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The liver is a large organ that is located in the right upper abdomen. It is involved in many important functions like, protein synthesis, elimination of waste material, cholesterol production, storage and release of energy and metabolizing many drugs, thus maintaining homeostasis. It also produces bile that flows through bile ducts into the intestine where it helps in digestion of food. Liver has the ability to regenerate itself if it is injured or partially removed.
Many types of chronic injury to the liver can result in scar tissue; this scarring distorts the normal structure and re-growth of liver cells. The flow of blood through the liver from intestine is blocked and the work of liver such as processing of drugs or proteins is hindered. The hepatitis C virus is a liver infection that is spread by contact with an infected person's blood. Chronic hepatitis C causes inflammation and damage to the liver over time that can lead to cirrhosis. (Tibbs Chirstopher J. et al.)
Cirrhosis is a serious condition where normal liver tissue is replaced by scar tissue, it progress slowly and often does not cause symptoms in early stages, as the function of the liver gradually becomes worse, serious problems can develop. The common causes of cirrhosis are heavy alcohol drinking and infection with hepatitis c. Cirrhosis may lead to portal hypertension in which the pressure in the portal vein increases, this vein carries blood from intestine and spleen to liver, this process is slowed down due to which pressure in portal vein is increased which causes varices enlargement of vein, develop across oesophagus and stomach which have a tendency to bleed easily. Portal hypertension may not always associate with symptoms related to liver but in cirrhosis the chance of developing hypertension is high.
Symptoms of hypertension are gastrointestinal bleeding occur from abnormal blood clotting as blood flow through the liver is progressively impede, hepatic portal venous pressure rises. In response to the elevated portal venous pressure, there is enlargement of blood vessels and portal veins, such as these enlarged vessels are termed as varices. Physical examination may reveal enlargement of haemorrhoidal and per umbilical vessels.
Gastro-esophageal varices are of more significant because they have a tendency to rupture, resulting in bleeding which is life threatening. GI bleeding from varices and other sources such as duodenal ulcer, gastritis in patients with cirrhosis is often worsen by connected coagulopathy. (Mcphee Stephen j et al. 2005)
Ascites is accumulation of fluid in abdomen as kidneys retains salt and water in the body. The excess salt and water first accumulates in the tissue below the skin of the ankles and legs because of the effect of gravity when standing or sitting. This accumulation of fluid is called edema or pitting edema. The swelling often is worse after standing or sitting, as cirrhosis worsens and more salt and water is retained, fluid also may accumulate in the abdominal wall this accumulation of fluid is called ascites, encephalopathy confusion or forgetfulness and decreased level of platelet count which may include vitamin K deficiency and thrombocytopenia. Thrombocytopenia is associated with advanced liver failure.
Blood test gives indication of quality of blood cells, if RBC and haemoglobin are low it indicates bleeding somewhere in the body. The amount of haemoglobin which is carried in RBC is indication of bloods ability to carry oxygen to cells, a low RBC count is referred as anaemia and person may feel tired. Liver disease may be suspected because platelet count is very low, platelet are cell fragments that play important role in clotting as bilirubin level is high there must be kind of blockage in the liver due to hepatitis, long term alcohol abuse or drug reaction. High INR indicate bruising or bleeding from the open wound, prolonged aptt ratio indicates liver disease. A condition where virus infects liver for years, patients infected with hepatitis c virus develop chronic hepatitis which in turn causes progressive liver damage which leads to cirrhosis and sometimes liver cancer. (Hoffbrand.A.V et al.)
Different diagnostic test used are as follows
Biopsy of the liver- It is reserved for patients whose diagnosis is of type of liver disease or presence of cirrhosis is not clear biopsy is performed when person shows elevated liver enzymes, abnormal blood result, pain in abdomen in region of liver, jaundice and suspected liver disease, evaluation of alcoholic liver disease, diagnosis of hepatocellular carcinoma, monitoring treatment in chronic active hepatitis and estimation of liver enzyme. Liver biopsy is removal of small piece of liver tissue using a special needle and then it examined. Blood tests can indicate only a possible problem. When a doctor suspects cirrhosis, he may use diagnostic imagery machines to see how much damage has been done to the liver. (bateson Malcolm et al.)
CAT scan (computed axial tomography) - CAT scan is used to view the organ uses x-rays and computer imagery to build a virtual model of an internal organ. The CAT scan is used for viewing scarring and abnormal growth.
Liver Ultrasound- It uses high-frequency sound to create a picture of organs, blood vessels and internal organs. Ultrasound is often used to look for gallstones, determine areas of scar tissue and show the size of an organ. Cirrhosis can also be diagnosed by scanning the body with radioactive isotopes.
Laproscope - It is a small camera inserted through a surgical incision in the abdomen. It is very useful because actual damage can be seen through the camera.
In cirrhosis there is increased synthesis of collagen and other connective tissue of extracellular matrix helps in development of hepatic fibrosis, extracellular matrix is involved in modulating cell activity, fibrosis affect blood flow through liver and also functions of cells. Hepatic fibrosis occurs in two stages
It is characterized by a change in extracellular matrix composition from non cross linked collagen to collagen that is more dense and subject to cross linked formation.
Involves formation of subendothelial collagen cross links, proliferation of myoepithelial cells and distortion of hepatic architecture the appearance of regenerating nodules. (Worman et al.)
Cirrhosis is development of scar tissue replacing the normal parenchyma cells which blocks the portal flow of blood through liver disturbing the normal function, damage of parenchyma cells leads to activation of stellate cells which stores vitamin A in development of cirrhosis these cells become contractile and obstructs blood flow in circulation it secretes TGF-β1(transforming growth factor)which leads to fibrotic response and proliferation of connective tissue it distributes balance between matrix and inhibitors leading to matrix breakdown and replacement of connective tissue. (Ali shakhir et al. 2006)
Treatments for cirrhosis include preventing further damage to the liver by avoiding drugs and alcohol. Eradicating hepatitis B and hepatitis C virus by using anti-viral medications, not all patients with cirrhosis due to chronic viral hepatitis undergo drug treatment. Some patients may experience serious weakening in liver function or unbearable side effects during treatment. Currently there is no vaccination available for immunizing against hepatitis C. If there is large varices development in the esophagus or upper stomach in patients with cirrhosis they are at risk for serious bleeding due to rupture of these varices, they tend to re bleed and the possibility of patient dying due to this is high, therefore treatment is necessary to prevent the first bleeding episode as well as re bleeding. Treatments include medications and procedures to decrease the pressure in the portal vein and to destroy the varices.
These patients have a high risk of developing impulsive bacterial peritonitis and should be given antibiotics early during the hospitalization to prevent impulsive bacterial peritonitis.
Prevention and early detection of liver cancer
Some types of liver disease that cause cirrhosis are related with a high incidence of liver cancer, for example, hepatitis B and C, and it would be useful to screen for liver cancer as early as possible because surgical treatment or transplantation of the liver can cure the patient of cancer. The difficulty is that the methods available for screening are only partially effective, identifying at best only 50% of patients at a curable, despite the partial effectiveness of screening, most patients with cirrhosis, particularly hepatitis B and C, are screened every six months with ultrasound examination of the liver and measurements of cancer-produced proteins in the blood, e.g. alpha fetoprotein.
Cirrhosis is irreversible, despite treatment, liver function gets worsen and complications of cirrhosis increases and become difficult to treat. Therefore, when cirrhosis is far advanced, liver transplantation often is the only option for treatment. Recent advances in surgical transplantation and medications to prevent infection and rejection of the transplanted liver have greatly enhanced survival after transplantation. On average, more than 80% of patients who receive transplants are alive after five years, not everyone with cirrhosis is a candidate for transplantation. Furthermore, there is a shortage of livers to transplant, and there usually is a long wait, even years before a liver for transplanting becomes available. Therefore, measures to slow down the progression of liver disease and treat and prevent complications of cirrhosis are really important. Liver transplant is divided into three phases
Pre transplant 2) transplant 3) post transplant
Some patients may be ineligible for transplant because of serious illness such as cancer, AIDS, or heart disease identified during pre transplant phase. (Worman et al.)
These diagnostic test, treatment are used to identify liver disorder as many different causes such as hepatitis, heavy alcohol and symptoms related to it can lead to liver disorder such as cirrhosis which can further lead to liver carcinoma.
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