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 Gallstones

A Simple Guide to Gallstones
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What are gallstones?
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Gallstones are stones which are found in the gallbladder which is a sac storing bile from the liver.
They are made from cholesterol and other substances in the bile.


What causes gallstones?
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Gallstones are formed when cholesterol and other substances like calcium found in bile combine to form stones.

They are more common in
1.overweight people

2.Females more than males

What are the symptoms?
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Most people with gallstones do not have symptoms.

Symptomsoccur when a gallstone causes blockage in the bile duct causing obstruction to flow of bile from the liver to the intestine.

The symptoms may be:

1.mild pain in the upper right part of the abdomen and also just below the sternum just like gastritis.

2.Pain in the right upper back or shoulder blade area.

3.Pain is worse when you eat.

4.fever and chills

5.Yellowness of the eyes or skin

6.Dark coloured urine

7.Chest pain occurs when the pain radiates to the chest

How are gallstones diagnosed?
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1.Pain in the right side of the abdomen

2. Murphy's sign positive.
A thumb pressing against the right of the epigastrium causes more pain when the patients breathes in deeply

3.An ultrasound of the right side of the abdomen is the best way to find gallstones.
Most gallstones can be detected from the ultrasound.

4.gallbladder scan. A dye is injected into a vein in your arm.
X-rays are taken as the dye moves through your liver, bile duct, gallbladder.

What are the complications of gallstones?
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A gallsone which is stuck in the bile duct(a tube which leads the bile from the liver to the gallbladder and small intestine) can give rise to:
1.Gallbladder inflmmation or infection(Cholecystitis)

2.Swelling and inflammation of the Pancreas(pancreatitis)

3.Hepatitis due to reflux of the bile back to the liver

4.Peritonitis(inflammation of the inner lining of the abdomen) if the bile duct or gallbladder perfoates or burst.
This is an emergency.

What is the treatment of gallstones?
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1.If there is no symptoms, treatment is not needed.

2.If there is mild pain, some pain and antispasmodic medicines are given.
Patient is kept for observation.
If the pain goes away, the gallsone may have become unstuck in the bile duct and pass out into the intestine.

3.If there is severe pain or recurrence of another attack of pain, it is advisable to have the gallbladder removed.

a.Normal surgery to remove the gallbladder and the gallstones involve 4 holes in the abdomen and the use of a laparoscopic to cut away the gallbladder followed by stitching.
The surgery is usually very safe and the patient may not need to be hospitalised.

b.In an emergency, such as perforated gallbladder, immediate surgery may be required to remove the gallbladder and cleared the inner abdomen of leaked bile.

What is the prognosis of gallstones?
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Most people with gallstones do not have symptoms.

Sometimes gallstones may be detected while having tests for other health problems.

Sometimes an ultrasound done on an woman during pregnancy may show gallstones.

The prognosis for patients after surgery is usually good.

The bile will go straight to the intestine from the liver.
Digestion of oily food may not as good as before and is usually not noticeable.