary liver cancer one of the common complication of cirrhosis and has a high mortality rate.

6.Portal hypertension - blood normally carried from the intestines and spleen through the hepatic portal vein flows more slowly and the pressure increases causing :

a.Ascites - fluid leaks through the vasculature into the abdominal cavity.
b.Esophageal varices - collateral portal blood flow through vessels in the stomach and esophagus. These blood vessels may become enlarged and are more likely to burst.

7.Immune system dysfunction, leading to

a.nonspecific infection in the body organs
b..Spontaneous bacterial peritonitis -fluid in the abdomen may become infected with bacteria normally present in the intestines

8.Hepatorenal syndrome - insufficient blood supply to the kidneys, causing acute renal failure and a very high mortality (over 50%).

9.Hepatopulmonary syndrome - blood bypassing the normal lung circulation leading to cyanosis and dyspnea (shortness of breath) characteristically worse on sitting up

10.Portopulmonary hypertension - increased blood pressure over the lungs as a consequence of portal hypertension.


What is the treatment of Liver Cirrhosis?
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In all cases of liver cirrhosis, the liver damage from cirrhosis cannot be repaired so treatment is aimed at reducing progression and complications of the disease.

1. A healthy fat free diet is needed as energy use in cirrhosis is high

2.Close monitoring of the liver function is important.

3.Antibiotics will be prescribed for infections,

4.Antihistamines can help with itching.

5.Laxatives such as lactulose decrease risk of constipation

6.Treating alcoholism
Alcoholic cirrhosis caused by alcoholism is treated by abstaining from alcohol.

7.Treatment for hepatitis-related cirrhosis involves medications to treat the different types of hepatitis, such as

a.interferon for viral hepatitis
b.corticosteroids for autoimmune hepatitis.

8.Cirrhosis caused by Wilson's disease in which copper builds up in organs is treated with chelation therapy (e.g. penicillamine ) to remove the copper.

9.Preventing complications:
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a. Ascites
Salt restriction
Diuretics may be necessary to reduce fluid in abdomen.

b. Esophageal variceal bleeding -
Vasopressin
surgical portacaval shunting

c. portal hypertension
propranolol lower blood pressure over the portal system.
Transjugular intrahepatic portosystemic shunting will relieve pressure on the portal vein as a temporary measure .

c. Spontaneous bacterial peritonitis
antibiotics.

10. Decompensated cirrhosis
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Decompensation in previously stable patients may occur due to various causes:

a.constipation
b.infection
c.increased alcohol intake,
d.medication
e.bleeding from esophageal varices
f.dehydration.

Patients with decompensated cirrhosis has to be admitted to hospital for
1.close monitoring of the:

fluid balance
mental status,

2.emphasis on adequate nutrition

3.medical treatment -

a.diuretics
b.antibiotics
c.laxatives
d.enemas
e.thiamine
f.steroids
g.acetylcysteine
h.pentoxifylline

Surgical Liver Transplantation
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Liver transplantation is necessary if:

liver stop functioning
severe complications cannot be controlled

Survival rate from liver transplantation has improved to 80% for five year postoperative period.

Transplantation necessitates the use of immune suppressants for life.

What is the prognosis for Liver Cirrhosis?
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Prognosis is generally not good unless detected at very early stage.

Most liver cirrhosis patient are in the moderate to advanced stage of the disease when detected.

If there are complications, the prognosis is poor.


What is the best prevention for Liver Cirrhosis?
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1. Alcohol- stop the abuse of alcohol

2. Vaccination against hepatitis B

3. Reduce fat in obese -fat cells in liver can lead to cirrhosis

A Simple Guide to Liver Cirrhosis I

A Simple Guide to Liver Cirrhosis I
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What is Liver Cirrhosis?
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Liver Cirrhosis is a chronic liver disease where the normal liver tissue is replaced by bands of fibrous scar tissue separating nodules of regenerated liver cells resulting in gradual loss of liver function.

Who is at risk of getting Liver Cirrhosis?
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1.Alcohol abuse

2.Genetic causes of Biliary Obstruction such as biliary atresia

3.Hepatitis viral infection

4.Obese -fatty liver can end in liver cirrhosis

5.Exposure to excessive chemicals(factory) or medications(eg statins)

What are the causes of Liver Cirrhosis?
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The main causes of Liver Cirrhosis are:

1.chronic alcoholism:

Alcohol tends to block the normal metabolism of protein, fats, and carbohydrates leaving toxic material behind which can injure the liver and ends in liver cirrhosis.

2.hepatitis C virus infection:

Chronic hepatitis c viral infection causes inflammation of the liver which over the years can damage the liver and lead to cirrhosis.

3.Primary biliary and secondary cirrhosis:

Primary biliary cirrhosis cause is unknown.
Secondary biliary cirrhosis results from chronic obstruction of the biliary tract resulting in chronic inflammation of the liver cells and fibrosis of the liver.
Nodular regeneration of the liver cells occurs subsequently.
Obstruction to the bile ducts can be caused by:
Cholecystitis
Gallstones
Biliary cholangitis

4.Others:
Metabolic diseases:
Hemachromatosis
Wilson Disease

Parasitic Disease:
Schistosomiasis

Cardiac cirrhosis
Liver congestion results from right sided heart failure

Autoimmune Diseases:
Autoimmune hepatitis

Exposure to chemicals and medications

Glycogen storage disease


What are the Symptoms and signs of Liver Cirrhosis?
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Common symptoms of Liver Cirrhosis are:

1.Anorexia

2.fatigue and weakness

3.Gradual onset of jaundice(Yellow discoloring of the skin, eye, and mucus membranes due to increased bilirubin)

4.weight loss.

5.Fetor hepaticus - odor in breath due to increased dimethyl sulfide

Signs:

1.Spider nevi- central arteriole surrounded by many smaller vessels due to an increase in estradiol .

2.Palmar erythema -redness of the palms due to impaired sex hormone metabolism.

3.Liver size. Can be enlarged, normal, or shrunken.

4.Splenomegaly - Due to congestion of the spleen as a result of portal hypertension.

5.Ascites . Accumulation of fluid in the peritoneal cavity

6.hydrocele and penile flomation (swelling of the penile shaft)

7.Hypogonadism - impotence, infertility, poor sexual drive, and testicular atrophy due to primary gonadal injury or suppression of hypothalamic or pituitary function.

8.Gynecomastia - This is due to increased estradiol in male patients.

9.Hypertrophic osteoarthropathy - Chronic proliferative periostitis of the ribs can be very painful.

10.Dupuytren's contracture -palmar fascia tightens to cause flexion deformities of the fingers.

11.Nail changes:

Muehrcke's nails - paired horizontal bands due to hypoalbuminemia
Terry's nails - proximal 2/3 of the nail appears white with distal one-third red due to hypoalbuminemia
Clubbing - angle between the nail plate and proximal nail fold > 180 degrees

12.Caput medusa -In portal hypertension, the umbilical vein may be distended.

13.Cruveilhier-Baumgarten murmur. Venous blood flow hum heard in epigastric region due to portal hypertension

14.Asterixis - Bilateral asynchronous flapping of outstretched, dorsiflexed hands seen in patients with hepatic encephalopathy.


How is the diagnosis of Liver Cirrhosis made?
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1. liver biopsy will confirm liver cirrhosis through a percutaneous laparoscopic , or fine-needle approach but may not necessary if the clinical, laboratory, and radiologic data suggests cirrhosis.

there is a small but significant risk to liver biopsy, and cirrhosis itself predisposes for complications due to liver biopsy

2.Lab findings
The following findings are typical in cirrhosis:

a.Aminotransferases - AST and ALT are moderately elevated, with AST > ALT.
b.Alkaline phosphatase - usually slightly elevated.
c.GGT - correlates with AP levels- much higher in chronic liver disease from alcohol.
d.Bilirubin - may elevate as cirrhosis progresses.
e.Albumin - levels fall as the synthetic function of the liver declines with worsening cirrhosis
f.Prothrombin time - increases since the liver synthesizes clotting factors.
g.Globulins - increased due to shunting of bacterial antigens away from the liver to lymphoid tissue.
h.Serum sodium is low due to inability to excrete free water resulting from high levels of ADH and aldosterone
i.Thrombocytopenia - due to both congestive splenomegaly as well as decreased thrombopoietin from the liver. Platelet count is rarely < 50,000/mL.
j.Leukopenia and neutropenia - due to splenomegaly with splenic margination.
k.Coagulation defects - the liver produces most of the coagulation factors and thus coagulopathy correlates with worsening liver disease.

l.Serology for hepatitis viruses, autoantibodies (ANA or Anti-nuclear antibody, anti-smooth muscle, anti-mitochondria n.antibody, anti-LKM)
n.Ferritin and transferrin saturation (markers of iron overload),
o.copper and ceruloplasmin Ceruloplasmin> (markers of copper overload)
p.Immunoglobulin levels (IgG, IgM, IgA) - high

To determine various causes
p.Cholesterol and glucose
r.Alpha 1-antitrypsin

3.Imaging
Ultrasound is used to assess the degree of cirrhosis:

a.small and nodular liver in advanced cirrhosis
b.increased echogenicity with irregular appearing areas.

Ultrasound may also screen for
a.hepatocellular carcinoma
b.portal hypertension
c.Budd-Chiari syndrome by checking the blood flow in the hepatic vein

FibroScan (transient elastography) uses elastic waves to assess liver stiffness which can grade the severity of cirrhosis.

Abdominal CT and liver and bile duct MRI - may show the the degree of liver cirrhosis

4.Imaging of the bile ducts, such as
ERCP Endoscopic_retrograde_cholangiopancreatography or
MRCP Magnetic_resonance_cholangiopancreatography (MRI of biliary tract and pancreas)
can show abnormalities in the liver

5.Endoscopy
Gastroscopy is performed in patients with liver cirrhosis to exclude the possibility of esophageal varices.

A Simple Guide to Pancreatic Cancer

A Simple Guide to Pancreatic Cancer
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What is Pancreatic Cancer?
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Pancreatic Cancer is a malignant disease of the exocrine pancreas. 90% are adenocarcinomas.

What are the causes of Pancreatic Cancer?
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1.Smoking. cigarettes smoke chemicals has been known to damage the pancreatic cells

2.Diets rich in red meat- high protein tends to stmulate more enzymes frm pancreas and cause dysfunction in the cells

3.Diabetes mellitus -damage to islets in pancreas may contribute to pancreatic cancer

4.Chronic pancreatitis has been found to have some causal effect

5.Helicobacter pylori infection -known to cause stomach cancer and also pancreatic cancer

6.Occupational exposure to certain chemicals including insecticides

7.Family history -there is a family history in 5-10% of pancreatic cancer patients

8.Obesity - the high fat diet may induce more disease of bile system with blockage of its tract

What are the symptoms and signs of Pancreatic Cancer?
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Symptoms - non-specific and varied.

1.pain in the upper abdomen that typically radiates to the back

2.pain relieved by leaning forward

3.painless jaundice related to bile duct obstruction (carcinoma of the head of the pancreas)

4.depression is sometimes associated with pancreatic cancer


Signs:

1.tenderness in upper abdomen

2.mass in the abdomen

3.Trousseau sign- Spontaneous blood clots in veins of extremities, or the superficial veins may indicate presence of pancreatic cancer.


How do you diagnose Pancreatic Cancer?
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Diagnosis can usually be made by :

History
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1.pain in upper abdomen radiating straight to the back, worse on eating

2.Weight loss severe with anorexia, early satiety, diarrhea, or steatorrhea.

3.Jaundice -initially painless, itchy with dark urine.
Painful jaundice occurs later

4.onset of atypical diabetes mellitus

5.unexplained recent thrombophlebitis

6.past history of pancreatitis

Location of cancer
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1.Tumors in the pancreatic body or tail usually present with pain and weight loss

2.Tumors in the head of the gland typically present with steatorrhea, weight loss, and jaundice.

Courvoisier sign
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presence of jaundice and a painlessly distended gallbladder is suggestive of pancreatic cancer

Liver function tests
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may show a combination of results indicative of bile duct obstruction (raised conjugated bilirubin, SGGT and alkaline phosphatase levels).

CA19-9 (carbohydrate antigen 19.9)
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is a tumor marker that is frequently elevated in pancreatic cancer.

Ultrasound or abdominal CT
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may be used to identify tumors.

Endoscopic ultrasound (EUS) is another procedure that can help visualize the tumor and obtain tissue to establish the diagnosis.

What is the treatment of Pancreatic Cancer?
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Treatment of pancreatic cancer can be surgery or chemotherapy depending on the stage of the cancer.

Surgery
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1.Where the head of the pancreas is involved, the Whipple procedure is the most common surgical treatment for pancreatic cancers.
It is a major surgery involving the the resection of the head of pancreas and requres the patient to be fit for the surgery and the tumor to be localised without metastases. Only in small number of cases can the surgery be done.

2.Cancers of the tail of the pancreas can be removes by a technique called distal pancreatectomy

3.localized tumors of the pancreas have been surgically removed using laparoscopy.

4.Surgery may be performed for relief of symptoms especially if the cancer is invading or pressing on the duodenum or colon.

5.Bypass surgery may prevent the obstruction of the pancreatic ducts and improve quality of life.

Chemotherapy
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is used for patients not suitable for surgery. It can relieve symptoms and improve quality of life

Gemcitabine was approved by the US FDA after a clinical trial reported improvements in quality of life in patients with advanced pancreatic cancer

Gemcitabine may used after surgery to remove tumor tissue remaining in the body. As a result 5-year survival rates has improved.

Other drugs such as oxaliplatin and fluorouracil have also beneficial effect.

Radiation therapy
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The use of additional radiation therapy follwing surgery has been used in USA while rejected by most doctors in Europe.

What is the Prognosis of pancreatic cancer?
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The prognosis of pancreatic cancer is poor

1.because the cancer usually causes no early symptoms resulting in advanced or metastatic disease at the time of diagnosis.

2.Median survival from diagnosis is around 3-4 months;

3.5-year survival is lower than 5%.

4.Pancreatic cancer has the highest mortality of all the cancers.

5.Pancreatic cancer may sometimes cause diabetes.

How to prevent Pancreatic Cancer?
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1.a healthy lifesyle

2.increase consumption of fruits, vegetables

3.reduce red meat intake

4.Vitamin D can reduce the risk of pancreatic cancer

5.B vitamins such as B12, B6, and folate in food but not in tablets may reduce the risk of pancreatic cancer

6.Avoid smoking and drinking of alcohol

A Simple Guide to Pancreatitis

A Simple Guide to Pancreatitis
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What is Pancreatitis?
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Pancreatitis is an acute or chronic inflammation of the pancreas.

What are the causes of Pancreatitis?
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Pancreatitis is usually caused by the following:

1. Alcoholism and diseases of the biliary tract

2. bacterial infections from salmonella typhi and streptococcus

3. viral infection especially mumps, coxsackie virus, cytomegalovirus

4. trauma

Chronic disease follows attacks of acute infection.

What are the symptoms and signs of Pancreatitis?
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Persons who has Acute Pancreatitis has the following symptoms:

1.acute onset of abdominal pain starting from the epigastrium, radiating to the back in 50% of cases.

2.Pain usually very severe occuring a large meal or drinking bout

3.Pain is worse lying supine, therefore patients sit or lean forward

4.mild fever and bodyaches

5.nausea and vomitting

6.hypotension followed by clinical shock

Signs:

1.Tenderness at the epigastrium with muscle spasm

2.Distension and diminished bowel sounds

3.Pleural effusion 10%,abdominal mass 20%, ascites 20%

4. Acute renal failure, respiratory failure following shock.

Chronic Pancreatitis
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Symptoms:

1.repeated attacks of epigastric abdominal pain

2.Pain worse after eating, radiates to the back

3.weight loss

4.Fever

Signs:

1.abdominal tenderness

2.abdominal mass may suggest swelling and pseudocysts

3.tender subcutaneous masses seen indicating fat necrosis

How do you diagnose Pancreatitis?
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Diagnosis can usually be made by :

1.Physical examination with tenderness in the epigastrium

2.Serum and urine amylase very high after 6 hours

3.White blood cell count high

4.Serum lipase high in 50% patients

5.Blood calcium may be low

6.Blood glucose tolerance test for diabetes

7.Ultrasound may show up the presence of pseudocyst in pancreas

8.CAT scan and MRI may show swelling and pseudocysts in pancreas

What is the complications of Pancreatitis?
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1.Pseudocysts from damage to pancreatic tissues

2.Hemorrhage - bleeding due to damage to the blood vessels in pancreas

3.peritonitis from rupture of pseudocysts and bleeding

4.diabetes mellitus from damage to the glands in the pancreas producing insulin

What is the treatment of Pancreatitis?
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Acute Pancreatitis:
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Admission to hospital

Gastric suction and fluid replacement

Analgesic or antispasmodic medicine usually by injection

Antibiotics for infections

Treat biliary tract diseases and alcoholism

surgical drainage of pseudocysts after acute episode.

Chronic Pancreatitis:
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Pancreatic extracts and enzymes together with meals

Sodium bicarbonate and cimetidine to prevent enzymes breakdown

Analgesic or antispasmodic medicine usually by injection

Surgical procedures usually unsuccessful

What is the prognosis of Pancreatitis?
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Prognosis is usually good after treatment of acute pancreatitis with recovery in 5-7 days.

Hemorhagic Pancreatitis has high mortality of 50-90%

Most trauma cases has complete resolution

Some alcoholic pancreatitis may go on to chronic pancreatitis.

Chronic pancreatitis relapses frequently

Rupture of pseudocysts may result in death

How do you prevent Pancreatitis?
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Avoid alcohol and oily food

Take precautions during mumps and other viral infection

Avoid injury to the abdomen especially the mid section below the sternum

A Simple Guide to Liver Cancer

A Simple Guide to Liver Cancer
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What is Liver Cancer?
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Liver Cancer develops when the liver cells undergo abnormal changes to form cancer cells.
Most Primary cancer of the liver begins as mutated hepatocytes(liver cells).
Secondary cancer of the liver is due to spread from the stomach, colon, breast, lungs, ovaries etc

What is the incidence of Liver Cancer?
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Liver cancer is one of the most common cancer.
It occurs in men more than women.
It is more common in the 40s and 50s age groups.

What are the Risk Factors of Liver Cancer?
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The main risk factor for liver cancer is
1.Hepatitis B infection.

Other important risk factors include
2.Hepatitis C infection

3.alcoholic liver disease (disease of the liver caused by heavy alcohol consumption).

4.family history of liver cancer

5.Chemicals exposures such as nitrites,solvents, hydrocarbons,viny chloride

6.poisons (e.g. aflatoxin present in some spoilt or mouldy peanuts).

7.inherited liver diseases (alpha-1 anti-trypsin deficiency)

8.Drug abuse eg heroin


What are the Signs and Symptoms of Liver Cancer?
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During the early stages, most people with liver cancer do not show any signs or symptoms.
Signs and symptoms, when they do appear, include:

1.loss of appetite and weight

2.discomfort or swelling in the upper part of the abdomen on the right side

3.weakness and fatigue

4.nausea and vomiting

5.jaundice - yellowness of the skin and eyes

6.dark color urine

7.Persistent or swinging fever

How is the Diagnosis of Liver Cancer confirmed?
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1. full medical history especially history of Hepatitis B and alcohol

2. full examination especially of the liver

3.an ultrasound scan of the liver and gallbladder, if possible the whole abdomen.
4.CT scan or MRI of the liver and surrounding tissues


5.blood tests (a protein present in blood called the alpha- fetoprotein or AFP may be found to be raised in liver cancer)

6.needle liver biopsy into the liver swelling as detected by ultrasound or MRI (to confirm the liver cancer).

With the diagnosis confirmed, the doctor will proceed with further tests to find out how advanced the liver cancer is. This will help the doctor to plan the treatment.

What is the Treatment of Liver Cancer?
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As in all cancers, treatment includes surgery, radiation therapy, chemotherapy.

In Liver cancer percutaneous ethanol (alcohol) injection is injected directly into the tumour, by means of a small needle, to kill the cancerous cells.

Liver transplant can also be carried out in selected cases where the size of the cancer is not too massive but surgery is not feasible due to the patient's limited liver reserve(provided a suitable liver donor can be found).

Treatment depends on the the stage of the cancer as well as health of the affected person.

The goal of treatment is complete cure.

However, where this is not possible, treatment is aimed at
preventing the tumour from spreading or growing.
Helping to eliminate uncomfortable symptoms is also an important aspect of liver cancer treatment.

How to Protect yourself from Liver Cancer?
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Prevention from getting liver cancer is by taking steps to reduce your risk factors.

1. Reduce your risk of Hepatitis B by getting vaccinated. The Hepatitis B vaccine is safe and effective.
Both Hepatitis B and C are spread through infected blood or sexual fluids as well as intravenous drug abuse. It is therefore important to avoid activities that put you at risk:

2.Avoid multiple sex partners and having sex with commercial sex workers, strangers or anyone with multiple sex partners.

3.Do not abuse drugs or share injection needles.

4.Never share personal items like razors, toothbrushes or other items that may cause breaks in the skin.

5.Visit only reliable operators for ear/body piercing, tattooing or acupuncture.

6.It is also important that you limit your consumption of alcohol as excessive drinking can give rise to liver disease and increase your risk of liver cancer.

The liver is one of the largest and most important organs in your body. It performs many essential functions including:
making and storing of essential nutrients
making important hormones and enzymes
breaking down harmful substances.

Do not abuse Your LIVER by excessive drinking or taking drugs!