Liver Diseases

Dr. Avnish Upadhyay
Clinical Research Scientist Department of Clinical Research Patanjali Yog Peeth, Divya Yog Mandir Trust, Haridwar (An Recognized R & D Institution by DSIR)

1. Introduction
a. anatomical Position and weight- weighing between 3-4 pounds (Approximately 1.5 Kg). Your Liver is the largest internal organ in the body. It is located on the right side of your abdomen, just beneath your lower ribs. b. Functions- Processing most of the nutrients absorbed from the intestine. c. Removing drugs, Alcohol and other harmful substances from the blood stream. d. Manufacturing bile, its storage in GB. e. Produces cholesterol- Blood clotting factors and certain other Proteins.

Introduction contd….
f. It needs to be stressed that the liver may be Palpable after deep inspiration in the right hypochondriam in normal healthy adults, 10 to 12% are such cases. The incidence of palpability of the left lobe in the epigastrium is still more but in small children this part is sometimes difficult to feel, Again the incidence of palpability is still higher, because in infants, the relative size of liver is bigger for the size of the abdomen.

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

 Because of the complexity of the liver and

its exposure to so many potentially toxic substances, it would seem specially valnerable to disease. But the liver has an amazing capacity for regeneration- it can heal itself by replacing or repairing injured cells. In cirrhosis healing process seems to go slightly wrong. In response to chronic injury, cells called stellate cells increase dramatically in size and number. This lead to formation of excess scar tissue that interferes with the liver’s ability to function. And although group of cells may continue to regenerate , the pattern of regeneration is not normal.

Causes
1. Some people have cirrhosis

without an obvious cause (Cryptogenic cirrhosis) 2. Major cause is drinking excessive amount of Alcohol over many in years. 3. Having certain forms of viral hepatitis.

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

a. swelling in the Rt. Hypochondrium which on palpation seems to be in the liver the common conditions are 1. Amoebic Liver Abscess. 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.

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 hypochondrium (Right) and /or epigastrium 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 specially in cases who have developed chest complications; often there is fever. 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 favors 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 sub costal area after a deep inspiration. Rarely tenderness may be only in the epigastrium 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 given 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 or 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 intestinal amoebiasis.  If pain, fever and tenderness of the liver persists even 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, neighbour 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. These patients 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. The disease 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 in 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 hepatitis.

Three stages
Stage 1 Complete loss of appetite, 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 coloured urine. In viral hepatitis patient does not complain of pain in the liver area, may complain vague discomfort on questioning. Patient 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 improves weight gains. Jaundice clears up by the end of third week.  90-95% patients 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 Behaviour 3. Irritability 4- Tremors Better to hospitalize nothing can be done at this stage.

Signs of Infective hepatitis
 Jaundice  Tender liver  may or may not be 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, though they are very costly but should ideally be given to all family members. 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