The liver is the main warehouse for nutrients absorbed from the small intestine. Its job is to store, package and change these nutrients according to the needs of the body and then supply them to the blood stream for delivery to the various organs. The liver is a very large organ located in the upper right quadrant of the abdomen protected by the rib cage. It also produces bile that is stored in the gallbladder. Bile is necessary for the digestion and absorption of fat in the diet.

LIVER DISORDERS

Hepatitis

The term "hepato" refers to the liver and "itis" refers to "inflammation of". The term, hepatitis, therefore, means inflammation of the liver. The terms acute and chronic hepatitis are defined mainly by the duration of the inflammation. Acute hepatitis is used to describe any form of liver inflammation of less than six (6) months duration, whereas chronic refers to a process lasting longer than this. There are many different causes of acute and chronic hepatitis. Common causes of acute hepatitis include viruses, medications and alcohol. These same processes can also result in chronic hepatitis. Other causes include autoimmune diseases, certain genetic diseases, disorders of the bile ducts and damage from fatty liver.

Common types of viral hepatitis include hepatitis A, B and C. There are also hepatitis viruses D, E, G, EBV (associated with mononucleosis) and CMV (cytomegalovirus).

Hepatitis A ("infectious hepatitis") is present in the stool of infected persons and can be transmitted when infected stool contaminates food or water and is ingested. Type A doesn't lead to chronic hepatitis and almost all individuals who acquire it recover within several weeks to months.

Hepatitis B is usually spread by intimate sexual contact or exposure to infected body fluids, such as through intravenous drug use. Hepatitis B is frequently transmitted from an infected mother to the newborn, unless the baby receives proper vaccination at birth. Hepatitis B can cause chronic hepatitis in seven percent (7%) of infected adults. Some individuals carry the virus in their bodies without significant liver damage, while others eventually develop cirrhosis, liver failure or liver cancer. Long term monitoring of liver function is very important if one has chronic hepatitis B. Several medications are now available for certain individuals with chronic hepatitis B.

Hepatitis C is most often spread by contact with contaminated blood. Since the screening test for hepatitis C became available in 1989, only very rarely are cases transmitted by contaminated blood transfusions. However, anyone who received a blood transfusion prior to 1989 is at risk. The most common means of transmission now is from contaminated blood exchanged by sharing dirty needles during illegal drug use or questionable tattoo application practices, and sometimes through sexual intercourse. In some cases of hepatitis B and C, the source of infection cannot be determined. Most individuals who acquire hepatitis C will develop chronic hepatitis. Within 20 years or more, 25 percent (25%) of patients develop cirrhosis or scarring of the liver. Some patients also develop liver failure or liver cancer.

There are estimated to be over four million cases of hepatitis B and C in this country. Many individuals are not aware that they are at risk and do not know they are infected. Many of these infected persons do not have any symptoms, such as jaundice, to alert them of their infection. History and physical examinations and blood tests can usually diagnose asymptomatic forms of hepatitis. Sometimes a liver biopsy may be required.

The treatment now available for hepatitis C is a medication called Interferon. There are different types of interferons that the body makes in response to different infections. The type of interferon used to treat hepatitis C is given by subcutaneous (beneath the skin) injection. Not all persons are candidates for treatment and not all persons will respond to treatment. Common side effects of this treatment include flu-like symptoms, fatigue, nausea and mood changes.

Ribavirin is another medication used to treat hepatitis C in combination with interferon. It may cause hemolytic anemia that results from a breakdown of red blood cells. A patient's blood count is monitored during treatment. Serious anemias occur in a small percent of cases.

Drug Induced Liver Disease

Medications, sometimes, may cause liver disease. The extent of liver injury may vary widely from mild hepatitis to severe injury. Drug reactions will rarely cause acute liver failure. Acetaminophen, present in many pain medications, may cause liver damage if taken in large doses or mixed with alcohol. When a drug-induced liver injury is recognized, the medication should be stopped immediately. In most cases, if the problem is detected promptly, the liver is able to recover.

1. Alcohol fatty liver

2. Alcoholic hepatitis

3. Cirrhosis

Autoimmune Liver Disease is a disorder in which a person's immune system attacks the liver and causes liver damage, which can progress from hepatitis to cirrhosis. Females are more often affected than males. The diagnosis can usually be made by blood tests and liver biopsy. Treatment is by immunosuppression, e.g., prednisone (a steroid) and often Imuran (azothioprine). Autoimmune liver disease is generally treatable, but not curable. Treatment helps bring about remission, although flare-ups can occur.

Genetic Liver Disease

Genetic Liver Diseases include hemochromatosis and Wilson's Disease. In hereditary hemochromatosis, excessive amounts of iron are absorbed from the intestine and stored in the liver. If iron overload is not prevented, the iron can be toxic to the liver, resulting in cirrhosis. The diagnosis can be made with blood tests and liver biopsy. Phlebotomy (removal of blood) to eliminate excess iron is very effective treatment and liver damage can be prevented if the condition is detected at an early stage. Family members can be screened with blood tests. Wilson's Disease is a disorder of copper metabolism that most often presents in individuals less than 45 years of age. Excessive copper is deposited in the liver and other organs, resulting in damage. With early detection and medication to bind the copper, liver damage is preventable.

Primary Biliary Cirrhosis (PBC) & Primary Sclerosing Cholangitis (PSC)

Primary Biliary Cirrhosis (PBC) and Primary Sclerosing Cholangitis (PSC) are two (2) forms of cholestatic (stasis of bile flow) liver diseases which involve the bile ducts. The cause of these disorders is uncertain, but is thought to be related to a problem with the immune system attacking the bile ducts. PBC is most often detected in middle-aged women. Itching may be a presenting symptom. Medication can help impair the progression of liver damage. PSC is more commonly found in young adults to middle-aged men. Patients often have underlying inflammatory bowel disease. The diagnosis is made by a cholangiogram that involves taking an x-ray picture of the large bile ducts after dye is injected.

Fatty Liver

Fatty Liver is a very common cause of abnormal liver blood tests. If fat accumulates inside liver cells (hepatocytes), the cells may become irritated or inflamed. This may produce elevated or abnormal liver enzymes. Although fatty liver is often a benign process, in some individuals, it can cause hepatitis and even advance to cirrhosis. Certain conditions such as being overweight, having diabetes mellitus, high cholesterol or fat content in the blood may be risk factors for fatty liver. There are no specific blood tests to make the diagnosis. Often, it is necessary to perform blood tests to exclude other conditions that may cause hepatitis. An ultrasound or CT scan of the liver may be helpful. In some cases, a liver biopsy may be needed. Treatment may involve weight loss as well as controlling diabetes and/or high cholesterol, if present.

COMPLICATIONS OF ADVANCED LIVER DISEASE

Ascites is a condition in which fluid accumulates in the abdomen, causing swelling. Ascites is treated by restricting salt intake and with diuretics (water pills). Sometimes ascites can become infected with bacteria, resulting in a process called spontaneous bacterial peritonitis, (SBP). This is a very serious condition that requires prompt evaluation and treatment. If SBP is suspected, it is usually necessary to obtain a sample of the ascites for testing. This is done by performing a procedure called paracentesis, in which a small needle is passed through the abdominal wall into the abdomen (peritoneal cavity) using a local anesthetic.

Encephalopathy results when waste material, such as ammonia, accumulates in the blood because of improper removal by the liver.

Symptoms of encephalopathy may include:

1. Irritability

2. Confusion

3. Difficulty concentrating

4. Sleep disturbance

5. Coma and death may result.

Treatment includes lactulose, a sugary syrup medication designed to trap ammonia molecules in the stool to prevent them from being absorbed into the blood.

Cirrhosis can result in the spleen enlarging due to the back up of blood flow and increased blood pressure in the vein that carries the blood from the spleen to the liver. Platelets then become trapped in the spleen as the blood is filtered through en-route to the liver. Less platelets are available in circulation in this untreatable condition known as thrombocytopenia.

The liver also makes proteins to help the blood clot or coagulate properly. When the liver is damaged, sufficient amounts of clotting proteins may not be made, resulting in coagulopathy (thin blood). This problem can be temporarily improved by giving Vitamin K or fresh frozen plasma.

The esophagus has small veins just beneath its surface lining. Normally nutrients absorbed from the intestine reach the liver through the portal vein and are processed. Blood flows through the liver into the hepatic veins to the inferior vena cava, then into the heart. When cirrhosis (scarring) of the liver develops, the normal flow of blood from the portal vein through the liver is blocked (partially or even completely). Blood must then return to the heart by other routes. Once such route is through the esophageal veins.

Blood flow follows an alternate route: Portal Vein to Coronary Vein to Esophageal Varices to Azygous Vein to Superior Vena Cava to Heart.

The esophageal veins are normally quite small, but with the increased flow of blood, become quite dilated and are known as varices.

Varices sometimes rupture if the blood flow becomes too great, resulting in gastrointestinal hemorrhage. This is a serious situation and requires immediate medical attention. A physician can pass a scope down into the esophagus and inject the varices with a chemical that will stop the bleeding. This technique is called endoscopic variceal sclerosis or scleropathy. Usually, these injections need to be repeated to decrease the size of the varices and prevent further bleeding. Another method to treat the varices through the scope is to apply very small rubber bands to the varices and ligate them.

Sometimes, if these methods and medications fail to control the bleeding, a procedure called TIPS, transjugular intrahepatic portosystemic shunt (or stent) is performed by a radiologist. In this procedure, an expandable metal stent is placed inside the liver to connect the portal vein to the hepatic vein (and inferior vena cava). The radiologist gains access to the blood vessels by going through the jugular vein in the neck. The shunt or stent will help to reduce the pressure inside the esophageal varices making them less likely to rupture and bleed. The shunt can become occluded over time. If this happens, the varices may re-bleed. The radiologist may then need to dilate the shunt. Since the stent serves to shunt blood through the liver, some of the waste materials may not be adequately filtered out. This may cause encephalopathy, which can usually be treated with medication.

Evaluation of the liver can be done by history and physical examinations, blood tests and radiographic tests (x-rays, ultrasound and CT scans). Another important method to assess the liver is to perform a liver biopsy. This involves removing one or more very small pieces of the liver by needle biopsy. A physician at the patient's bedside or radiologist using ultrasound to guide the direction of the biopsy may perform the biopsy. In either case, the patient is positioned on his or her back; the skin overlying the liver is sterilized and a local anesthetic is given to numb the skin and muscle down to the capsule of the liver. The biopsy is usually performed while the patient holds his or her breath after deep expiration. The patient is observed for several hours for any signs of complications (internal bleeding or puncture of another internal organ). Pain may occur after the biopsy at the site or around the right shoulder area, but is usually not severe. The main risk of liver biopsy is internal bleeding. Significant bleeding requiring transfusion or other intervention occurs in less than one percent (1%) of cases. Serious complications are rare.

Liver Wellness

Much attention is given to liver disease - as it should be. Your liver is a vital organ. But liver wellness and disease prevention are very important! What can a person do to keep his or her liver working well? There are several things that are simple, but helpful. Proper nutrition with a good, balanced diet, low in fat and cholesterol is important. Maintaining ideal body weight and exercise are helpful also. Avoiding damaging the liver by too much alcohol and abstaining from drug abuse and unsafe sexual practices, which may expose a person to viruses and other illnesses, is essential. There are now vaccines for hepatitis A and B that can control the spread of these viruses. Vaccination against hepatitis B is currently being considered as a universal precaution and persons at high risk for hepatitis A also should be vaccinated. Patients with cirrhosis should be vaccinated against hepatitis A and B.