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Chronic Liver Disease

Here the liver is damaged over a prolonged period by continued and repeated injury. The cause of injury could be chronic viral infections such as hepatitis C or hepatitis B infection, prolonged abuse of alcohol. Recently, fatty liver disease is on the rise due to unhealthy dietary habits and sedentary life style. Over a period of time, fatty liver disease can lead to inflammation (damage) of the liver and this can also cause chronic liver disease. Long-term diabetes is another cause of chronic liver disease due to fat accumulation in the liver.

Uncommon causes of chronic liver disease are primary biliary cirrhosis, primary sclerosing cholangitis, autoimmune liver disease where the own cells damage the liver due to their inability to recognize the liver as its own.

The chronically damaged liver goes through the stages of fibrosis and cirrhosis during which the liver becomes hard and shrunken. This affects the liver function causing jaundice, encephalopathy (confusion, forgetfulness, slowing of thought process), swelling of the abdomen and feet and abnormalities in the ability of blood to clot. The hardened liver increases the resistance to blood flow through the liver causing complications, such as blood vomiting, blood in stools and fluid in the abdomen. The third serious problem with cirrhosis is the development of liver cancer. Liver transplantation cures all these problems of cirrhosis by replacing the damaged liver with a new healthy liver.

Severity of Chronic Liver Disease

Not all patients with cirrhosis need transplantation. Liver transplantation is only advised when the risk of serious complications and death is high enough to justify a major operation such as liver transplantation. In most instances, a careful history, clinical examination and standard blood tests can help in estimating the severity of liver disease and the risk of complications. Symptoms of end stage liver disease include:

  • Accumulation of fluid in the abdomen (Ascites). Infection of this abdominal fluid, called Spontaneous Bacterial Peritonitis, is even more ominous.
  • Deteriorating kidney function along with liver function (Hepatorenal Syndrome)
  • Vomiting of blood or passage of black stools suggestive of bleeding from the stomach and intestine.
  • Altered consciousness, confusion or slow mentation (Hepatic encephalopathy)

Scoring system to assess need for Liver Transplantation:

Child Pugh score (CPT) and the Model for End Stage Liver Disease score (MELD score). As a general rule, patients with MELD score greater than 15 have a survival benefit with transplantation. In addition, presence of liver cancer on a background of cirrhosis is a strong indication for liver transplantation, provided the tumor stage fits into internationally recognized criteria.

CHRONIC LIVER DISEASE

Chronic liver disease is one of the important causes of morbidity and mortality around the world. Excess alcohol consumption, chronic viral infection and obesity are the leading causes of chronic liver disease. Liver is a unique organ that regenerates quickly, however, progressive long-term damage leads to scarring and eventually to ‘cirrhosis’. In patients with cirrhosis the liver is stiff, shrunken and nodular. Cirrhosis leads to complications such as jaundice, blood vomiting, poor nutrition, confusion, fluid accumulation and liver cancer. Once patients develop symptoms of severe cirrhosis, less than one third of patients will survive for one year.

Symptoms of liver disease:

Liver is a fairly large organ with versatile function. Therefore, the diseases affecting the liver may not cause any symptoms until late in the illness where most of the cells are damaged. Some people may feel tired but being a non-specific symptom, one may not think about liver disease.

Symptoms of chronic liver disease

  • Loss of appetite
  • Fatigue & weakness
  • Jaundice
  • Blackening of skin
  • Leg swelling
  • Abdominal distension
  • Increased bleeding tendency
  • Blood vomit
  • Black motion
  • Slow speech Confusion episodes
  • Abdominal pain, fever and vomiting due to infection

Signs of liver disease that you may see

  • Muscle wasting
  • Jaundice
  • Ascites
  • Scratch marks
  • Enlarged liver
  • Enlarged spleen
  • Leg oedema
  • Prominent blood vessels on the skin
  • Endoscopy to look for oesophageal varices
  • Hyperpigmentation
  • Low blood sugar

Complications of Chronic Liver Disease

Hepatic Encephalopathy:

Here the patient becomes confused usually due to accumulation of toxins in the brain. Many times the confusion episode worsens and the patient may become frankly comatose. Most patients with hepatic encephalopathy require hospitalization; almost 50% get admitted in the ICU and few of them require incubation to protect the airway. Rarely, patients may develop seizure. Usually, there will be some precipitating event such as infection, constipation or some times sleeping medications, salt imbalance etc. This should be promptly identified and treated.

Ascites:

Ascites is the accumulation of fluid in the abdominal cavity. Most patients also have leg swelling. Most of these patients may not eat properly because of abdominal fullness. If left untreated, this will lead to progressive distension and breathing difficulty. Also, kidneys get affected in the later stages. Ascites can be controlled with salt restriction, water tablets (diuretics). With progression in liver disease, ascites may not respond to the above therapy and most of these patients require liver transplantation. Whilst awaiting transplantation they may require recurrent tapping (draining using a needle) of the fluid or rarely, TIPS

Gastrointestinal Bleeding:

Gastrointestinal bleeding related to portal hypertension is a serious complication in patients with liver cirrhosis. Most patients bleed from esophageal or gastric varices, but bleeding from ectopic varices or portal hypertensive gastropathy is also possible. Patients are managed with a combination of endoscopic and pharmacologic treatment. The endoscopic treatment of choice for esophageal variceal bleeding is variceal band ligation. Bleeding from gastric varices is treated by injection with cyanoacrylate. Treatment with vasoactive drugs as well as antibiotic treatment is started before or at the time point of endoscopy. The first-line treatment for primary prophylaxis of esophageal variceal bleeding is nonselective beta blockers. A trained interdisciplinary team consisting of endoscopists, hepatologists, and specialized nurses as well as interventional radiologist should administer treatment of acute bleeding related to portal hypertension.

Acute Kidney Injury:

Acute kidney injury (AKI) is associated with detrimental effect on early survival in hospitalised cirrhotic patients. Due to several hemodynamic modifications, both at the systemic and renal level, induced by cirrhosis, these patients are at increased risk to present acute kidney injury. Regular monitoring of the renal status in cirrhotic patients is warranted as the occurrence of AKI is associated with an increased risk of long-term CKD development.

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