• “... because the liver is a source of many diseases, and is a noble organ that serves many organs, almost all of them: so it suffers, it is not a small suffering, but a great and manifold one”

    Theophrastus Bombastus von Hohenheim, known as Paracelsus (1493-1541)
    (Liber tertius paramiri, de morbis ex Tartaro. St. Gallen, 1531)
  • Have you been diagnosed with liver disease and are feeling lost?
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  • When you or someone you love is first diagnosed with liver disease, you have a lot of questions about what to expect, how to cope and where to get help?

  • When only the experts can answer those queries and give you clear direction.

Information

What is the liver?

The Liver is a vital organ of the human body, located in the abdomen, just beneath the right dome of the diaphragm. It is the largest organ in the body. It has a role to play in majority of body processes like digestion, protein synthesis, lipid metabolism, glycogen storage, detoxification, etc.

The liver is necessary for survival; there is currently no way to compensate for the absence of liver function in the long term, although new liver dialysis techniques can be used in the short term.

What is liver disease?

Although, the diseases of the liver are commonly believed to be caused by alcohol and drugs, the fact is that these two causes only form a small portion of the huge spectrum of hepatic illnesses. Liver diseases may affect anyone from infancy to old age and there are more than a 100 causes for the same. Some of the more common ones are

  • Hepatitis
  • Alcoholic liver disease
  • Fatty liver (Non-alcoholic Steatohepatitis)
  • Autoimmune liver disease
  • Genetic and metabolic liver diseases
  • Vascular diseases of liver
  • Hepatocellular carcinoma

What are signs and symptoms of liver disease?

Liver disease can often be difficult to diagnose because its symptoms can be vague and easily confused with other health problems. In some cases, a person may have no symptoms at all but the liver may already have suffered significant damage.

The most significant thing to recognize about liver disease is that up to 50 percent of individuals with underlying liver disease have no symptoms.

The most common symptoms are very non-specific and they include fatigue, decreased appetite, weakness or excessive tiredness, lack of drive.

However signs of liver disease that are more prominent are jaundice or yellowing of the eyes and skin, dark urine, pale or light colored stool, itching over body, bleeding from the GI tract, mental confusion, and swollen abdomen or belly.

Ascites in liver disease

What is Ascites?

Ascites is the excessive accumulation of fluid in the abdominal cavity, which is abnormal.

What does ascites signify in liver disease?

Ascites is the most common complication of cirrhosis. Approximately 50% of patients with “compensated” cirrhosis develop ascites during 10 years of follow up. Ascites is the most common complication of cirrhosis that leads to hospital admission. The development of ascites is associated with a poor prognosis and impaired quality of life in patients with cirrhosis. Development of ascites in cirrhosis is an important landmark in the natural history of chronic liver disease; approximately 40% of patients with ascites succumb in 1 year and 50% succumb in 2 years.

What are the causes of ascites other than liver disease?

The commonest cause of ascites is severe liver disease with the development of cirrhosis and portal hypertension. The other causes include cancers involving the peritoneum, nephrotic syndrome, heart failure, pancreatitis and infections like peritoneal tuberculosis

What are the symptoms of ascites?

The most common symptoms are distension of abdomen, weight gain, swelling feet, abdominal discomfort or pain abdomen. When there is excessive fluid in the abdomen it might be associated with breathlessness.

How is Ascites diagnosed?

The cause of ascites can often be determined on history and physical examination, however the aim of investigations is to confirm the presence of ascites, finding the cause of ascites and for assessing any complication due to ascites.

  • Grade 1 is mild ascites and is only detectable by ultrasound examination
  • Grade 2 is moderate ascites causing moderate symmetrical distension of the abdomen
  • Grade 3 is large ascites causing marked abdominal distension

Ultrasound is the best investigation for confirming the presence of ascites as it can pick up small amount of fluid in the abdominal cavity.
To exclude other causes of ascites, examination of the ascitic fluid should be done along with investigations like blood tests, urine examination, echocardiography, thyroid function depending on the history and physical findings.

How is ascites treated?

Treatment depends on the cause of ascites. Since the most common cause of ascites is chronic liver disease these patients benefit with salt restricted diet and addition of diuretics. Ascites that is not controlled with diuretics and salt restriction may require frequent removal of fluid from the abdominal cavity. Placing a special tube or shunt inside the abdomen (TIPS) to reduce the portal pressures may also be helpful. However liver transplantation remains the treatment of choice if medical management fails.

Risk factors for liver disease

  • Significant alcohol consumption
  • Past blood transfusions
  • Sexual activity
  • Occupational exposure to blood products
  • Exposure to toxic chemicals
  • Family history of liver disease
  • Travel to high risk areas

Liver Biopsy

What is a liver biopsy?

Liver biopsy is an invasive diagnostic procedure done in order to obtain a small amount of liver tissue, which is useful to determine the cause and stage of liver disease and also to monitor the response to treatment.

How is liver biopsy performed?

The most common way a liver tissue is obtained is by inserting a needle into the liver from the right intercostal space. The procedure is done in the hospital and the patient is kept for observation for around six hours if there are no complications. The Hepatologist performs the biopsy usually with a needle biopsy gun after determining the best site, by physical examination or by ultrasound. The skin and area under the skin are anesthetized, and a needle is passed quickly into and out of the liver to get the tissue sample.
Liver biopsy can also be done under direct guidance of Ultrasound, or less commonly CT scan.
Other liver biopsy techniques include transvenous or transjugular liver biopsies, Laparoscopic biopsies and during open surgical procedures performed for other reasons.

What are the indications of liver biopsy?

Liver biopsy is often used to diagnose the cause and the stage of liver disease. It is done to determine the damage to the liver by diseases like Hepatitis C, Hepatitis B, Autoimmune liver disease and Non alcoholic fatty liver disease. Liver biopsy is also used after liver transplantation to determine the cause of elevated liver tests and determine if rejection is present.

What are the complications of liver biopsy?

The most common complication of liver biopsy is bleeding from the site of needle entry into the liver, although this occurs in less than one per cent of patients. Other possible complications include the puncture of other organs, such as the gallbladder. However the risk of death from liver biopsy is extremely low.

Fibroscan

What is Fibroscan?

Fibroscan is called transient elastography, is a technique used to assess liver stiffness without invasive investigation. The Fibroscan examination is an instant and non-invasive technique capable of detecting and quantifying liver fibrosis. Fibroscan can also detect and quantify liver fat simultaneously using the Controlled Attenuation Parameter (CAP).

What is the principle of Fibroscan?

The Fibroscan device works by measuring shear wave velocity. In this technique, a 50-MHz wave is passed into the liver from a small transducer on the end of an ultrasound probe. The probe also has a transducer on the end that can measure the velocity of the shear wave (in meters per second) as this wave passes through the liver. The shear wave velocity can then be converted into liver stiffness, which is expressed in kilopascals. Essentially, the technology measures the velocity of the sound wave passing through the liver and then converts that measurement into a liver stiffness measurement; the entire process is often referred to as liver ultrasonographic elastography.

What is the use of Fibroscan in assessment of liver disease?

Fibroscan is useful in assessing the degree of fibrosis in patients suffering from variety of chronic liver diseases such as hepatitis B, hepatitis C, Autoimmune hepatitis, non-alcoholic fatty liver disease, chronic hepatitis and cirrhosis. Follow up Fibroscan examination can also be used to assess the response to treatment

How is Fibroscan performed?

The patient is made to lie on his back and the right arm is raised behind the head. A probe quite similar to an ultrasound probe is kept on the right lower chest wall of the patient. The ultrasound probe sends a shear wave in to the liver and detects the stiffness of the liver by pressing a button. The on-board computer automatically processes this data and the liver stiffness is displayed on the screen in kilopascals. Ten such readings are recorded. The result is delivered at the end of the 10 acquisitions.

How much time is required to perform a single Fibroscan examination?

The entire procedure takes around 10 to 20 minutes. However it might be difficult to perform Fibroscan in obese patients. The patient is immediately free to go back to home or work. The Fibroscan examination is a non-invasive procedure and no anesthesia is required for this procedure.

Transjugular intrahepatic portosystemic shunt

What is transjugular intrahepatic portosystemic shunt (TIPSS)?

TIPSS or transjugular intrahepatic portosystemic shunt is a minimally invasive image-guided procedure in which a bypass is created within the liver for the treatment of problems of cirrhosis and portal hypertension.

How is TIPSS performed?

In TIPSS liver is approached through the skin puncture and a new track (pathway) is formed within the liver tissue to serve as a communication between circulation of blood to the liver and the body circulation, which carries oxygenated blood. This track is between the hepatic vein and portal vein within the liver parenchyma with a placement of a specialized stent within this track to maintain long term patency.

What are the indications of TIPSS?

TIPSS is indicated in patients with cirrhosis with portal hypertension in which the patient is not responding to the medical management in the following situations.

    • Bleeding from the food pipe, stomach and upper small intestine (Upper Gastointestinal bleeding) not responding to endoscopic therapy.
    • Fluid in abdominal cavity (Ascites) uncontrolled with diuretics
    • Persistent fluid in the space around the lungs (Hepatic Hydrothorax)
    • Kidney dysfunction due to liver disease (Hepatorenal syndrome type 2)
    • Blockade in the veins of liver leading to complications (Budd chiari syndrome / Hepatic Venous OutflowTract Obstruction)

What are the specific situations where TIPSS should not be done?

The absolute contra indications of TIPSS are severe liver disease and presence of neurological problems in patient with liver cirrhosis. The patients of severe heart failure should also be considered a contraindication for TIPSS.

What are the complications of TIPSS?

The early complications are inability to place a stent, bleeding, trauma to the liver, shunt infection and confusion or altered level of consciousness(Hepatic encephalopathy) which can be managed conservatively. Delayed complications are occlusion and thrombosis of the shunt and persistent encephalopathy not responding to medical therapy.

Cirrhosis of Liver

What is cirrhosis of the liver?

Cirrhosis is a slowly progressive disease that results from permanent damage or scarring of the liver. Cirrhosis lead to loss of liver function, including processing of nutrients, hormones, drugs, toxins as well as production of proteins and other substances synthesized by the liver.

What are the major causes of cirrhosis?

The major causes of cirrhosis are as follows:

  • Chronic viral hepatitis B & C
  • Alcohol
  • Metabolic diseases such as Wilson’s disease, Hemochromatosis, Alpha-1-antitrypsin deficiency
    Non- alcoholic fatty liver disease
  • Cholestatic liver disease such as primary biliary cirrhosis (PBC) and primary sclerosing
    cholangitis (PSC)
  • Autoimmune liver disease
  • A small proportion of patients are also diagnosed as cryptogenic cirrhosis when the cause of
    cirrhosis is not clear

What are the symptoms of liver cirrhosis?

The common symptoms of early cirrhosis are non-specific such as decreased appetite, weight loss, fatigue, generalized weakness and exhaustion. As the disease advances it may result in, swelling feet, accumulation of fluid in abdomen development of jaundice, bleeding from the gastrointestinal tract, altered sleep pattern and behavior. Once the disease is advanced there can be involvement of kidneys leading to rapid deterioration of liver disease.

How is cirrhosis diagnosed?

Cirrhosis is often diagnosed by clinical signs and symptoms suggestive of liver disease supported by relevant investigations including liver function tests, complete hemogram with platelet count, coagulation profile, viral markers, Autoimmune markers, metabolic profile. Certain radiological investigations including ultrasound or CT scan of the abdomen also help to make a diagnosis of cirrhosis. Endoscopy and liver biopsy (in some cases) is required as a apart of evaluation of cirrhosis.

How to treat cirrhosis?

Treatment is urgently required and is aimed at stopping or delaying the disease progression, minimizing liver cell damage and reducing complications. Specific treatment in the form of antivirals for chronic viral hepatitis and immunosuppression for autoimmune liver disease may be required. If alcohol is the cause of cirrhosis strict abstinence from alcohol is mandatory. Medications can also be given to control the symptoms of cirrhosis such as ascites and bleeding and altered sensorium if present. However in end stage liver disease when the patient is not responding to medical management liver transplant is the only viable option.

Alcoholic liver disease

How does Alcohol affect the liver?

When the liver exceeds the capacity to detoxify alcohol, it cannot work properly. Liver cells contain enzymes that metabolize alcohol. These enzymes break down alcohol into other chemicals, which in turn are then broken down into water and carbon dioxide. The liver cells can process only a certain amount of alcohol per hour. So, if you drink alcohol faster than your liver can deal with it, the level of alcohol in your bloodstream rises. Once the detoxification process of alcohol in the body is exceeded in a person who is drinking more than the liver can remove, liver cells can be destroyed or changed.

What is safe drinking?

Alcohol is one of the most common causes of liver disease worldwide. The liver is the major body organ responsible for removing toxins from the body and in the process of trying to clear alcohol from the blood, the liver cells get damaged, as alcohol is toxic to them. People often wonder whether all alcohol is bad or they can take a small amount without the risk of endangering their health. Well, in fact, the liver has an immense capacity to regenerate. Hence, the ‘safe limit’ for alcohol consumption is said to be 21 units per week in men, no more than four units in any one day, and have at least two alcohol-free days a week. Women should drink no more than 14 units of alcohol per week, no more than three units in any one day, and have at least two alcohol-free days a week. (1unit of alcohol =one ounce of spirits=one, 12-ounce beer=one, 4-ounce of wine)

What is the spectrum of Alcoholic liver disease?

The spectrum of alcoholic liver disease varies from fat deposition in liver (fatty liver disease), more serious inflammation (alcoholic hepatitis) to permanent scarring (cirrhosis of liver).
Fatty liver:It develops in about 90% of individuals who drink more than 60 g/day of alcohol, but may also occur in individuals who drink less. Simple, uncomplicated fatty liver is usually asymptomatic and self-limited, and may be completely reversible with abstinence after about 4-6 weeks.
Alcoholic Hepatitis: A subset of patients with alcoholic liver disease will develop alcoholic hepatitis, which has a substantially worse short-term outcome. Alcoholic hepatitis also represents a spectrum of disease, ranging from mild injury to severe, life-threatening injury, and often presents acutely against a background of chronic liver disease. The symptomatic patients present with advanced liver disease, with concomitant cirrhosis in more than 50%, and superimposed acute deterioration.
Alcoholic Cirrhosis: Simple steatosis is regarded as a benign condition; nevertheless, given continued abuse, it too, can induce fibrogenesis. In any case up to 20% of the patients with simple steatosis are likely to develop fibrosis or cirrhosis within a period of ten years. The prognosis of a patient with cirrhosis depends mainly on the presence of complications because of portal hypertension and continued abuse of alcohol.

What are the symptoms of alcoholic liver disease?

In many cases, people with alcoholic liver disease do not have any noticeable symptoms until their liver is badly damaged. The initial symptoms are nonspecific and include pain abdomen, loss of appetite, fatigue, body aches and sense of being unwell. However as the disease progresses the symptoms become more obvious and serious. The common symptoms are yellowing of the skin and eyes (jaundice), swelling in the legs (edema) and swelling in your abdomen due to fluid (ascites). Bleeding in the gastrointestinal tract, which can present as blood in vomiting and in the stools can be another manifestation. There might be weight loss and muscle wasting and change in sleep pattern as the disease progresses.

How is Alcoholic liver disease diagnosed?

Alcoholic liver disease can be diagnosed by simple blood tests including liver function tests, which can detect enzymes that represent liver dysfunction. Blood tests can also detect low levels of albumin a protein synthesized by the liver. A blood test may also look for signs of abnormal blood clotting, which can indicate significant liver damage. Certain imaging studies including an ultrasound, computerized tomography (CT) and a magnetic resonance imaging (MRI) of the abdomen may also be carried out to assess the degree of liver damage. An endoscopy to look for swollen veins in the food pipe (varices) may also be required which is the sign of cirrhosis.

What is the treatment of Alcoholic liver disease?

Treatment for alcohol-related liver disease involves stopping drinking alcohol. It is important to eat a balanced diet to help ensure all the nutrients are being supplemented. Alcoholic hepatitis can be treated with corticosteroids if there is no contraindication. However end stage liver disease due to alcohol might require liver transplantation as the definitive therapy

Fatty Liver

What is fatty liver disease?

A fatty liver is the result of the accumulation of excess fat in liver cells. Fatty tissue slowly builds up in the liver when a person’s diet exceeds the amount of fat his or her body can handle. A person has a fatty liver when fat makes up at least 5-10% of the liver. Simple fatty liver can be a completely benign condition and usually does not lead to liver damage. However, once there is a buildup of simple fat, the liver becomes vulnerable to further injury, which may result in inflammation and scarring of the liver.

The most common cause of fatty liver disease is obesity.

The other conditions that contribute to liver disease are

  • High blood Sugars (Diabetes Mellitus)
  • Elevated lipids in the blood (Hyperlipidemia),
  • High blood pressure (Hypertension).

What are the symptoms of fatty liver disease?

In general, there are no symptoms in people with fatty liver disease. A small proportion of patients may complain of vague discomfort in the abdomen, weakness and fatigue,

How is fatty liver disease diagnosed?

Fatty liver disease is usually suspected in patients who have an enlarged liver or abnormal liver tests. An ultrasound of the liver can suggest the presence of a fatty liver.

What is the treatment of fatty liver disease?

Patients are advised to achieve a gradual and sustained weight loss through proper nutrition and exercise. Patients with diabetes and high lipids in their blood have to improve their sugar control and lower lipids levels.

Usually, a low fat, low calorie diet is recommended along with insulin or medications to lower blood sugar in people with diabetes.

Currently, there is no medication proven to effectively treat fatty liver disease.

Can fatty liver disease be prevented?

A healthy life style will prevent obesity, which is the commonest cause of fatty liver disease.

Certain suggestions for preventing fatty liver disease:

  • Avoid alcohol
  • Choose a healthy lifestyle
  • Aim for a gradual and sustained weight loss if you are obese.
  • Diet low in saturated fats and high in fiber.
  • Daily exercise

Hepatitis E

What is Hepatitis E?

Hepatitis E is a liver disease caused by the hepatitis E virus: a non-enveloped, positive-sense, single-stranded ribonucleic acid (RNA) virus.

How does Hepatitis E spreads?

The hepatitis E virus is transmitted primarily through the faecal-oral route due to faecal contamination of drinking water. The other modes like person-to-person transmission and foodborne transmission from ingestion of products derived from infected animals are rare.

What are the symptoms of Hepatitis E?

The signs and symptoms following exposure to the hepatitis E virus usually develop within three to eight weeks, with a mean of 40 days. Symptomatic infection is most common in young adults aged 15–40 years. Typical signs and symptoms of hepatitis include jaundice, anorexia, abdominal pain and tenderness, nausea,vomiting and fever.

How to make a diagnosis of Hepatitis E?

The cases of hepatitis E are indistinguishable from other types of acute viral hepatitis. The diagnosis of acute infection is based on the detection of specific IgM antibodies to the virus in the blood. Additional tests, which are rarely required, include reverse transcriptase polymerase chain reaction (RT-PCR) to detect the hepatitis E virus RNA in blood and/or stool.

How can we treat Hepatitis E?

There is no specific treatment capable of altering the course of acute hepatitis. As hepatitis E is usually self-limiting, hospitalization is generally not required. Treatment is symptomatic and is aimed at maintaining hydration and adequate calorie intake. However a small proportion of patients with fulminant hepatic failure and pregnant women require hospitalization.

How can we prevent Hepatitis E?

Improving sanitation and maintaining quality standards for public water supplies with proper disposal systems to eliminate sanitary waste can reduce the risk of infection and transmission

Hepatitis A

What is Hepatitis A?

Hepatitis A is an acute infectious form of liver disease caused by the hepatitis A virus. It is a viral liver disease that can cause mild to severe illness.

How does Hepatitis A spreads?

Hepatitis A is spread through close contact with an infected person, or by eating hepatitis A contaminated food or drinking water. 

Eating raw or undercooked seafood and shellfish from water polluted with sewage, or eating salad greens that are rinsed in contaminated water are other ways of becoming infected. The virus can also be transmitted through close physical contact with an infectious person, although casual contact among people does not spread the virus.

What are the symptoms of hepatitis A?

Not all people infected with hepatitis A virus are symptomatic. Adults have signs and symptoms of illness more often than children, and the severity of disease and mortality increases in older age groups. Symptoms may occur 14 to 28 days from the time you first come in contact with the hepatitis A virus. Typical symptoms of an acute hepatitis A infection include: fatigue, nausea and vomiting, abdominal discomfort, jaundice (yellowing of the whites of the eyes and skin), dark urine, low grade fever and loss of appetite.

How to make a diagnosis of hepatitis A?

It is not possible to clinically distinguish cases of acute hepatitis A from other types of acute viral hepatitis. Specific diagnosis of acute infection is made by the detection of HAV-specific IgM antibodies in the blood. However additional tests include reverse transcriptase polymerase chain reaction (RT-PCR) to detect the hepatitis A virus RNA may be required in special situations.

How can we treat hepatitis A?

There is no drug treatment for hepatitis A. Treatment is symptomatic and therapy is aimed at maintaining comfort and adequate nutritional balance, including replacement of fluids that are lost from vomiting and diarrhea. The persons infected with hepatitis A are advised to take small frequent meals and there is no restriction on dietary intake. The disease will eventually run its course and an infected person will recover completely although recovery time varies for each person.

How can we prevent hepatitis A?

Improved sanitation, food safety and immunization are the most effective ways to combat hepatitis A. There is a safe and effective vaccine that can protect you from getting hepatitis A. The vaccine is usually given in two doses six months apart.

Hepatitis B

What is hepatitis B?

Hepatitis B is an infectious illness of the liver caused by the hepatitis B virus. It is a major global health problem. Around 5% of adults who get acute hepatitis B develop chronic hepatitis, which can lead to cirrhosis and/or liver cancer later in life. Chronic hepatitis B is a “silent” disease because often no symptoms appear until your liver is severely damaged.

How can you get hepatitis B?

A person who has acute or chronic hepatitis B can spread the infection to other people through his/her blood and other body fluids or by sexual contact. The hepatitis B virus is found mainly in the blood, semen, and vaginal fluid of an infected person.

The risk of exposure to hepatitis B is through unprotected sex, tattoos, piercings, pedicures, manicures or medical procedures with improperly sterilized equipment, sharing personal hygiene items with an infected person (e.g. razors, toothbrushes, nail clippers)

Risk factors for getting hepatitis B

  • Blood Transfusion and transfusion with other blood products
  • Babies born to a hepatitis B infected mother
  • Unprotected sex with an infected person or multiple sexual partners
  • Injection drug abusers and sharing contaminated drug preparation/ injection materials
  • Exposure to siblings or other family members who have hepatitis B
  • Exposure to blood and body fluids because of your job.

What are the symptoms of Hepatitis B?

The symptoms depend on the age of acquiring Hepatitis B infection. In adults a brief illness with prodrome such as fatigue, body aches, decreased appetite, followed by jaundice, dark urine and abdominal discomfort might be present. Most of the adults will clear the infection completely and developing lifelong protection against this virus.

However infection acquired by babies and children exposed to this virus usually do not develop any signs and symptoms. Most of the cases develop chronic infections, which are often detected later in life when the person becomes seriously ill with liver disease.

Although most people with chronic hepatitis B have inactive disease and will remain healthy, about one in four will have active disease that may lead to cirrhosis, liver failure, and liver cancer.

How to treat Hepatitis B?

There is no specific treatment for acute hepatitis B. Management includes supportive and prevention of complications.

For Chronic hepatitis B antiviral medicines have been approved for treatment. These treatments do not provide a cure, but they offer control of the virus so that further damage to your liver can be prevented.

How can you prevent hepatitis B?

There is a safe and effective vaccine that can protect you from getting hepatitis B. The vaccine is usually given in three doses over a six months period. The vaccine gives long-lasting protection and can be given at birth of newborn.

Hepatitis C

What is hepatitis C?

Hepatitis C is an infectious liver disease that ranges in severity from a mild illness lasting a few weeks to a serious, lifelong illness that attacks the liver. It results from infection with the Hepatitis C virus. The infection is often asymptomatic, but chronic infection can lead to scarring of the liver and ultimately to cirrhosis, which is generally apparent after many years.

How is hepatitis C transmitted?

Hepatitis C is spread through blood-to-blood contact.

What are the risk factors for contracting hepatitis C?

  • Use of injection drugs
  • If you have received blood or blood products before 1990
  • Tattooing or body piercing
  • Multiple sexual partners
  • Accidental injury from a needle or syringe
  • By sharing personal items with a hepatitis C-infected person (e.g., razors, nail clippers, toothbrush)

What are the symptoms of Hepatitis C?

Acute infection phase is usually asymptomatic and can last from six to eight weeks, or longer. If symptomatic, they are usually mild and may include fatigue, lethargy, nausea, reduced appetite, abdominal pain and jaundice. Two thirds of people exposed to hepatitis C will develop chronic infection, which can lead to more serious problems including cirrhosis, liver failure and liver cancer over a period of 25 to 30 years.

How to diagnose Hepatitis C?

Since most acute HCV infections are asymptomatic, early diagnosis of the HCV infection is rare. In those people who go on to develop chronic HCV infection, the infection may remain undiagnosed, often until serious liver damage has developed. Diagnosis is established by screening for anti-HCV antibodies with a serological test, which identifies people who have been infected with the virus. If the test is positive for anti-HCV antibodies, a nucleic acid test for HCV RNA is needed to confirm chronic HCV infection.

How to treat Hepatitis C?

Hepatitis C does not always require treatment, as the immune response in some people will clear the infection. When treatment is necessary, the goal of hepatitis C treatment is cure. Depending upon what form (genotype) of the hepatitis C virus you are infected with, treatment can cure your illness. At present, the standard treatment for hepatitis C is a combination of Pegylated interferon and ribavirin. However new oral drugs have recently been approved for treatment of hepatitis C and have high efficacy and cure rates

How can I avoid getting hepatitis C?

There is no vaccine to protect you against hepatitis C. To avoid contracting hepatitis C, take the following precautions:

  • Adopt safe sex practices
  • Avoid sharing personal hygiene items (e.g. razors, toothbrushes, nail clippers);
  • Do not share needles

Autoimmune Hepatitis

What is Autoimmune Hepatitis?

Autoimmune hepatitis is a disease characterized by chronic inflammation of the liver of unknown cause. In this disease there is failure of immune tolerance leading to immune attack against the liver cells.

What is the cause of Autoimmune Hepatitis?

The exact cause why our own immune system attacks the liver cells is unknown. However it appears that certain types of white blood cells misinterpret liver cells as foreign substances and start attacking these cells leading to the inflammation in the liver.

What are the types of Autoimmune Hepatitis?

There are two types of AIH described in literature
Type 1 (classic): This is the most common type of the disease. It can occur at any age and is more common in females. It is also associated with other autoimmune disorders, such as thyroiditis, rheumatoid arthritis or ulcerative colitis in about one third of patients.
Type 2 AIH: Although adults can develop type 2 autoimmune hepatitis, it is most common in young girls and often occurs with other autoimmune problems. It is usually more severe and can present with advanced liver disease at the onset of symptoms.

What are the symptoms of Autoimmune Hepatitis?

The initial symptoms are nonspecific symptoms such as fatigue, jaundice, nausea, abdominal pain, and arthralgias,but the clinical spectrum is wide, ranging from an asymptomatic presentation to an acute severe disease. In many patients there will be no symptoms at all and the condition is diagnosed on a routine liver function tests by an elevation in levels of liver enzymes.

What are the tests useful for diagnosis of Autoimmune Hepatitis?

Blood tests will almost always reveal elevations of certain liver enzymes that are synthesized by the liver. In addition, other blood tests will reveal antibodies such as anti-smooth muscle antibody and antinuclear factor antibody and anti LKM antibody. The levels of immunoglobulin G may be elevated in the blood. Finally, a liver biopsy is required to confirm the diagnosis.

What is the treatment for Autoimmune Hepatitis?

Autoimmune hepatitis is one of the few liver diseases with excellent response to therapy. Corticosteroids are the mainstay of treatment and are used as first line drugs. These drugs will reduce inflammation in the liver. In addition to, or in place of corticosteroids, other drugs with anti-inflammatory activity, such as azathioprine, mycophenolate mofetil, methotrexate or tacrolimus may also be used. However some patients with very mild or inactive disease may not need any type of active treatment and require close follow up.

Liver Tumors

The most common malignant primary tumors are hepatocellular carcinoma (HCC) or hepatoma and cholangiocarcinoma. HCC arises from the hepatocytes and cholangiocarcinoma from the epithelium of the intrahepatic biliary tract.

What is hepatocellular carcinoma?

Hepatocellular Carcinoma is one of the most common malignant primary liver tumors worldwide. The incidence of hepatocellular carcinoma is rising in many countries. Between 500,000 and one million new cases are reported each year. HCC affects persons of all age groups.

What are the common risk factors for Hepatocellular Carcinoma?

The common risk factors for hepatocellular carcinoma are infection with hepatitis viruses like Hepatitis B and Hepatitis C. Any one with liver diseases suffering from chronic hepatitis or cirrhosis due to any cause is itself a risk factor for hepatocellular carcinoma.

How does Hepatocellular Carcinoma present?

HCC develops without subjective complaints hence it is usually detected at a late stage. The complaints are explained as general symptoms relating to cirrhosis or to an existing chronic liver disease. Complaints are very varied and common presentation is with pain abdomen, weight loss, fatigue weakness, bloating, nausea and jaundice is usually rare at the beginning.

How to diagnose hepatocellular carcinoma?

The tests used to diagnose Hepatocellular carcinoma include radiology and biopsy. Hepatocellular carcinoma can be diagnosed radiologically, without the need for biopsy if the typical imaging features are present. This diagnosis can be established by doing a Dynamic Contrast CECT or a Dynamic MRI. If atypical features are present on an imaging study then a biopsy may be required to confirm the diagnosis.

How do we treat Hepatocellular carcinoma?

The therapies with a potential for cure of hepatocellular Carcinoma are surgical resection, percutaneous ablation and transplantation. The non-curative therapies for treatment of Hepatocellular carcinoma which have shown to have a positive impact on survival are Transarterial chemoembolization and Sorafenib.

Radio frequency Ablation for Primary Liver Cancer (Hepatocellular Carcinoma)

What is Radiofrequency ablation (RFA) for primary liver tumours?

Radio Frequency ablation is a simple, effective and minimally invasive treatment for small hepatocellular carcinoma (HCC). It is best suited for ablating lesions smaller than 3 cm but may be used for HCC measuring 4-5 cm in diameter.

How is Radiofrequency ablation (RFA) procedure performed?

The procedure is performed using a specialised needle probe (electrode) which is inserted within the liver tumor and connected to a Radio Frequency Generator via cable. The Radio Frequency needle is precisely placed within the tumor under ultrasound or CT guidance. After setting the various parameters the generator is switched on. This leads to controlled heating of the specified area within the liver and tumor death due to high temperature. The adjacent areas within the liver mostly remain unaffected. Once the ablation is complete the needle is removed.

What are the contraindications for Radio Frequency Ablation (RFA) ?

The RFA procedure is relatively safe however contradictions for RFA include deranged coagulation profile (higher tendency to bleed due to liver dysfunction), presence of ascites (fluid in the abdomen) and tumor adjacent to any large vessel (artery or vein) or any other vital structure including gallbladder.

What are the complications of Radio frequency Ablation (RFA)?

Pain is the most common complication of Radio Frequency Ablation and therefore the procedure is mostly performed under anaesthesia cover (conscious sedation) and pain killers (analgesics) are required for post procedure pain management (12-24 hrs). Some patients may have fever following the procedure which is mostly self limiting. Rarely some patient may have component of liver decompensation (deranged liver functions with appearance of ascites) which is again managed conservatively. Mostly the hospital care is required for 24to 48 hrs.

Screening for Primary Liver Cancer(Hepatocellular Carcinoma)

What is screening for primary liver cancer (HCC)?

It is the application of diagnostic tests in patients at risk for liver cancer, but in whom there is no a prior reason to suspect that liver cancer is present.

What is Surveillance?

It is the repeated application of screening tests for diagnosis of liver cancer.

Why do we need to screen for liver cancer (HCC)?

Liver cancer is the sixth most cancer and the third most common cause of cancer related deaths in the world. Hence screening and pick up of liver cancer at an early stage can lead to improved care and treatment of such patients.

Why is liver cancer (HCC) increasing?

Liver cancer is on the rise because of increasing prevalence of patients with cirrhosis primarily due to Hepatitis C, Hepatitis B, Non alcoholic liver disease and alcoholic liver disease. Other cause might be improved survival of patients with cirrhosis and development of liver cancer in such patients in the long run.

Who should be screened for liver cancer?

Screening should be done in patients of cirrhosis due to any cause. Patients suffering from hepatitis B with active hepatitis, family history of liver cancer and Hepatitis C with advanced fibrosis should also be screened for liver cancer.

What Modality should be used for screening?

Screening of liver cancer is done with the help of blood test alphafetoprotein which is a tumour marker along with an ultrasound of liver.

What is the optimal interval of Screening?

The optimal time for screening of liver cancer is every six months.

Prevention of Liver Cancer(Hepatocellular Carcinoma)

Why should prevention of liver cancer be encouraged?

Prevention of cancer seems to be the most cost-effective strategy in the war against cancer. In the context of liver cancer, most liver cancers are amenable to prevention. The most common causes of liver cancer include Hepatitis B & C, Nonalcoholic fatty liver disease, Alcoholic liver disease and cirrhosis due to any cause. The prevention is aimed at treatment of these diseases and progression to cirrhosis

What is Primary Prevention of liver cancer?

Hepatitis B is one of the major causes of liver cancer and can be prevented by universal immunization against Hepatitis B. The universal immunization is vaccinating all newborn children at birth. This vaccine can also be given to adults of all age groups for prevention of Hepatitis B.
In patients with Hepatitis C no vaccination is availabe, however all efforts should be made to prevent infection. The focus should be on identifying persons at increased risk, counseling and testing for presence of virus, reducing incidence of new infections and risk of progression to chronic liver disease.
Other measures to prevent chronic viral hepatitis B & C is by having safe injection practices and screening of blood products before transfusion.
In patients with Non alcoholic fatty liver disease and Alcoholic liver disease measures to prevent liver disease is by changing lifestyle. This can be achieved by abstinence of alcohol, good nutritious diet, increasing physical activity to reduce development of obesity and control of Diabetes mellitus and deranged lipids.

What is secondary prevention of liver cancer?

It is the prevention of development of chronic liver disease. This can be done by treatment of Hepatitis B & C by antivirals drugs, which are easily available.

What is tertiary prevention of liver cancer?

It is the prevention of recurrence of liver cancer after treatment. This can again be achieved by controlling the chronic viral infections (Hepatitis B & C) of the liver after treatment.

Cholangiocarcinoma

What is Cholangiocarcinoma?

Cholangiocarcinoma is the most common bile duct tumor that arises from the intra and extra hepatic bile ducts. It is second most common primary liver tumor and constitutes 10%- 20% of deaths related to hepato-biliary cancers .

What are the risk factors for Cholangiocarcinoma?

The common risk factors are Caroli’s disease, Choledochal cyst, Hepatolithiasis (stones in the intrahepatic bile ducts), liver fluke infection, primary sclerosing cholangitis and exposure to chemicals like thorotrast.

How are Cholangiocarcinoma classified?

The Cholangiocarcinoma can be classified as intrahepatic (arising within the liver) or extra hepatic (arising outside the liver) from the bile ducts. Intrahepatic tumors constitute around 20-25% and extra hepatic constitutes around 80% of cholangiocarcinomas

What are the symptoms of Cholangiocarcinoma?

The most common symptom of extra hepatic Cholangiocarcinoma is painless progressive jaundice. Around 10% may present with fever, pain abdomen and jaundice. The intrahepatic tumors most commonly present with abdominal pain, cachexia, malaise and fatigue.

How is Cholangiocarcinoma diagnosed?

Tumor marker CA19-9 is elevated in majority of patients with Cholangiocarcinoma. Ultrasound and CT/MRI scan of abdomen will tell us the level of bile duct obstruction, presence of liver, lymph nodal and vascular structures involvement. Endoscopic retrograde cholangiography can be done to get tissue for diagnosis and relief of jaundice by placing stents in the bile ducts.

What is the treatment of Cholangiocarcinoma?

Treatment of choice is surgery if it is feasible both for intrahepatic and extrahepatic cholangiocarcinoma. However it is difficult due to close proximity to neural and vascular structures. A small proportion of extrahepatic cholangiocarcinoma can be considered for liver transplantation under special protocols. If surgery is not possible then measures to decrease bilirubin can be undertaken by endoscopic or percutaneous methods. Local and systemic chemotherapy and radiotherapy has a limited role in the management of Cholangiocarcinomas.

Liver Transplantation

What is liver transplantation?

Liver transplantation is surgical procedure to remove a diseased liver and replace it with a healthy liver. An entire liver may be transplanted, or just a portion of liver may be transplanted. Since liver is the only organ in the body which can rapidly regenerate, a transplanted portion of a liver can rebuild to normal capacity within weeks.
A successful liver transplant is a life-saving treatment for people with liver failure, a condition in which the liver no longer works, as it should.

What are the types of liver transplantation?

It is of two types:
Deceased Donor Liver Transplantation is a procedure that uses a liver that becomes available when a person dies and his or her family donates the organ for transplantation.
Living Donor Liver Transplantation is a procedure, in which a portion of liver is surgically removed from a live donor and transplanted into a recipient.

Who needs a liver transplant?

Liver Transplantation is indicated for severe acute or advanced chronic liver disease when the limits of medical therapy have been reached.
Acute liver failure (ALF) occurs suddenly in a person who is otherwise healthy and has a normal liver. There is rapid deterioration of liver functions and development of organ failure if not treated immediately.
End-stage liver disease occurs most commonly as a result of cirrhosis that is a slowly progressive disease and results from permanent damage or scarring of the liver. Cirrhosis lead to loss of liver function, including processing of nutrients, hormones, drugs, toxins as well as production of proteins and other substances synthesized by the liver.

What are the indications of liver transplantation?

The common indications of liver transplantation are acute liver failure, development of complications in a patient of cirrhosis like infection of ascitic fluid (spontaneous bacterial peritonitis), alteration of sensorium (hepatic encephalopathy), kidney failure due to liver disease (Hepatorenal syndrome), gastrointestinal bleed (Refractory variceal bleed) and liver cancer. Certain other metabolic conditions like Wilson’s disease, hemochromatosis, and alpha1 antitrypsin deficiency are also indications of doing a liver transplantation once the medical management fails.

What are the contraindications of liver transplantation?

The common contraindications of liver transplantation are advanced heart or lung disease, presence of cancer other than liver cancer, uncontrolled infection, ongoing illicit substance abuse and lack of adequate social support.

What is the process for getting a liver transplant?

The process for getting a liver transplant begins by consulting a doctor at a transplant center. A team of liver transplant surgeons, liver specialists called hepatologists, transplant coordinators, a psychiatrist, and other medical specialists carefully evaluates the patient seeking a liver transplant to determine whether they are suitable candidates for transplantation. Once complete medical examination is done the patient is listed for undergoing a liver transplantation.

What is the outcome of people who have a liver transplant?

Most liver transplants are successful with good survival of 80 to 85 percent after 1 year. People who have a liver transplant are usually able to return to normal activities after recovering from the illness. Liver transplant recipients require intensive medical follow-up during the first year after a transplant because most of the complications develop during the first year.