Liver

Hepatitis
Alcoholic liver disease
Cirrhosis
Liver biopsy
Alpha-1 anti-trypsin de-efficiency
Jaundice
Hepatocellular carcinoma


Hepatitis

The word "hepatitis" means inflammation of the liver. This can be caused by a number of things, such as chemicals, alcohol, drugs and infection by viruses. The symptoms of acute viral hepatitis include fever, headache, lethargy, nausea, dark urine, pale stools and jaundice. The most commonly encountered viral hepatitis are type A, type B and type C.


Alcoholic Liver Disease

Alcoholic liver disease is damage to the liver that results from excessive drinking of alcohol.

Alcoholic liver disease is a common, preventable health problem. In general, the amount of alcohol consumed (how much and how often) determines the risk and the degree of liver damage. Women are more vulnerable to liver damage than men. In women who drink over a period of years, the equivalent of as little as 2/3 of an ounce of pure alcohol a day (6½ ounces of wine, 13 ounces of beer, or 2 ounces of whiskey) can cause liver damage. In men who drink over a period of years, the equivalent of as little as 2 ounces a day (20 ounces of wine, 40 ounces of beer, or 6 ounces of whiskey) can cause liver damage. However, the amount of alcohol that causes liver damage varies from person to person.

Alcohol also provides calories without essential nutrients, decreases the appetite, and causes poor absorption of nutrients because of its toxic effects on the intestine and pancreas. As a result, people who regularly drink alcohol without eating properly develop malnutrition.

Alcohol may cause three types of liver damage: fat accumulation (fatty liver), inflammation (alcoholic hepatitis), and scarring (cirrhosis).

Cirrhosis

What is cirrhosis?

In cirrhosis of the liver, progressive scarring (fibrosis) of the liver causes scar tissue to replace normal liver tissue. The scar tissue damages the normal structure of the liver which affects the normal flow of blood through the liver. The liver itself becomes distorted, hardened and lumpy. Without a good blood flow the liver can't work as it should and its normal functions are impaired.

The liver is the largest organ in the body and is a very important organ to keep the body functioning properly. It is involved in the processing of nutrients and fats, poisons or toxins that find their way into the body, hormones and medications. It controls blood clotting and produces proteins. So, cirrhosis of the liver can affect the functioning of the entire body.

Course of cirrhosis

Cirrhosis happens when the cells of the liver are damaged by toxins, or by inflammation and disorders of the body's normal metabolic processes. Although many people associate liver cirrhosis with alcoholism, it can have other origins, all of which cause the same characteristic damage.


What causes it?

Cirrhosis of the liver has a number of different causes.

Long-term heavy drinking of alcohol. It usually takes about 10 years of heavy drinking of alcohol for cirrhosis to develop. Women can develop cirrhosis with a daily intake of 2-3 alcoholic drinks a day, which might not be considered by some to be 'heavy'. Similarly, men who have 3-4 alcoholic drinks a day can also develop cirrhosis.

Chronic viral hepatitis types B, C & D. These hepatitis viruses cause inflammation of the liver and liver damage that after a few decades can cause cirrhosis.
· Wilson's disease. This is an inherited disorder where excessive amounts of copper are absorbed in body tissues, particularly the liver.

Haemochromatosis. Another inherited disorder, this time one in which too much iron is absorbed by the body and the excess is deposited in the liver.

Other inherited metabolic disorders, such as cystic fibrosis. Certain disorders that interfere with the body's metabolism and how the liver stores substances can result in cirrhosis.

Autoimmune hepatitis. This is hepatitis caused by a problem in the body's immune system. The immune system doesn't recognise its own cells and tissues as 'self' and attacks them thinking they are 'foreign', like invading bacteria.

Blocked bile ducts. Bile is made in the liver and then the bile ducts carry the bile out of the liver to the gallbladder where it is stored. If the bile ducts become blocked due to scarring or inflammation, bile backs up in the liver and damages the liver tissues causing cirrhosis. Primary biliary cirrhosis is a disease of adults where the bile ducts become damaged. Biliary atresia is a condition of babies in which they are born without bile ducts or the bile ducts are damaged causing build-up of bile in the liver.

Toxic hepatitis. This is rare and is caused by severe reactions to medications or environmental toxins.

Chronic congestive heart failure with liver congestion. Repeated episodes of congestive heart failure with liver congestion can cause cirrhosis of the liver.

Liver biopsy

A liver biopsy involves removing a small sample of tissue from your liver so that it can be examined for abnormalities. It is very useful to help doctors diagnose liver problems and to determine the extent of liver damage caused by chronic conditions such as hepatitis, alcoholism and cholestasis. Cholestasis is obstruction of the flow of bile, a substance secreted by the liver which helps the intestine absorb fats.

Liver biopsy provides more detailed information about the health of the liver than a liver function blood test can do and can help diagnose the cause of liver disease. Your doctor may decide to refer you for a biopsy after you have had an abnormal liver function test that suggests your liver isn't working properly.

There are 3 ways liver biopsies can be done. These are known as percutaneous biopsy, transvenous biopsy and laparoscopic biopsy.

Liver biopsies are done in hospitals, mostly on an outpatient day-surgery basis.
Before the test

Because a liver biopsy is a (minor) surgical procedure, your doctor may do a blood test before you book in, to ensure you have no bleeding or blood clotting problems. An ultrasound or CT (computed tomography) scan of your liver may be done to help doctors locate a particular area of tissue or abnormality from which the sample will be taken.

Talk to your doctor about any medicines you are taking. Some medicines can put you at a higher risk of bleeding. These include non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, and blood thinners such as warfarin (Coumadin). Your doctor should be aware of this and will advise you accordingly.
You will probably be asked not to eat or drink anything in the 8 hours before the test.
Percutaneous liver biopsy

This is the most common way of doing a liver biopsy. You will be asked to lie on a hospital bed on your back or facing slightly to the left, and a tube will be put into your arm to give you sedative medication. A local anaesthetic will be injected into your skin to numb the area around your rib cage on your right hand side. Then the doctor will make a small incision over the liver and gently insert a special biopsy needle through your skin and between the ribs to the liver.

You will be asked to keep very still and hold your breath for about 5 seconds while a sample of tissue (about 1 mm thick) is withdrawn from your liver. This is to ensure the needle goes into the right place and doesn't harm any other internal organs.

After the procedure a bandage will be put over the incision and you will need to stay in the hospital for a few hours for observation. This is to enable the effects of the sedative to wear off and to make sure there are no complications before you go home.

Although they are very rare, complications can include:

leaking of bile into the abdomen, which can cause inflammation of the abdominal lining (peritonitis);

bleeding from the place where the biopsy needle goes into the liver. This can occur up to 15 days after the biopsy (doctors advise that, until the 15 days are up, you stay within one hour's drive of the hospital where the biopsy was conducted);

puncture of the lung or gallbladder during the biopsy itself; and

infection.

You may feel some pain in your upper right abdomen or right shoulder for a while after the biopsy. This pain is usually not serious and can be relieved by paracetamol (don't take aspirin or over-the-counter non-steroidal anti-inflammatory drugs such as aspirin or ibuprofen because they can cause bleeding). Contact your doctor if the pain becomes worse.


Transvenous liver biopsy

Doctors often use this method for people who have bleeding problems or medical conditions that make percutaneous biopsy dangerous. A catheter (a thin flexible tube) is inserted through a vein in your neck and guided into the hepatic vein (the vein that takes blood from the liver to the heart). The biopsy sample is obtained by inserting a needle into the catheter and so through the hepatic vein and then directly into your liver.

Laparoscopic liver biopsy

This is where a special instrument known as a laparoscope, which allows doctors to view the liver, is inserted through a small cut in your abdomen. The laparoscope is a small tube with a camera on the end. The doctor will use instruments attached to the laparoscope to remove tissue samples from your liver. This technique is useful when the doctor wants to take a biopsy from a specific part of the liver.
If your doctor recommends a liver biopsy, he or she will advise which method would be best for you.

Alpha1-Antitrypsin Deficiency
Alpha1-antitrypsin deficiency is a disorder in which a hereditary deficiency of alpha1-antitrypsin may cause lung and liver disease.

Alpha1-antitrypsin, an enzyme produced by the liver, is present in saliva, duodenal fluid, lung secretions, tears, nasal secretions, and cerebrospinal fluid. This enzyme inhibits the action of other enzymes that break down proteins. A lack of alpha1-antitrypsin allows the other enzymes to damage tissue in the lungs. The deficiency in blood represents a failure of the liver to secrete the enzyme. Its retention inside liver cells may cause damage, fibrosis (scarring), and cirrhosis.



Jaundice

Jaundice is a yellow discolouration of the skin, whites of the eyes and mucous membranes.

In adults, jaundice can be an indication of more serious health problems. It can develop as a result of:

alcohol and other drugs (legal and illegal) damaging the liver
Hepatitis A, B and C
Gall Stones
Tumours
Prosthetic heart valves
Sickle cell crisis
Reaction to a blood transfusion

Jaundice in babies

About six out of 10 newborns have jaundice to varying degrees, while the condition is more common among premature babies. Jaundice is caused by an excess of a chemical called bilirubin, which is normally eliminated by the liver. However, a newborn's liver takes a few days to process this chemical. If the baby is full term and healthy, mild jaundice is nothing to worry about and will resolve by itself within a week or so. However, a premature or sick baby, or a baby with very high levels of bilirubin, will need close monitoring and medical treatments. Other causes of jaundice in babies include blood group antibodies (Rhesus factor & ABO incompatibilities), haemolytic anaemia, hepatitis and galactosaemia.


Symptoms

The symptoms of jaundice depend on the cause and severity, but may include:

Yellow tinge to the skin, usually appearing first on the skin of the face and scalp.

Yellow tinge to the white parts of the eyes (sclera).

In moderate jaundice, the yellow tinge will spread to the skin of the body.

In severe jaundice, the palms of the hands and soles of the feet will turn yellow.

Unusual drowsiness.

Feeding difficulties.

In some cases, light-coloured faeces and dark urine.


Physiological jaundice explained

Red blood cells are red because of the protein haemoglobin. Old and damaged red blood cells are broken down into their chemical components, which are then either recycled or eliminated from the body as waste. The chemical bilirubin is produced as a by-product when haemoglobin is metabolised (used) by the body. The liver helps to eliminate bilirubin as waste. In utero, the baby's bilirubin is sent down the umbilical cord and eliminated by the mother's body. After birth, the baby's liver has to eliminate the bilirubin. A baby's liver may take a few days to function at full speed; in the meantime, the excess bilirubin in the baby's body causes the characteristic symptoms of jaundice. Every newborn has elevated bilirubin, but only around 60 per cent of full term babies will have noticeable symptoms. Treatment isn't usually necessary, unless the baby has very high bilirubin levels, or is premature or sick.

Other causes of jaundice

Jaundice can also be caused by a range of other conditions and events including:
Breast milk - the mother's breasts produce small amounts of colostrum in the first few days after childbirth. Until the milk comes in, the limited amounts of fluid received from breastfeeding may hinder the functioning of the baby's liver. Certain enzymes in breast milk are also thought to contribute to 'breast milk jaundice'.

Neonatal hepatitis - some of the viruses that can trigger hepatitis in babies include cytomegalovirus, rubella, and hepatitis A, B and C. In around eight out of 10 cases, the cause isn't known but viral infections are suspected. The baby was either exposed to the viral infection in utero, or within the first month or so of life.

Rhesus and ABO blood group incompatibilities - the mother may produce antibodies that can attack the baby's red cells during the latter stages of pregnancy. This means that higher than normal levels of damaged red blood cells have to be eliminated from the body, which in turn triggers high bilirubin levels. The baby may be born anaemic and develop severe jaundice within hours of birth.

Haemolytic anaemia - the inherited types of haemolytic anaemias are autoimmune disorders, characterised by the destruction of red blood cells by the immune system. Haemolytic anaemia can be a complication of other disorders, such as malarial infection.

Galactosaemia - galactose is a milk sugar. A baby with galactosaemia lacks the enzyme needed to metabolise galactose. The high levels of milk sugar can cause cirrhosis of the liver and subsequent jaundice.

Biliary atresia - the ducts that allow the flow of bile from the liver to the small intestine are destroyed, for reasons unknown. Without bile ducts, bile accumulates within the liver and causes the characteristic symptoms of jaundice.

Diagnostic methods

The underlying cause of jaundice in babies must be found. Some of the diagnostic tests may include:

Physical examination

Blood tests

Ultrasound scans

Liver biopsy

Exploratory surgery.

Liver cancer

The liver will function normally with only a small portion of it in working order.

Liver cancer can be a primary cancer (starts in the liver) or a secondary cancer (starts in another part of the body and spreads to the liver).

Primary liver cancers

Primary liver cancer is one of the less common cancers in Victoria with about 170 people diagnosed each year. It is more common in men and people aged over 60 years. Most primary liver cancers are called hepatocellular carcinoma, as they start in liver cells called hepatocytes. Others start in a bile duct and are called cholangiocarcinoma.

In the western world, most people who develop primary liver cancer also have cirrhosis of the liver. This is scarring of the liver which is due to a variety of causes including heavy alcohol drinking over a long period of time. However, only a small proportion of people who have cirrhosis of the liver develop primary liver cancer. Infection with hepatitis B, C or D can also increase the risk of developing cirrhosis and, later, primary liver cancer.

Secondary liver cancers

Secondary liver cancer is the most common liver cancer in the western world. A secondary liver cancer is a cancer that starts somewhere else in the body and spreads (metastasises) to the liver. Most cancers can spread to the liver but the common ones are breast, stomach and bowel cancers. These liver cancers are named after the primary cancer for example, breast cancer that has spread to the liver is called metastatic breast cancer. Sometimes, the liver cancer is discovered first, which leads to the diagnosis of the primary cancer.

Symptoms

Liver cancer usually has no symptoms in the early stages. Symptoms can include:
Pain in the upper right side of the abdomen

Fever

Yellowing of the skin and eyes (jaundice)

Nausea

Weakness

Weight loss

Loss of appetite

Swelling of the abdomen.


Diagnosis methods

Liver cancer is usually diagnosed with a number of different tests, which may include:

Blood tests - to check your general health and to check for a chemical (AFP), which is usually found in increased levels in people with a certain type of primary liver cancer.

Ultrasound - a picture of the liver is taken using sound waves.

CT scan - a specialised x-ray taken from many different angles to build a three-dimensional picture of the body.

Magnetic resonance imaging (MRI) - similar to a CT scan but uses magnetism instead of x-rays to build a picture of the body.

Liver biopsy - a small piece of liver tissue is removed with a needle and examined for cancer cells.

Laparoscopy - a small cut in the lower abdomen allows a thin mini-telescope (laparoscope) to be inserted to look at the liver and take a sample of the liver tissue.
If the tests show you have secondary liver cancer (and you did not know that you had a primary cancer), you may need further tests to find out where the primary cancer is.

Treatment options

Treatment for liver cancer will depend on whether it is a primary or secondary cancer. Treatment options may include:

Surgery - to remove the cancer and as much damaged tissue as possible. This is the main treatment for primary liver cancer. It is only useful for secondary liver cancer if the cancer cells only affect one part of the liver.

Chemotherapy - either tablets or injections of anti-cancer drugs. Sometimes they are injected directly into the artery that feeds the tumour in the liver (hepatic arterial infusion). It is the main treatment for secondary liver cancer and sometimes used for primary liver cancer.

Radiotherapy - x-rays are used to target and kill cancer cells. It may help in treating some types of primary liver cancers and may be used to relieve symptoms of pain and discomfort from secondary liver cancer.

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