Liver Diseases

Dr. Avnish Upadhyay Senior Research Scientist, Patanjali Yog Peeth, Haridwar

1. Introduction
a. anatomical Position and weight. b. Functions- Processing most of the nutrients absorbed from the intestine. c. Removing drugs, Alcohol and harmful substances from the blood stream. d. Manufacturing bile, its storage in GB. e. Produces cholesterol- Blood clotting factors and certain other Proteins. f. The liver may be Palpable in normal healthy adult, 10 to 12% are such cases.

Healthy Liver
 This is what a healthy

liver is supposed to look like:

Damaged Liver
 This is what a

damaged liver looks like:

Damaged liver Continuation

2. Examination of Liver
1. On inspection if one sees

a. swelling in the Rt. Hypochondria which on palpation seems to be in the liver the common conditions are 1. Amoebic Liver Abscesses. 2. A malignancy b. First palpate Right and then Lt Lobe of Liver. c. Edge whether thin or thick, firm or soft. d. Surface- smooth or nodular. e. Pulsatile Tricuspid Regurgitation.

2. Examination of Liver Contd.
2. Look for Tenderness- it is very important Point to consider. it is tender in 3 conditions. a. Infective hepatitis. b. Amoebic Hepatitis and Amoebic Abscess. c. CCF  Exclude CCF by the presence of dyspnoea, enlarged heart, engorged neck veins, edemas of feet.  Now there remain 2 common causes 1. Hepatic Amoebiasis or Amoebic Liver Abscess. 2. Infective Hepatitis

3. Hepatic Amoebiasis
 It includes Amoebic Hepatitis and Amoebic Liver

Abscess a. main symptom is pain in hypochondria (Right) and /or epigastria rarely in Rt Shoulder b. it may be of dull ache or as severe as biliary colic c. The duration of pain Could be from a few days to few weeks. d. The pain in increased on turning on the side, more on the Rt Side. e. The pain is increased on deep breathing. f. Nausea. Vomiting, lose of appetite, jaundice are absent. g. alcoholic are more prone to get disease. h. Past history of dysentery may or may not be present however a recent attack of diarrheas or dysentery if present would favour the diagnosis very much.

4. Physical sign is Tenderness of the Liver
a. May be elicited by hammering over the liver area Or by pressure on subcostal area after a deep inspiration. Rarely tenderness may be only in the epigastria in the area of left lobe. The liver may not be enlarged or may be enlarged, slightly, moderately or markedly, Therefore more time should be give in eliciting tenderness than size of the liver. b. A lump in the liver area is a rarity. c. No investigations are required. The may be normal raised. d. The Rt dome of diaphragm may be raised or immobile. Immobility is more important. It can be seen on screening of the chest (Fluoroscopy) e. Best is Therapeutic test with emetine Injection.

Treatment
1. Emetine 60 mg 1M for 8-10 days - Rest if Possible 2. Chloroguin or Metronidazole- 2 Tabs twice daily for 2 days. After then 1 Tab twice daily for 21 days (May cause slight nausea)  Flagyl (Metronidazole):- 400 to 800 mg TD for 8 days may cause nausea and loss of appetite but this is the effective dose, Dose of 200 mg TD is only for infantile amoebiasis.  If pain, fever and tenderness of the liver persists ever after emetine Tapping must not be delayed finally, if an obvious lump is seen in the liver area, it would always need aspiration.

INFECTIVE HEPATITIS
It is due to virus and therefore a single case can infect many others, So it should be taken seriously.  Incubation Period is about 3-4 weeks, history of jaundice in any family member or any friend, neighbor or locality during past one month is an important point to be elicited in history taking.  One can get 2-3 attacks of viral hepatitis during the life time  Disease is common in small children and young adults, It is rare after the age of 45-50 yrs.

Dot Call This disease "Jaundice" because
Many People may suffer and recover without jaundice. The patient get loss of appetite, slight nausea and do not generally feel well for a week or two. The only way to diagnose will be, by eliciting history of jaundice in the family or neighborhood during previous 3-4 weeks. An the same time, in that particular patient, it is impossible whether he is going to develop jaundice or whether he would recover without developing jaundice. Jaundice without jaundice is called anicteric jaundice.  Fever with complete loss of appetite.

Surgical jaundice will have to be excluded, surgical jaundice means jaundice caused by the disease which produce obstruction the flow of bile and the treatment is mainly surgical such as bile duct obstruction due to stones. Carcinoma head pancreas (leading to obstructing common bile ducts) Presence of one or more severe upper abdominal pain, while colored stool and excessive pruritis would favour for surgical jaundice. Prolonged administration of hormones or promazine group of drugs will favour the diagnosis of drug hepatits.

Three stages
Stage 1 Complete loss of appetites, Patient does not want even to see food. Nausea, vomiting, Fever, body ache, general malaise. In the 1st week there is no evidence of jaundice. Towards the end of 1st week the patient might notice very high colored urine. In viral hepatitis patient don’t complain of pain in the liver area, may complain vague discomfort on questioning. Patient to may lose 2-3 kg body weight.

Stage 2
 Patient's relatives see jaundice.  As Jaundice deepens, the temperature

starts coming down and appetite starts improving, So that by the end of 2nd week the patient is left with deep Jaundice but good appetite and no fever.

Stage 3
 Recovering to normal. Resume his work

Appetite improve weight gains. Jaundice clears up by the end of third week.  90-95% behave the above manner, 5 to 10 PC would die after going to hepatic coma (specially Pregnant women)

Symptoms of Prehepatic coma
1. Presence of Drowsiness 2. Abnormal Behavior 3. Irritability 4- Tremors Better to hospitalize nothing can be done at this stage.

Signs of Infective hepatitis
 Jaundice  Tender liver  may be enlarged and may bends  Enlarged.

Investigations SGPT SGOT Serum Billirubin

Treatment
1. Inj Gamma Globulin .06 cc/LB body weight

should be given to all family members as prophylaxis, but they are very costly but should ideally be give to all family. 2. Tonics for appetite, Inj glucose 25 pc Iv. Cal. gluconate iv, Inj B comp., vit c, vit k, Antibiotics, Prednisolone 1 BD or TD, Inj. liver ext., two drugs are harmful as they can precipitate hepatic coma. only glucose iv or orally is useful along with rest.

Drugs
Antihistaminic and IV glucose is sufficient. In severe case prednisolone 40 to 60 mg/day gradually tapered off very slowly

danger signals
 The following are the danger signals, the

presence of any of them indicates on coming hepatic coma and death 1. Drowsiness 2. Reversal of sleep rhythm 3. Irritability 4. Tremors Deep Jaundice is not a sign of danger.

Thanks