Disease of the liver caused mostly by infection, alcohol and cancers.
Causes
The largest internal organ of the body, the liver is a powerhouse of activity. It is a storage site for glucose, the fuel ol the body, and can synthesize it rapidly if stores are insufficient. It makes bile, later kept in the gall bladder. Bile is necessary for the absorption of fat from food. The liver also makes the fats needed for cell metabolism, including triglycerides and cholesterol. The bulk of protein synthesis takes place in the liver and, crucially, it makes the proteins needed for blood clotting such as fibrinogen.
Also, the liver contains cells that catch and destroy bacteria and viruses from the intestine and so prevent them gaining access to the rest of the body. Lastly, the liver inactivates many hormones once they have done their jobs and this caretaking function extends to the destruction of drugs, alcohol and old blood cells. These are the main source of the pigment bilirubin, which is responsible for the jaundice of liver disease and which eventually makes the motions and urine brown.
With its huge blood supply and never-ending activity, it is to be expected that the liver is prone to disease. Many infections and drugs cause temporary effects on the liver, which may be felt simply as a vague discomfort over the liver or detected on monitoring of liver function blood tests.
early cirrhosis may be reversible, established cirrhosis is permanent. In the case of paracetamol poisoning the effects may be fatal rapidly. Chronic cirrhosis is a risk for people regularly drinking more than about 30 units of alcohol per week, i.e. 15 pints of beer or 5 bottles of wine.
Infections
Many infections, including the common glandular fever virus, cause a mild hepatitis – inflammation of the liver. Some specific viruses cause a more severe hepatitis. New hepatitis viruses are occasionally discovered and now range from A to G. Some are acquired through pure chance; others such as B and C are transmitted by sexual contact (especially male homosexual activity) in semen or saliva or through blood products and intravenous drug abuse. Internationally, hepatitis B is a huge cause of chronic hepatitis, cirrhosis and liver cancer, affecting hundreds of millions of people mainly in the Far East and Africa. It carries a 1% risk of death from liver failure and a permanent risk of future cirrhosis (up to 50%) and liver cancer. Mothers positive for hepatitis B almost always pass on the virus to their unborn baby.
Alcohol, drugs and immune conditions
These can all lead to cirrhosis of the liver. Cirrhosis is a degeneration of the active cells of the liver, being replaced by fibrous tissue, which is of course non-functioning. Although
Tumours
In the West the majority of tumours within the liver have spread there via the rich blood supply from cancers elsewhere, especially bowel tumours. This so-called secondary liver cancer is often the way in which people with cancer finally die. Worldwide, primary cancer of the liver is common and often follows previous infection with the hepatitis B virus.
Symptoms
Viral infections produce hepatitis of rapid onset. There is an incubation period from the time of infection with the virus. In the case of the common hepatitis A this is two to three weeks; in the cases of hepatitis B, four to twenty weeks. There is a week or so of nausea, vague ill health, fever and upper abdominal discomfort, after which the individual becomes jaundiced (yellow) from the deposit of pigments that the liver would ordinarily handle. In most cases the illness settles over another week or so. It is rare for people suffering from hepatitis A to have other problems.
Alcohol, drugs, immune conditions and tumours
The immediate effects on the liver of a serious drug or alcohol overdose are nausea, jaundice and itching, followed by bleeding because blood-clotting factors are no longer being made. As toxins build up in the blood stream there may be confusion and a slide into unconsciousness.
Chronic poisoning has more subtle and widespread effects. Itching is common and there may be a hint of jaundice. Men notice breast development and may suffer from impotence (see Erectile dyseunction) because female hormones normally broken down by the liver are at higher than usual levels. The palms become red – also related to female hormones.
Tiny dilated veins appear on the hands, face and chest, called spider naevi. As the cirrhosis worsens, there is accumulation of fluid in the abdomen called ascites and in the ankles. There is a risk of bleeding, leading to widespread bruising and possibly bleeding into the gullet. Eventually the liver fails, with increasing jaundice, confusion, then unconsciousness.
Means used to confirm and measure liver disease are blood tests of the chemicals produced by the liver and markers of any viruses responsible. An ultrasound scan (see page 349) can show typical features of cirrhosis. A liver biopsy (see page 353) is the best way of establishing the exact diagnosis.
Treatment
Acute liver damage is usually due to viral infection or drug damage, especially overdose of paracetamol. The drug itself is neutralized by biochemical means in a drip. Patients then have to be nursed in intensive care, receiving correction of the widespread biochemical changes in the blood stream that accompany acute liver failure. They need infusion of clotting factors to prevent internal bleeding and measures to reduce swelling of the brain, which is the main reason for death. Liver transplantation may be the final hope (see below).
Acute liver failure is a very serious condition, with a high mortality rate even in the best centres. If the liver disease is caused by spread of a cancer, there is little that can be done other than general supportive care.
Chronic damage (cirrhosis)
You must stop any behaviour contributing to the cirrhosis, i.e. give up alcohol. This will not reverse the changes in the liver, but will reduce the load it has to bear. Outlook is poor: a 50% five-year survival. A major risk from chronic cirrhosis is bleeding from dilated veins in the gullet called oesophageal varices, which may bleed torrentially and need emergency repair.
Liver transplantation
This now offers hope to those facing inevitable liver failure, from many causes. It is not suitable in cases of liver failure caused by spread of cancer, which will invariably spread into the new liver, but it can be done in cases of people with primary liver cancer.
The risk from the surgery is low; the major risk is from rejection of the liver. The results now offer a remarkable 90% survival to 1 year and better than 70% five-year survival, figures that are improving all the time.
QUESTIONS
What is a dangerous dose of paracetamol?
As little as 10 g (20 standard tablets) can be enough to cause serious liver damage. Just 15 g (30 tablets) can be a fatal dose. Urgent treatment is needed within hours of a suspected overdose.
What vaccination is there against hepatitis?
Hepatitis A vaccination is for travellers who might eat shellfish and poorly washed salads, and protects for up to ten years. Vaccination against hepatitis B is for healthcare workers who face exposure to contaminated blood, needles and body fluids.
Are women’s livers weaker?
They have to handle the breakdown of the female hormone oestrogen, and therefore have less capacity to cope with alcohol or drugs.
Complementary Treatment
No complementary therapies can prevent or cure hepatitis in its various forms. Chinese herbalism can be very helpful, but note a reputable practitioner will insist on regular blood tests to monitor liver function. Shiatsu-do strengthens the blood quality through improved organ functioning and toxin discharge. In nutritional therapy the liver is considered to be stressed by an excess of saturated fat in the diet; a number of foods and herbs could be used to help drain these fats, for example beetroot and dandelion. Hypnotherapy – anxiety interrupts the free flow of enzymes; hypnotherapy can lessen anxiety, and hence help reduce problems. Ayurveda – liver tonics and special preparations for inflammatory liver disease are available; detoxification is an essential part of healing. Other therapies to try: acupuncture; tai chi/chi kung.
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