Monday, March 12, 2012

Cirrhosis of the liver

Introduction 
Cirrhosis is a chronic liver disease characterized by damage to liver tissue, creating a fibrous scarring and progressive deterioration of liver function, accumulation of fluid in the abdomen (ascites), bleeding (coagulopathy), increased pressure in the portal veins (portal hypertension) and certain disorders of brain function (hepatic encephalopathy).

How is cirrhosis?

Alcoholic cirrhosis
The liver is particularly susceptible to the influence of alcohol. In the body of the alcohol is broken down to specific compounds some of which are very harmful to the liver. After a while, enjoying excessive alcohol leads to increased need for oxygen at the same time causes an accumulation of fat that prevents the liver to take oxygen. The immune system responds in a way that creates an inflammatory process that eventually destroys the liver cells. During this initial phase of the liver was significantly increased ("fatty liver"), to be reduced at a later stage and suffered scarring and nodules, which are clusters of regenerated liver cells ("grainy liver").

Cirrhosis due to chronic hepatitis
One of the causes of cirrhosis is chronic hepatitis (B or C). The viruses that cause hepatitis produce inflammation in liver cells leading to destruction of liver cells. If the inflammation is very severe destruction of liver cells progresses, creating a layer of scar tissue. In advanced cases the liver is reduced in size.

Primary biliary cirrhosis
Primary biliary cirrhosis is very rare. Probably just an autoimmune process where the immune system attacks liver cells, replacing them with a foreign antigen. Primary cells are attacked by the gall water and subsequently destroy the liver cells. Rare disorders that also include cirrhosis are hemochromatosis (accumulation of iron in the liver), Wilson disease (copper accumulation in the cells of the liver), cystic fibrosis and so on.

Who gets the liver?
About 10 to 35% of alcoholics will develop alcoholic hepatitis, which is the first step for the development of cirrhosis.
After years of drinking damage can be extensive and associated with other habits (poor diet and insufficient intake of vitamins). Alcoholics should be vaccinated against hepatitis B and should make them larger doses than usual.Experts believe that the number of liver cirrhosis caused by chronic hepatitis due to increase by 60% and especially due to hepatitis C. It is not clear that the risk of cirrhosis in patients with hepatitis C. Alcohol consumption contributes to greater risk. Genetic type of virus affects the strength of the disease and the potential development of cirrhosis. Patients with multiple viruses in the blood and liver tissue have a higher risk of developing cirrhosis.About 3 to 5% of people infected with hepatitis B develop a chronic form, and only half of them will develop cirrhosis.

What are the main symptoms of cirrhosis?
Fatigue and energy loss are common early symptoms associated with loss of appetite and nausea. "Spider nevi" usually occur on the skin (dotted red spots from which to spread spider blood vessels). Patients in advanced stage of develop jaundice (yellow skin color and the whites of the eyes) caused by the inability of the liver to remove bilirubin from the body. At present the so-called hands. palmar erythema (redness). In males, the observed decreased body hair, and may develop testicular atrophy, and sometimes painful breast enlargement (gynecomastia). The accumulation of fluid in the abdomen (ascites) is a common sign of advanced cirrhosis. Fever, abdominal pain and tenderness on pressure is usually a sign that infection is present. Forgetfulness, difficulty maintaining attention and answering questions are the first signs of brain damage, toxins caused by improper liver function. Other symptoms include a specific smell (like land) and tremors. Late symptoms of encephalopathy are stupor and eventually coma.

How serious is liver disease?
The most serious complication of cirrhosis, bleeding, infection and brain damage. Almost every process in the body is disrupted due to a malfunction of the liver (digestive, hormonal, vascular). The liver is also responsible for the degradation of numerous toxic substances that accumulate and damage brain function. Cirrhosis is also a cause of cancer of the liver. Cirrhosis is an incurable disease. No proper dietary program and treatment can slow its course.In patients with hepatitis B after a five-year survival of established cirrhosis is 71%. In alcoholic cirrhosis, if the patient stops drinking alcohol, the percentage survival of 5 years was 85%. For those who continue to drink the chance to live more than 5 years were 60%. Also, it is very difficult to establish when the liver is actually occurring.

Portal hypertension and its complications
In cirrhotic liver cell deterioration slows blood flow and blood pressure rises. This pressure causes the return of blood through the portal vein, which leads to portal hypertension. Ascites is a fluid that accumulates in the abdomen, and usually the result of portal hypertension and its occurrence is important for the further prognosis.Once ascites occurs only half of patients survive for more than two years. We also see swelling of the hands and feet and an enlarged spleen. Ascites itself is not fatal, but is uncomfortable and can impair breathing function and urination. One of the most serious consequence of portal hypertension is the development of varices (enlarged blood vessels that are cross-road drain blood bypassing the liver). Such vessels are very thin walls and izvijugane.Varices occur most commonly in the esophagus and stomach. Internal bleeding from varices occurs in 20 to 30% of patients with cirrhosis and bleeding favoring ascites, encephalopathy, varicose veins. Bleeding in the digestive system occurs because of impaired blood clotting system, usually caused due to deficiency of vitamin K, the reduced concentrations of clotting proteins and the low number of platelets (blood cells that normally start the clotting process). Abdominal infections occur in 25% of patients within a year of diagnosis. Higher Risk of infection in patients with a low protein and high bilirubin values. Encephalopathy (brain damage) causes mental confusion, and in severe cases, coma and death. The development of encephalopathy is usually associated with other complications such as gastrointestinal bleeding, constipation, infection, surgery, or dehydration.

What tests can be done to determine the liver?

Physical examination
Cirrhotic liver is usually enlarged, and often feels rough grainy and hard. If the stomach is bloated doctor can gently blow sideways feel the moving fluid in the abdomen.

Biopsy
A biopsy is a sampling of liver tissue using a special needle. A biopsy can be performed through peritoneoskopa, a catheter with a camera, to see the surface of the liver. A biopsy is not performed in patients with the problem of blood clotting or with ascites. It is recommended in patients with chronic hepatitis who have no real symptoms of cirrhosis to determine the degree of damage.

Blood tests
Numerous tests are performed to determine the function of the liver, but most important is determining the value of bilirubin in the blood. Bilirubin is a pigment ┼żutocrveni normally metabolized in the liver and excreted in urine.Increased values ​​of bilirubin in the blood causes jaundice. Measurement of specific enzymes is also useful for diagnosis. The values ​​of certain blood clotting factors and albumin in serum may be important for diagnosis.Prothrombin time is the time in seconds needed to form blood clots. The longer the time the higher the risk of bleeding. Specific tests for chronic hepatitis include the value of aminotransferase, bilirubin, and clotting tests. The values ​​of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are particularly important. The high ratio of AST / ALT in chronic hepatitis C is usually a sign of cirrhosis. Methods immunoassays can detect antibodies to the hepatitis viruses.

Imaging techniques
Abdominal ultrasonography, computed tomography (CT) and magnetic resonance (NMR) techniques that may be useful in determining the degree of illness. These tests can show the initial ascites, grainy surface of the liver, blood returning to the portal vein, liver cancer, and may show enlarged blood vessels. They can also be applied arteriography (contrast is injected into a blood vessel and then takes x-ray) and splenoportografija (contrast injected into the spleen and thus can measure pressure in the portal circulation). Through the catheter can be directly measured pressure in the veins of the liver. Paracentesis is performed in the present case of ascites. He takes a thin needle to suck fluid from the abdominal cavity. The fluid is analyzed (proteins, bacteria, white blood cells).

Treatment of cirrhosis
Cirrhosis can be treated by acting on its causes. In the case of alcoholic cirrhosis, primarily to stop drinking alcohol and treat alcoholism. Since alcoholics are often malnourished and have higher caloric needs should be compensated. Corticosteroids may be useful in treating alcoholic hepatitis. Chronic hepatitis B and C treated with interferon. Unfortunately, the percentage of those who benefit from these therapies is low. In some cases, short-term use of corticosteroids may be helpful. If there is ascites must take drugs that potentiate the secretion of fluids so. diuretics. The loss of fluids should not be too fast, due to disturbances in the metabolism of potassium. If diuretics are not successful enough to resort to paracentesis. Through the needle and tube fluid is drawn from the abdominal cavity (4 to 6 liters). If the patient is better paracentesis should be renewed every two weeks. Liver transplantation should be considered as the only solution in some patients with cirrhosis and ascites. Healthy life is particularly important for patients with cirrhosis. Food must be rich in fruits, vegetables and whole grains that are rich in vitamins and other substances important for health. Vitamin supplements is not well taken without consulting your doctor. Some patients must avoid foods rich in iron. It is recommended to reduce the salt in the diet, especially in patients with ascites. The less salt the better. Reduced fluid intake is not always necessary, unless there is ascites. Meat proteins must be taken in moderation, but intake of vegetable protein (eg soy) is not limited. Exercise may provoke bleeding, so is not recommended.
Treatment of varices
Varices can be treated by endoscopy, surgery and medication.



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