LIVER DISEASES

Medical terminology for common liver problems

What is Acute Hepatitis?

Hepatitis is liver swelling as a result of infection or toxic injury . Common causes of acute hepatitis are hepatitis viruses (A, B, C, E), alcohol, certain medications, and herbal drugs.

Symptoms of acute hepatitis :

• Loss of appetite
• Nausea
• Abdominal pain
• Jaundice

Most patients with acute hepatitis recover completely in a few weeks. Some severe cases may progress to liver failure which is a life threatening condition.

What is Chronic Hepatitis?

Inflammation or swelling of the liver that lasts for more than six months is known as Chronic Hepatitis. Common causes of chronic hepatitis are hepatitis B or C infection, alcohol, autoimmune liver disease and fatty liver disease. Patients with chronic hepatitis may be completely symptom free or have very few symptoms like loss of appetite and fatigue. Chronic hepatitis may progress to cirrhosis (scarring) of the liver if it is not identified.

What is Cirrhosis?

Normal liver has a smooth surface and is soft to feel. Cirrhosis is the scarring of the liver – hard scar tissue replaces soft healthy tissue. Any long standing liver disease related to excess alcohol use, hepatitis B, hepatitis C, autoimmunity or fatty liver can cause cirrhosis. It usually takes many years for liver damage to lead to cirrhosis. As cirrhosis becomes worse, liver failure develops. Patients with cirrhosis also have a high risk of developing liver cancer. Recognizing liver diseases early and treating them can thus prevent development of cirrhosis, liver failure and liver cancer.

Picture of normal liver and a cirrhotic liver

What is Fatty Liver Disease?

Fatty liver disease is the accumulation of excess fat in the liver. It usually occurs in people who drink alcohol (Alcoholic fatty liver disease). It is also very common in people who are overweight, or in those with diabetes (Non-alcoholic fatty liver disease). Except for liver enlargement, it may not cause any symptoms. Over years it can lead to cirrhosis in some patients.

What is Liver Failure?

This is the term used when the liver is unable to perform its functions. The most important symptoms are jaundice, mental confusion, accumulation of fluid in the belly and bleeding tendency. Some patients with acute hepatitis can develop liver failure within a short period of days to weeks. Others with progressive liver disease like cirrhosis develop liver failure after several years. The only way to treat liver failure is by liver transplantation.

What is Hepatocellular (Liver) Cancer?

Patients who have liver cirrhosis are at risk of developing liver cancer. Small liver cancers may not produce any symptoms and can be treated effectively if detected early. It is  important for patients with cirrhosis to do regular checks to detect small cancers.

Essential facts about “JAUNDICE”

What is Jaundice ?

Jaundice is the yellow appearance of the eyes and skin. Jaundice itself is not a disease. It is the marker of a disease.

What is Bilirubin ?

Jaundice occurs due to increase in the level of a chemical called “Bilirubin” in the blood. Bilirubin is of two types – Unconjugated (also known as Indirect) and Conjugated (also known as Direct). Unconjugated Bilirubin is formed when ageing red blood cells breakdown under normal physiological conditions. The unconjugated bilirubin is taken up by the liver and converted into conjugated bilirubin which is then excreted into the intestines through the bile duct. The normal level of bilirubin in the blood is less than 1 mg per deciliter (1 mg/dl). A value more than this is classified as hyperbilirubinemia or jaundice.

What causes Jaundice ?

Jaundice may occur due to excess breakdown of red blood cells (known as hemolysis). It may occur due to a disease of the liver or due to blockage of bile ducts when bilirubin cannot be excreted into the intestines.

What are the common diseases that cause Jaundice ?

Hepatitis virus infection of the liver (hepatitis A, B, C, D or E virus), excess alcohol, certain drugs and medications can cause jaundice. Blockage of the bile ducts by stones, narrowing (stricture), cancers and diseases of the pancreas can also cause jaundice. Excess breakdown of red blood cells in certain diseases such as hemolytic anemia, malaria and thalessemia can also cause jaundice.

What are other symptoms that can accompany jaundice ?

Other symptoms that usually accompany jaundice are abdominal pain, lack of appetite, nausea, vomiting, dark urine, itching of skin and generalized weakness.

How can one find out if jaundice is because of a liver disease or blockage of bile ducts ? An ultrasound or CT scan is helpful in deciding if jaundice is because of liver disease of blockage of bile duct. Blood tests (known as Liver Function Tests) are essential to assess the degree of jaundice and cause of jaundice.

How is Jaundice treated ?

Treatment depends upon the exact cause of jaundice. Most patients with jaundice due to a recent viral infection of the liver like hepatitis A or hepatitis E recover on their own. Patients with jaundice due to blockage of the bile duct need some form of surgery. Patients with jaundice and underlying chronic liver disease or cirrhosis may not recover soon and need detailed evaluation.

What are the danger signs in Jaundice ?

Patient with jaundice who develop signs of liver failure such as swelling of feet or belly, mental confusion, or bleeding are at high risk of complications including death. Persistent high fever is also a danger sign.

Are herbal or Ayurvedic medicines useful in treating Jaundice ?

There is no scientific evidence that any form of herbal, Ayurvedic or other alternative medications are effective in treating any form of liver disease. On the contrary, such products may contain undisclosed chemicals and heavy metals that may be toxic to the body. We strictly advise patients with liver disease from using any such product without consulting their primary doctor.

What is acute hepatitis ?

Acute Hepatitis is recent injury to the liver caused by a virus (Hepatitis A/B/C/E), alcohol, infections (dengue, malaria, typhoid) or certain drugs and medications.

What are the symptoms of acute hepatitis ?

In the early stages, a person may have tiredness, slight fever, nausea, poor appetite, and mild pain in the right upper abdomen. A few days after these symptoms, patients may develop jaundice in which there is yellowness of the eyes and dark urine. Symptoms usually last for 2 to 6 weeks.

What are the danger signs in acute hepatitis ?

Few patients with acute hepatitis develop signs of liver failure such as swelling of feet or belly, or mental confusion.  These patients are at high risk of complications including death. They need to be urgently hospitalized and may need a liver transplantation.

How is acute hepatitis diagnosed ?

Blood tests will help determine the cause and severity of the hepatitis. Further information may be obtained from ultrasound and other types of liver scans. In certain situations a liver biopsy may be required.

How is acute hepatitis treated ?

Specific medical treatment is not required for acute hepatitis caused by a virus infection. More than 99 percent patients recover. Alcohol should be completely stopped. Any offending drug should be stopped. Regular blood tests should be done to ensure that patient is improving.

Are herbal or Ayurvedic medicines useful in treating acute hepatitis ?

There is no scientific evidence that any form of Herbal or Ayurvedic medications are effective in treating liver disease. It is absolutely dangerous to use these medicines as some of them may contain undisclosed chemicals and heavy metals that may be toxic to the body.

What is the recommended diet ? 

There are no specific restrictions. Eat a well balanced diet with lot of milks. Food containing excess oil should be avoided. If alcohol is the cause, it must be stopped completely.

What other precautions are necessary ?

During the early phase of disease, patient requires rest. Once patient feels better, daily work and normal activities can be started. If you have hepatitis A or hepatitis E and your job involves food handling, your doctor will advise you on when it is safe to return to work. People with hepatitis B must inform their family and their sexual partners about it. Sexual and other close contacts will need to protect themselves by being vaccinated for hepatitis B.

What is chronic hepatitis ?

Chronic hepatitis is ongoing inflammation of the liver caused by a hepatitis virus (hepatitis B or C), alcohol, fatty liver disease or uncommon conditions such as autoimmune liver disease. Chronic hepatitis lasts several years.

What are the symptoms of chronic hepatitis ?

Patients with chronic hepatitis may have no or very few symptoms. Chronic hepatitis is usually detected incidentally when blood tests for the liver are abnormal or when patients are incidentally detected to have hepatitis B or hepatitis C. Patients may have non-specific symptoms such as tiredness, nausea, poor appetite, and discomfort in the right upper abdomen. Some patients may have repeated episodes of jaundice.

Is chronic hepatitis a progressive disease ?

Chronic hepatitis is a progressive disease if the underlying cause is not treated. Untreated, chronic hepatitis may lead to cirrhosis and liver failure.

How is chronic hepatitis diagnosed ?

Blood tests will help determine the cause and severity of the hepatitis. Further information may be obtained from ultrasound and other types of liver scans. A liver biopsy may be required to assess the exact stage of disease.

How is chronic hepatitis treated ?

The treatment of chronic hepatitis depends on the underlying cause. Patients should stop alcohol consumption completely. Specific treatments are available for hepatitis B and C. Autoimmune liver disease can also be treated effectively with medications.

What are the danger signs in chronic hepatitis ?

Development of jaundice or signs of liver failure such as swelling of feet or belly, mental confusion, or bleeding are danger signs. These may signify that the patient has developed advanced liver disease and cirrhosis. These patients are at high risk of complications including death.

Are herbal or Ayurvedic medicines useful in treating chronic hepatitis ? 

There is no scientific evidence that any form of Herbal or Ayurvedic medications are effective in treating liver disease. It is absolutely dangerous to use these medicines as some of them may contain undisclosed chemicals and heavy metals that may be toxic to the body.

What can be done at home ?

• If alcohol is the cause, you must stop drinking completely and see your doctor.
• Eat a well-balanced diet. There is no restriction on dietary items.
• There are no restrictions on your daily work, exercise and activities.
• If you have hepatitis B or hepatitis C, you must start treatment. You cannot donate blood.
• People with hepatitis B must inform their family and sexual partners about it. Sexual and other close contacts should get hepatitis B vaccine.
• People with hepatitis C must inform their family and sexual partners about it. The risk of sexual transmission of hepatitis C is mush lower than hepatitis B. There is no vaccine for hepatitis C.

Hepatitis B – A treatable disease

What is Hepatitis B ?

Hepatitis B is a viral infection of the liver caused by the hepatitis B virus (HBV). Hepatitis B causes inflammation and swelling of the liver (acute hepatitis) and prevents it from working well. It may persist in the liver, and over many years can cause cirrhosis (scarring) of the liver that can lead to liver failure. Hepatitis B infection is the most important cause of liver cancer all over the world.

How does one get Hepatitis B ?

Hepatitis B virus is spread by contact with blood or other infectious body fluids. Adults get Hepatitis B through infected blood transfusion, contaminated needles and sexual transmission from a hepatitis B infected partner. Children usually get Hepatitis B from their mother during childbirth. Hepatitis B virus is not spread by air, food, or water.

Who is at risk of having Hepatitis B ?

Hepatitis B is very common in India. About 3 – 5 percent of all Indians have chronic hepatitis B infection. Certain practices like reuse of needles and syringes in hospitals and clinics in the past, tattooing using unclean and contaminated needles, & unregulated and unsafe blood transfusion has increased the risk of transmission of hepatitis B in our country. In view of the high prevalence of hepatitis B, everyone should get tested for hepatitis B.

What are the phases and symptoms of Hepatitis B infection ?

Infection with hepatitis B can cause both short-term (acute) disease and long-term (chronic) disease. Patient with acute HBV infections get symptoms such as loss of appetite, weakness, nausea, vomiting, abdominal pain, jaundice (yellow skin or eyes), and dark urine. The acute phase usually lasts 2-8 weeks and most patients recover completely. Few individuals develop a severe form of acute infection and can die as a result of liver failure. Some adults and almost all children who get infected during birth go on to develop chronic hepatitis B infection. These individuals often do not feel sick for many years. With progression of disease, liver failure develops and patients develop jaundice (yellowness of the eyes and skin), swelling of the legs (edema), fluid in the abdomen (ascites), vomiting of blood, and mental confusion.

What are the long term consequences of Hepatitis B ?

Hepatitis B damages the liver slowly over a period of 20-30 years. About 20 percent of patients with untreated hepatitis B progress to liver cirrhosis which is scarring of the liver. Once cirrhosis develops patients are at a risk of developing liver failure.

Are patients with Hepatitis B at risk of developing liver cancer ? Hepatitis B is the most common cause of liver cancer all over the world. One in 20 people with hepatitis B will develop liver cancer. The risk is more in patients with chronic hepatitis B who have progressed to cirrhosis. Risk also depends on the amount of virus in the blood. Patients with chronic hepatitis B should regularly do ultrasound scans to detect small liver cancers at an early stage. Small cancers can be effectively treated.

How is Hepatitis B diagnosed ?

Hepatitis B can be easily diagnosed by simple blood tests. A blood test (known as HBsAg)can determine whether a person is infected or not. It is also possible to know the amount of hepatitis virus in the blood by performing a test known as Hepatitis B virus DNA PCR. In patients who are not infected with hepatitis B, it is possible to know whether they have enough immunity (protection) that will protect them from developing hepatitis B in the future.

What should you do if you are diagnosed to have Hepatitis B ?

Eat healthy meals, exercise and lose weight if you are overweight Consult a liver disease expert (Hepatologist) and perform special tests to determine whether you need treatment Talk to your doctor about specific treatments for Hepatitis B DO NOT RESORT TO USE OF HERBAL MEDICINES. These can damage the liver and can cause liver failure Avoid alcohol completely Ask all your family members including spouse, siblings and children to get tested for Hepatitis B by doing a test known as HBsAg

How is Hepatitis B treated ?

If you have HBV, it is important to talk to your doctor about treatment options. There is a difference between treatment of acute hepatitis B and chronic hepatitis B infection. Most patients who develop acute hepatitis B infection recover on their own without any specific treatment. Your doctor will recommend bed rest, drinking lots of fluids, eating a healthy diet and avoiding alcohol. However, patients with chronic hepatitis B infection and those with hepatitis B related cirrhosis need specific medicines which act against the hepatitis B virus. Treatment depends on the amount of hepatitis B virus in the blood and this is determined by performing a blood test known as Hepatitis B virus DNA PCR. Some commonly used medicines for treatment of Hepatitis B are Entecavir and Tenofovir. These oral medications are usually required for several years and sometimes lifelong. Some patients may benefit from injections known as Pegylated Interferon. These injections are usually given once a week for up to one year.

What is the best way to stop the spread of Hepatitis B ?

Hepatitis B vaccination is the most effective way to prevent infection. The hepatitis B vaccine is given in 3 doses over a period of six months. After the vaccination course is completed it is important to do a blood test to check whether the vaccine is working or not. This form of blood test detects the level of protective antibodies in the blood (Anti HBs titer). All children should ideally be vaccinated at birth. However, vaccine can be taken by people of all age groups. Your doctor may advise some tests before you take the vaccine.

Hepatitis B : Facts at a Glance Hepatitis B is a liver disease caused by the hepatitis B virus (HBV). Adults get Hepatitis B through infected blood transfusion, contaminated needles and sexual transmission from a hepatitis B infected partner. Children usually get Hepatitis B from their mother during childbirth. About 1 in 20 Indians are infected with Hepatitis B. Most people with Hepatitis B have no symptoms. Hepatitis B can be easily diagnosed by a simple blood test. There are effective medications to treat Hepatitis B. Untreated Hepatitis B can lead to cirrhosis (scarring) of the liver, liver cancer, and liver failure. Vaccination is the best way to prevent Hepatitis B.

What is hepatitis C ?

Hepatitis C usually causes long-term or chronic infection of the liver and unless successfully treated with medications, can lead to cirrhosis (scarring) of the liver, liver failure, and liver cancer.

Who is at risk of having hepatitis C ?

HCV is spread by blood to blood contact. You may be at risk if you have:

• Used intravenous drugs in the past and shared needles for injecting these drugs
• Received blood transfusion in the past especially from unregulated blood banks
• Chronic kidney disease on hemodialysis
• Contact with infected needles or blood
• Unprotected sex with multiple partners

What are symptoms of hepatitis C ?

Patients during the early phase of infection have no symptoms and feel absolutely healthy. When the disease progresses and patient develops liver cirrhosis, symptoms occur such as tiredness, nausea, loss of appetite, skin itching, dark urine, and jaundice (yellowing of the skin and eyes). Once liver failure develops, patients develop swelling of the legs (edema), fluid in the abdomen (ascites), vomiting of blood, and mental confusion.

How is hepatitis C diagnosed ?

Hepatitis C is diagnosed by simple blood tests. Specialized blood tests can also tell you about the amount of virus and the genotype of the virus. An Ultrasound scan and a Fibroscan will assess whether you may have developed cirrhosis. Sometimes a liver biopsy may be required.

How is hepatitis C treated ?

There is effective treatment for HCV infection. New directly acting anti-viral drugs (DAA) have revolutionised the treatment of hepatitis C. These new drugs include Sofosbuvir (Sovaldi), Daclatsavir (Daklinza) and Ledipasvir/Sofosbuvir (Harvoni). Most patients are cured with three months of treatment. Some patients who have advanced disease or who have failed treatment in the past may require treatment upto 6 months. Such therapies are effective in curing 95% of patients.

• Patients with Genotype 1 and 4 infection : Harvoni (Sofosbuvir / Ledipasvir) for 3 months
• Patients with Genotype 2 infection : Sofosbuvir and Ribavirin for 3 months
• Patients with Genotype 3 infection : Sofosbuvir and Daclatsavir for 3 months
• Patients with cirrhosis : Treatment should be extended to 6 months to achieve optimal response

How can patients with Hepatitis C and liver failure be treated ?

Once patients with hepatitis C develops cirrhosis and liver failure, they cannot be treated with medicines. The only option in such patients is to undergo liver transplantation. Overall about 10 percent of patients with Hepatitis C require liver transplantation. However, patients who have only cirrhosis on a Fibroscan but no evidence of liver failure should take treatment with the new directly acting antiviral drugs as this can prevent further progression of disease.

I stay outside India. Can I get Sovaldi, Harvoni, Daclatsavir or their generic versions from India ?

Yes, it is possible to buy these drugs from India and get it shipped to your country. You will need a prescription from a liver specialist (hepatologist) in India. You can contact us and we can help you get these drugs shipped to your country. Most countries have no restrictions if medicines are imported for treatment of individual patients supported by a prescription from a doctor.

Autoimmune Liver Disease

(Autoimmune Hepatitis, Primary Biliary Cirrhosis, Primary Sclerosing Cholangitis)

What is autoimmune liver disease ?

Autoimmune liver disease is a disease in which the body’s own immune system attacks the liver and causes it to become inflamed. The disease is chronic, meaning it lasts many years. If untreated, it can lead to cirrhosis and liver failure.

There are various types of autoimmune liver disease. The most common one is known as Autoimmune Hepatitis. This is the form that mostly affects young women and children. Primary Biliary Cirrhosis is another autoimmune liver disease affecting predominantly women. Primary sclerosing cholangitis affects men and sometimes children.

What causes autoimmune liver disease ?

Your immune system normally attacks bacteria, viruses and other invading organisms. It is not supposed to attack your own cells; if it does, the response is called autoimmunity. In autoimmune hepatitis, your immune system attacks your liver cells, causing long-term inflammation and liver damage. We don’t know why the body attacks itself in this way, although heredity and prior infections may play a role.

What are the symptoms and complications of autoimmune liver disease ?

Often, the symptoms of autoimmune liver disease are minor. When symptoms do occur, the most common are fatigue, abdominal discomfort, joint pain, itching, jaundice (yellowing of the skin and eyes), dark urine, loss of appetite and nausea. Some patients may develop signs of liver failure such as include ascites (fluid in the abdomen) and mental confusion. In 10 to 20% of cases, autoimmune hepatitis may present with symptoms like an acute hepatitis. Itching is an important and sometimes the only symptom of primary biliary cirrhosis. Patients with primary sclerosing cholangitis may present with recurrent episodes of fever and jaundice.

How is autoimmune liver disease diagnosed ?

To confirm a diagnosis of autoimmune liver disease you will need to undergo a panel of special blood tests to detect presence of one or more antibodies in your blood that may be attacking the liver. These are known as auto-antibody tests. Some patients with autoimmune liver disease may not have detectable auto-antibodies in their blood. Often a liver biopsy is required for confirming the diagnosis and assessing the severity of the disease. Please see the section on liver biopsy procedure to understand how a liver biopsy is done.

How is autoimmune liver disease treated ?

The goal of treatment is to stop the body’s attack on itself by suppressing the immune system. Autoimmune hepatitis is typically treated with a medicine called prednisolone, a type of steroid that acts on the immune system. Other drugs such as azathioprine may also be used. Treatment starts with a high dose of prednisolone. When symptoms improve, the dosage is lowered. In most cases, autoimmune hepatitis can be controlled but not cured. Patients will need to stay on the medicine for years, and sometimes for life. The medicines (prednisolone) can cause side effects including diabetes, weakness of bones, high blood pressure, glaucoma, weight gain and decreased resistance to infection. Close medical follow-up is therefore necessary. Primary biliary cirrhosis is a slowly progressive disease and if detected early can be effectively treated with a medicine known as ursodeoxycholic acid. Patients with primary sclerosing cholangitis can develop narrowing (strictures) of their bile ducts that may require endoscopic or surgical treatment.

What is fatty liver disease?

Fatty liver disease is the accumulation of extra fat in liver. Excess alcohol intake is a common cause of fatty liver. However, fatty liver also occurs in patients who do not drink or drink very little alcohol. This form of fatty liver disease is known as Non-alcoholic fatty liver disease (NAFLD).

Who is likely to have Fatty Liver?

Fatty liver (non-alcoholic) usually develops in people who are overweight, have diabetes, high cholesterol or high triglycerides. Poor eating habits with a diet rich in fats also may lead to fatty liver. Some people develop fatty liver even if they do not have any risk factors. Fatty liver may affect up to 10 percent of people in India.

What are the risks linked to Fatty Liver?

Fatty liver may cause liver inflammation or swelling. This may progress to cirrhosis (scarring of the liver) over several years and may even lead to liver cancer or liver failure. Most people with fatty liver and inflammation are between the ages of 40 and 60 years. It may not have any symptoms and people may feel absolutely healthy even though the liver may be significantly damaged. Since people are getting overweight, diabetes is on the rise and oily food is being consumed more commonly, fatty liver disease is going to become a common cause of cirrhosis and liver failure in India in the coming years.

What are the stages of fatty liver?

Fatty liver has the following stages: Simple fatty liver Fatty liver with inflammation (known as non alcoholic steatohepatitis or NASH) Fatty liver with liver hardening and liver scarring (known as liver cirrhosis) Most individuals with simple fatty liver do not progress to severe liver damage. However, about 10 percent individuals, especially those with several risk factors will progress to liver inflammation and cirrhosis. Once liver cirrhosis develops there is a high risk of liver failure, liver cancer and death.

What are symptoms of Fatty Liver?

Fatty Liver often has no symptoms. When symptoms occur, they may include fatigue, weakness, weight loss, loss of appetite, nausea, abdominal pain, yellowing of the skin and eyes (jaundice), itching, swelling of the legs (edema) and abdomen (ascites), and mental confusion. Most of these symptoms occur when fatty liver has already lead to cirrhosis.

How is Fatty Liver diagnosed?

It is important to diagnose fatty liver early when there are no symptoms. A blood test (liver function test) usually shows elevation of liver enzymes. An ultrasound scan shows fatty liver. Several other blood tests and occasionally a liver biopsy may be required to make sure that there are no other reasons for these abnormal liver tests.

What are the associations of Fatty Liver Disease?

People with fatty liver disease are at higher risk of developing diabetes, high blood pressure, high cholesterol and triglyceride levels. They are also at higher risk of developing heart disease. It is important for these individuals to visit their doctor regularly so that appropriate tests can be done for early detection and treatment for these associated problems.

How should I do if I have Fatty Liver ?

Lose weight if you are overweight. Exercise at least 30 minutes per day. Reduce fat consumption in diet. Avoid a carbohydrate rich diet (potatoes, white bread, white rice). Diet rich in antioxidants (fruits, nuts, pulses and grains) is beneficial. Avoid excess fruits juices and carbonated drinks rich in fructose. Antioxidants such as Silymarin, vitamins C and E may have some benefit. Talk to your doctor before using these. Perform annual health checkups for liver enzymes, blood sugar and cholesterol levels every year. If you have diabetes and hypertension, treat it effectively. Even if you a light alcohol drinker, it is ideal to stop alcohol consumption completely. Consult a Liver Doctor (Hepatologist) to determine whether you have simple fatty liver or fatty liver with inflammation or cirrhosis

Is there a specific medicine for Fatty Liver?

Unfortunately there is no specific medicine that can reduce the amount of fat in the liver. Although some doctors prescribe vitamins and other liver protective medicines, in scientific studies no particular drug has been found to be effective. Occasionally if your doctor suspects that there may be too much inflammation in your liver, he may advise you to undergo a liver biopsy and then prescribe certain medicines that have been used in clinical trials and found to have beneficial effects.

I was diagnosed to have Fatty Liver and reassured. How often should I see a liver doctor?

You must see a liver doctor at least once a year and perform blood tests. During these visits you should also make sure that you have been checked for diabetes, high blood pressure and high cholesterol. You must also ask your doctor whether you need to check your heart. You must ask your doctor if you may be having a progressive form of fatty liver known as Non-alcoholic steatohepatitis (NASH).

What is cirrhosis ?

1111Normal liver has a smooth surface and is soft to feel. Cirrhosis is the scarring of the liver — hard scar tissue replaces soft healthy tissue. As cirrhosis becomes worse, the liver is not able to perform its functions and there occurs an increase in resistance to the flow of blood through the liver (portal hypertension).

What causes cirrhosis ?

Cirrhosis is caused by chronic (long-term) liver diseases that damage the liver. It usually takes many years for liver damage to lead to cirrhosis. Recognizing liver diseases early and treating them can thus prevent development of cirrhosis. Common causes of cirrhosis are alcohol, hepatitis B, hepatitis C, fatty liver disease and certain genetic diseases.

How does alcohol damage the liver ?

Chronic alcohol use is the leading cause of cirrhosis in India. Excess alcohol causes the liver to swell, which over time can lead to cirrhosis. Even small quantities of alcohol if taken over a prolonged period of time can lead to significant liver damage.

What infections cause cirrhosis ?

Chronic hepatitis B and C viruses are important causes of cirrhosis in India. One may get hepatitis B and C viruses by blood transfusion, infected needles and razors, sexual transmission and vertical transmission from mother to child. These viruses cause persistent infection of the liver that leads to cirrhosis over time. About one in four people with chronic hepatitis B or C may develop cirrhosis. Early detection of these viruses and successful treatment can prevent the development of cirrhosis.

Can fat in the liver cause cirrhosis ?

People who are overweight, have diabetes, or high cholesterol can accumulate fat in the liver. This is known as fatty liver. In some people fatty liver can progress to cirrhosis. Such patients are also at risk of developing liver cancer.

What other diseases can cause cirrhosis ?

Certain rare diseases of the bile ducts can lead to cirrhosis. In these diseases there is obstruction of bile flow to the small intestine. The bile backs up in the liver causing the liver to swell and can lead to cirrhosis. These diseases are known as primary sclerosing cholangitis and primary biliary cirrhosis. Some genetic diseases can lead to cirrhosis. These diseases include Wilson disease, hemochromatosis, glycogen storage diseases, alpha-1 antitrypsin deficiency, and autoimmune hepatitis.

What are symptoms of cirrhosis in its early stage ?

There are usually no symptoms of cirrhosis in its early stage. Patients feel healthy and unless certain blood tests and other investigations are done, it may not be possible to detect cirrhosis at all. Almost 80 percent of the liver needs to be damaged before a patient develop symptoms.

What are the symptoms of advanced cirrhosis?

Symptoms of advanced cirrhosis include loss of appetite, tiredness, nausea, weight loss, abdominal pain, and severe itching. Other severe complications include: Jaundice, a yellow discoloration of the skin and eyes Bruising and bleeding easily (nose, gums and skin) Excess water build up leading swelling of the legs (edema) and abdomen (ascites) Mental confusion Vomiting of blood

How is cirrhosis diagnosed ?

Cirrhosis is diagnosed by symptoms, medical history, blood tests, and physical examination. Scans of the liver – ultrasound or CT scan are often required. A liver biopsy may be needed to find out the exact cause of cirrhosis and to check how much of the liver has been damaged. During a biopsy, a small piece of liver tissue is removed with a needle passed into the liver. This tissue is then studied in the laboratory.

How is cirrhosis treated ?

Treatment options for cirrhosis depend on the cause and the level of liver damage. Depending on the disease causing cirrhosis, medications or lifestyle changes may be used for treatment. The goals of treatment are to prevent further liver damage and reduce complications. When cirrhosis cannot be treated, the liver will not be able to work and a liver transplant may be needed. Doctors will determine whether a liver transplant is the best treatment option.

What is the best way to manage cirrhosis ?

It is possible to prevent further liver damage with proper management of cirrhosis. Maintain a healthy lifestyle (eat a healthy diet and exercise regularly). Limit salt in your diet to prevent or reduce fluid buildup. Stop drinking alcohol completely. Talk to your doctor about all of the medications, vitamins and supplements you take. Talk to your doctor about hepatitis A and hepatitis B vaccinations. You may require regular blood tests to assess the condition of your liver periodically. You may need regular ultrasound scans to detect cancers that develop in cirrhotic livers. Liver cancers if detected early, when they are small, and be treated effectively. Do not take herbal therapies or other alternative medicines for cirrhosis before consulting your doctor. Some of these medications can actually cause more harm to the liver.

Liver Failure

What is Liver Failure ?

Liver failure occurs when the liver is unable to perform its functions. This usually happens when there is overwhelming damage to more than 80 percent of the liver cells due to an infection, toxin or drug. Liver injury of a lesser magnitude causes hepatitis. Although hepatitis is fairly common in the population, liver failure occurs in only 1-2 percent of patients with hepatitis.

What are the signs of Liver failure ?

The presence of only jaundice does not mean liver failure. When patients with jaundice develop mental confusion, swelling of the abdomen of legs due to accumulation of excess fluid, and abnormality of blood clotting, it signifies liver failure.

What are the types of Liver Failure ?

Liver failure is known as “acute” when a patient develops mental confusion within 4 weeks after the onset of jaundice. Liver failure is known as “subacute” when a patient develops mental confusion or swelling of the abdomen beyond 4 weeks but within 6 months after onset of jaundice.

What causes Liver Failure ?

Viral infections, excess alcohol intake, certain medications, and toxins can cause liver failure. Herbal drugs have unknown toxicities and can cause liver failure. Certain autoimmune and metabolic diseases can also cause liver failure. There are many patients in whom the exact cause of liver failure cannot be found. Usually these cases are attributed to unknown viruses or medications.

How is Liver Failure diagnosed ?

Liver failure is diagnosed on the basis of clinical symptoms such as presence of mental confusion and excess fluid accumulation in a patient with jaundice. Clotting of blood becomes abnormal and this can be detected by a test known as prothrombin time. Levels of ammonia and lactic acid in the blood also get elevated in patients with liver failure.

What is the treatment of Liver Failure ?

The treatment of liver failure in mainly supportive. Although it is important to find the cause of liver failure, but specific treatment of viruses and drugs is usually not available. Patients are managed in an intensive care unit. Complications such as infections, kidney failure, low blood sugar have to be prevented. Adequate nutrition has to be provided. Regular blood tests are done to monitor the progress of the patient.

Can a patient with Liver Failure recover with medical management ?

About 20 percent patients can recover. Liver is one of the few organs in the human body that has immense regenerative potential. Even after massive liver injury leading to liver failure, the liver cells over a period of time can regenerate to form a functioning liver. Unfortunately most patients with liver failure deteriorate rapidly and develop complications leading to death and there is not enough time for liver cells to regenerate.

When is a transplant required for a patient with Liver Failure ?

Any patient with jaundice, who develops signs of liver failure, should be transferred to a hospital with facilities for liver transplant. Close monitoring of patients is required to look for clinical deterioration so that a timely transplant can be performed. Unnecessary delay can prove fatal since substantial time is required for counseling of family, evaluation of the patient, search for an appropriate living donor and evaluation of the donor. It is important to prepare for a transplant at the earliest. In case a patient does show improvement, transplant may not be required.

What are the types of Liver Transplant done in Liver Failure ?

Liver transplants are of two types. The most common form of transplant done in the setting of liver failure is a living donor transplant. In this a healthy person donates part of his liver to a patient with liver failure. The other type is a cadaveric transplant in which families of unfortunate patients with serious brain injury, after declaration of brain death, opt to donate their organs. Organs such as liver, kidney, heart, lungs, intestine and eyes can be donated from brain dead patients.

What are the results of Liver Transplant done for liver failure ?

With advancements in surgical skills, medical technology and availability of excellent drugs that prevent rejection, over 90 percent patients do well after transplant for liver failure. Lifelong medications, blood tests and medical care is required. Most liver transplant patients, adults or children, can lead healthy and normal productive lives.

Obstruction of the bile duct causes JAUNDICE

What is bile ? 

Bile is a liquid released by the liver. It is a mixture of several chemicals and contains cholesterol, a yellow pigment called bilirubin and bile salts. Bile passes out of the liver through tubes known as bile ducts and is stored in the gallbladder. The gallbladder is connected to the intestine by a large bile duct known as common bile duct. After a meal, the gallbladder contracts and bile is released into the small intestine. Bile salts present in the bile help in digestion of fat within the intestines. When the bile ducts become blocked, bile accumulates in the liver. The accumulated bile in the liver leaks into the blood stream and this leads to an increase in the level of bilirubin in the blood causing jaundice (yellow color of the skin). Accumulation of bile salts in the blood causes pruritus (itching of the skin).

What is bile duct obstruction ?

It is the blockage in the tubes that carry bile from the liver to the gallbladder and small intestine.

What are the possible causes of a blocked bile duct ? 

• Stones in the common bile duct
• Cancer of the bile ducts or pancreas
• Narrowing (stricture) of the common bile duct due to previous gallbladder surgery
• Cysts of the bile duct
• Worms in the bile duct (rarely)

What are the symptoms of bile duct obstruction ?

• Abdominal pain in the upper right side
• Dark urine
• Fever
• Itching of the skin
• Jaundice (yellow colour of the skin and eyes)
• Nausea and vomiting
• Pale colored stools

What are tests done to confirm bile duct obstruction ?  

Liver function tests can suggest if there is a blockage of the bile duct. Usually the bilirubin level in the blood is increased and there is elevation of liver enzymes (alkaline phosphatase, GGT, AST and ALT). An ultrasound scan is a simple test that can show a enlarged and dilated bile duct. After determining that the bile duct is blocked, it is important to determine the cause of blockage. Stones causing bile duct obstruction can be seen on ultrasound scan. Frequently other specialized radiological investigations are required to determine the exact cause of blockage. These tests include abdominal CT scan, Magnetic resonance cholangiopancreatography (MRCP), Endoscopic retrograde cholangiopancreatography (ERCP), Endoscopic ultrasound (EUS), Percutaneous trans-hepatic cholangiography (PTC) and Radionuclide scan (HIDA scan). 

How is bile duct obstruction treated ? 

Treatment depends upon the cause of the obstruction. Stones in the bile duct can be removed by an endoscopic procedure known as ERCP. If there are stones present in the gallbladder in addition to the bile duct, then the gallbladder will usually be surgically removed by a procedure known as cholecystectomy. If the cause of bile duct obstruction is cancer, then a major surgery is required to remove the cancer. In some patients, the cancer may be advanced and cannot be removed by surgery. In such cases a plastic tube (known as stent) may be placed in the bile duct across the blocked area to relieve the obstruction. This procedure is known as bile duct stenting and this can be done endoscopically or radiologically by piercing the skin and abdominal wall overlying liver.

What are the complications of untreated bile duct obstruction ? 

Untreated bile duct obstruction can lead to progressive jaundice and severe itching. Frequently patients develop infection in the blocked ducts that spreads to the liver and causes high fever with shivering. Such an infection is known as acute cholangitis and this can be life threatening if not diagnosed and treated promptly. Prolonged obstruction of the bile duct over several months can cause permanent damage to the liver known as biliary cirrhosis, that can eventually lead to liver failure.