What is cirrhosis?

No body organ performs a wider variety of essential jobs than the liver. It:

• Produces essential proteins that help blood to clot

• Removes or neutralizes poisons, drugs and alcohol

• Manufactures bile that helps the body to absorb fats and cholesterol

• Helps to maintain normal blood sugar levels

• Regulates several hormones

Cirrhosis is a disease in which normal liver cells are replaced by scar tissue, which interferes with all of these important functions.Cirrhosis is long-term scarring of the liver. The liver makes enzymes and bile that help digest food and gives your body energy. Cirrhosis is caused by repeated damage to your liver over time. Scar tissue starts to replace healthy liver tissue. The scar tissue prevents the liver from working properly.

Scarring also impedes blood flow and increases pressure in the portal vein, which moves blood from the stomach to the liver. This condition is called portal hypertension. Blood vessels in the stomach and esophagus swell, and the body creates new ones in an attempt to bypass the liver. These vessels, called varices, have thin walls. If one bursts, the resulting hemorrhage (major bleeding) can cause death within hours if not treated.

What increases my risk for cirrhosis?

• Long term diabetes

• Long-term alcohol use

• Hepatitis B or C infection

• Fat or iron build-up in the liver

• A disease such as cystic fibrosis, or a family history of liver cancer

• Damage to the bile ducts that blocks the flow of bile

• Obesity

Rarer causes of cirrhosis include:

• Autoimmune diseases that attack the bile ducts or liver cells

• Severe reactions to prescription drugs

• Prolonged exposure to environmental toxins

• Infections from bacteria and parasites usually found in the tropics or Asia

• Repeated episodes of heart failure with liver congestion.

• Certain inherited diseases, including:

o Hemochromatosis, in which too much iron builds up in the liver and other organs

o Wilson's disease, which produces abnormal concentrations of copper

o Alpha-1-antitrypsin deficiency, which is the absence of a particular enzyme in the liver

What are the signs and symptoms of cirrhosis?

You may not have any signs or symptoms until your liver damage is severe. You may have any of the following:

• Fatigue

• Bleeding and bruising easily

• Bool vomiting

• Black stool

• Swelling of your feet, legs, or abdomen

• Nausea, loss of appetite, and weight loss

• Itching

• Jaundice (yellowing of your skin or eyes)

• Black bowel movements or dark urine

How is cirrhosis diagnosed?

• Blood tests may be used to check your liver enzymes.

• An ultrasound may be used to check for damage to your liver or other tissues or organs.

• CT or MRI pictures may be taken of your liver. You may be given IV contrast liquid to help your liver show up better in the pictures. Tell the healthcare provider if you have ever had an allergic reaction to contrast liquid. Do not enter the MRI room with anything made of metal. Metal can cause serious injury. Tell the healthcare provider if you have any metal in or on your body.

• A liver biopsy is a procedure used to take a small piece of your liver to be tested for liver damage.

How is cirrhosis treated?

• Medicines:

o Your doctor may recommend a low-sodium diet and diuretics if you are retaining excess fluid in your body.

o Lactulose or other medication will be prescribed if you have confusion caused by hepatic encephalopathy. Lactulose is a laxative that decreases the absorption of certain substances toxic to the brain.

o Medications can be prescribed for itching and infections.

o Blood pressure medicines may help to lower pressure in the portal veins to decrease the risk of internal bleeding.

• Endoscopy

o Bleeding varices pose an immediate, life threatening hazard. To prevent them from bleeding, doctors called gastroenterologists do endoscopy to find the varices and treat them. The varices can be injected with a solution to shrink them or they can be sealed with bands.

o The same procedure is done when varices are actively bleeding. Intravenous and oral drugs are also given to reduce bleeding.

• TIPS

o The person may also need a procedure called transjugular intrahepatic portosystemic shunt (TIPS). This involves creating a new blood channel in the liver that relieves some of the high portal pressure. With less portal pressure, there is less bulging of the varices. And new varices are less likely to form.

• Surgery-In extreme cases, the damage is so severe that the only solution is a liver transplant.You may need a liver transplant if your liver fails.

What can I do to manage cirrhosis?

• Do not drink alcohol. Alcohol will cause more damage to your liver.

• Do not smoke. Nicotine and other chemicals in cigarettes and cigars can cause blood vessel and lung damage. Ask your healthcare provider for information if you currently smoke and need help to quit. E-cigarettes or smokeless tobacco still contain nicotine. Talk to your healthcare provider before you use these products.

• Eat a variety of healthy foods. Healthy foods include fruits, vegetables, whole-grain breads, low-fat dairy products, beans, lean meat, and fish. Ask if you need to be on a special diet.

• Reach or maintain a healthy weight. You may develop fatty liver disease if you are overweight. Ask your healthcare provider for a healthy weight for you. He can help you create a safe weight loss plan if you are overweight.

• Limit sodium (salt). You may need to decrease the amount of sodium you eat if you have swelling caused by fluid buildup. Sodium is found in table salt and salty foods such as canned foods, frozen foods, and potato chips.

• Drink liquids as directed. Ask how much liquid to drink each day and which liquids are best for you. For most people, good liquids to drink are water, juice, and milk. Liquids can help your liver work better.

• Ask about vaccines. You may have a hard time fighting infection because of cirrhosis. Vaccines help protect you against viruses that can cause diseases such as the flu or hepatitis. Viral hepatitis is caused by a virus that leads to inflammation of the liver. You may need a hepatitis A or B vaccine. You may also need a pneumonia vaccine. Always get a flu vaccine each year as soon as it becomes available.

• Ask about medicines. Some medicines can harm your liver. Acetaminophen is an example. Talk to your healthcare provider about all your medicines. Do not take any over-the-counter medicine or herbal supplements until your healthcare provider says it is okay.

When should I seek immediate care?

• You have pain during a bowel movement and it is black or contains blood.

• You have a fast heart rate and fast breathing.

• You are dizzy or confused.

• You have severe pain in your abdomen.

• You have trouble breathing.

• Your vomit looks like it has coffee grinds or blood in it.

When should I contact my consultant doctor?

• You have a fever.

• You have red or itchy skin.

• You are in pain and feel weak.

• You have questions or concerns about your condition or care.

How to predict the prognosis

Cirrhosis is usually a progressive disease. Although it usually cannot be reversed, the liver damage can be halted or slowed down with treatment or changes in behaviour in many cases.

Two of the blood tests that indicate a poor prognosis in people with cirrhosis are a low albumin level and a high INR (adjusted Pro-Time). The high INR indicates the person's liver cannot make the normal amount of clotting proteins.

Prevention

The most important step you can take to prevent cirrhosis is to avoid excessive drinking.It is best to consume an average of no more than two alcoholic drinks a day for men or one drink a day for women. If you have chronic hepatitis or other liver problems, avoid alcohol completely.

Some other causes of cirrhosis can be prevented. To avoid infection with hepatitis B and C, do not inject illegal drugs, snort cocaine, or have unprotected sex, especially with multiple partners. If you are considering body piercing or tattooing, make sure that the equipment is cleaned properly. Health care and emergency workers should follow infection control precautions carefully whenever they are exposed to blood.

Hepatitis B also can be prevented with a vaccine, a series of three shots that is 90% effective.

By preventing non-alcoholic fatty liver disease, you prevent the small risk of developing cirrhosis. This means maintaining a healthy weight and getting plenty of exercise.

Liver cancer

Liver cancer is cancer that begins in the cells of your liver. Your liver is a football-sized organ that sits in the upper right portion of your abdomen, beneath your diaphragm, above your stomach and behind right lower rib cage.

Several types of cancer can form in the liver. The most common type of liver cancer is metastasis (Cancer that begins in another area of the body — such as the colon, lung or breast — and then spreads to the liver is called metastatic cancer rather than liver cancer), second most common is hepatocellular carcinoma, which begins in the main type of liver cell (hepatocyte – the original liver cancer). Other types of liver cancer, such as intrahepatic cholangiocarcinoma and hepatoblastoma, are much less common.

Hepatocellular carcinoma (HCC)

In current era HCC is most commonly found in cirrhosis patients. Cirrhosis is a condition that arises out of many situations namely, fatty liver, alcohol consumption, hepatitis C, Hepatitis B, Diabetes leading to steatohepatitis etc. Liver cancer arising in do novo normal liver is not very common. Most of the time it is associated with other liver diseases.

Symptoms

Most people don't have signs and symptoms in the early stages of primary liver cancer. When signs and symptoms do appear, they may include:

• Losing weight without trying

• Loss of appetite

• Upper abdominal pain

• Nausea

• General weakness and fatigue

• Abdominal swelling

• Yellow discoloration of your skin, urine and the whites of your eyes (jaundice)

• White, chalky stools

When to see a doctor

Make an appointment with your doctor if you experience any signs or symptoms that worry you. Especially if you are known case of cirrhosis of liver than u must take extra care and follow up should be desired as prescribed by the doctors.

Causes

Liver cancer happens when liver cells develop changes (mutations) in their DNA. A cell's DNA is the material that provides instructions for every chemical process in your body. DNA mutations cause changes in these instructions. One result is that cells may begin to grow out of control and eventually form a tumor — a mass of cancerous cells.

Sometimes the cause of liver cancer is known.

Risk factors

Factors that increase the risk of primary liver cancer include:

• Chronic infection with HBV or HCV. Chronic infection with the hepatitis B virus (HBV) or hepatitis C virus (HCV) increases your risk of liver cancer.

• Cirrhosis. This progressive and irreversible condition causes scar tissue to form in your liver and increases your chances of developing liver cancer.

• Certain inherited liver diseases. Liver diseases that can increase the risk of liver cancer include hemochromatosis and Wilson's disease.

• Diabetes. People with this blood sugar disorder have a greater risk of liver cancer than those who don't have diabetes.

• Nonalcoholic fatty liver disease. An accumulation of fat in the liver increases the risk of liver cancer.

• Exposure to aflatoxins. Aflatoxins are poisons produced by molds that grow on crops that are stored poorly. Crops, such as grains and nuts, can become contaminated with aflatoxins, which can end up in foods made of these products. This is very less common in India.

• Excessive alcohol consumption. Consuming more than a moderate amount of alcohol daily over many years can lead to irreversible liver damage and increase your risk of liver cancer.

Prevention

Reduce your risk of cirrhosis

Cirrhosis is scarring of the liver, and it increases the risk of liver cancer. You can reduce your risk of cirrhosis if you:

• Drink alcohol in moderation, if at all. If you choose to drink alcohol, limit the amount you drink. For women, this means no more than one drink a day. For men, this means no more than two drinks a day.

• Maintain a healthy weight. If your current weight is healthy, work to maintain it by choosing a healthy diet and exercising most days of the week. If you need to lose weight, reduce the number of calories you eat each day and increase the amount of exercise you do. Aim to lose weight slowly — 1 or 2 pounds (0.5 to 1 kilograms) each week.

Get vaccinated against hepatitis B

You can reduce your risk of hepatitis B by receiving the hepatitis B vaccine. The vaccine can be given to almost anyone, including infants, older adults and those with compromised immune systems.

Take measures to prevent hepatitis C

No vaccine for hepatitis C exists, but you can reduce your risk of infection.

• Know the health status of any sexual partner. Don't engage in unprotected sex unless you're certain your partner isn't infected with HBV, HCV or any other sexually transmitted infection. If you don't know the health status of your partner, use a condom every time you have sexual intercourse.

• Don't use intravenous (IV) drugs, but if you do, use a clean needle. Reduce your risk of HCV by not injecting illegal drugs. But if that isn't an option for you, make sure any needle you use is sterile, and don't share it. Contaminated drug paraphernalia is a common cause of hepatitis C infection. Take advantage of needle-exchange programs in your community and consider seeking help for your drug use.

• Seek safe, clean shops when getting a piercing or tattoo. Needles that may not be properly sterilized can spread the hepatitis C virus. Before getting a piercing or tattoo, check out the shops in your area and ask staff members about their safety practices. If employees at a shop refuse to answer your questions or don't take your questions seriously, take that as a sign that the facility isn't right for you.

Seek treatment for hepatitis B or C infection

Treatments are available for hepatitis B and hepatitis C infections. Research shows that treatment can reduce the risk of liver cancer.

Ask your doctor about liver cancer screening

For the general population, screening for liver cancer hasn't been proved to reduce the risk of dying of liver cancer, and it isn't generally recommended. People with conditions that increase the risk of liver cancer might consider screening, such as people who have:

• Hepatitis B infection

• Hepatitis C infection

• Liver cirrhosis

Discuss the pros and cons of screening with your doctor. Together you can decide whether screening is right for you based on your risk. Screening typically involves a blood test and an abdominal ultrasound exam every six months.

Diagnosis

Diagnosing liver cancer

Liver biopsy- is not at all primary test. It is only reserved whenever its not possible to diagnosis with other all modalities or testing.

Tests and procedures used to diagnose liver cancer include:

• Blood tests. Blood tests may reveal liver function abnormalities.

• Imaging tests. Your doctor may recommend imaging tests, such as an ultrasound, Triphasic liver CT and Triphasic liver MRI.

• Removing a sample of liver tissue for testing (liver Biopsy). Sometimes it's necessary to remove a piece of liver tissue for laboratory testing in order to make a definitive diagnosis of liver cancer.

During a liver biopsy, your doctor inserts a thin needle through your skin and into your liver to obtain a tissue sample. In the lab, doctors examine the tissue under a microscope to look for cancer cells. Liver biopsy carries a risk of bleeding, bruising and infection.

Determining the extent of the liver cancer

There are different methods of staging liver cancer. For example, one method uses Roman numerals I through IV, and another uses letters A through D. Your doctor uses your cancer's stage to determine your treatment options and your prognosis.

Treatment

Treatments for primary liver cancer depend on the extent (stage) of the disease as well as your age, overall health and personal preferences.

Surgery

Operations used to treat liver cancer include:

• Surgery to remove the tumor. In certain situations, your doctor may recommend an operation to remove the liver cancer and a small portion of healthy liver tissue that surrounds it if your tumor is small and your liver function is good. Whether this is an option for you also depends on the location of your cancer within the liver, how well your liver functions and your overall health.

• Liver transplant surgery. During liver transplant surgery, your diseased liver is removed and replaced with a healthy liver from a donor. Liver transplant surgery is only an option for a small percentage of people with early-stage liver cancer.

Localized treatments

Localized treatments for liver cancer are those that are administered directly to the cancer cells or the area surrounding the cancer cells. Localized treatment options for liver cancer include:

• Heating cancer cells. Radiofrequency ablation uses electric current to heat and destroy cancer cells. Using an imaging test as a guide, such as ultrasound or CT Scan, the doctor inserts one or more thin needles into small incisions in your abdomen. When the needles reach the tumor, they're heated with an electric current, destroying the cancer cells. Other procedures to heat the cancer cells might use microwaves or lasers.

• Freezing cancer cells. Cryoablation uses extreme cold to destroy cancer cells. During the procedure, your doctor places an instrument (cryoprobe) containing liquid nitrogen directly onto liver tumors. Ultrasound images are used to guide the cryoprobe and monitor the freezing of the cells. This technique is less frequently used.

• Injecting alcohol into the tumor. During alcohol injection, pure alcohol is injected directly into tumors, either through the skin or during an operation. Alcohol causes the tumor cells to die.

• TACE - Injecting chemotherapy drugs into the liver. Chemoembolization is a type of chemotherapy treatment that supplies strong anti-cancer drugs directly to the liver.

• Placing beads filled with radiation in the liver. Tiny spheres that contain radiation may be placed directly in the liver where they can deliver radiation directly to the tumor.

Radiation therapy

This treatment uses high-powered energy from sources such as X-rays and protons to destroy cancer cells and shrink tumors. Doctors carefully direct the energy to the liver, while sparing the surrounding healthy tissue.

Radiation therapy might be an option if other treatments aren't possible or if they haven't helped. For advanced liver cancer, radiation therapy might help control symptoms.

During external beam radiation therapy treatment, you lie on a table and a machine directs the energy beams at a precise point on your body.

A specialized type of radiation therapy, called stereotactic body radiotherapy, involves focusing many beams of radiation simultaneously at one point in your body.

Targeted drug therapy

Targeted drug treatments focus on specific abnormalities present within cancer cells. By blocking these abnormalities, targeted drug treatments can cause cancer cells to die. Many targeted drugs are available for treating advanced liver cancer. However, the use is very limited along with the tolerability of the drug is also an issue. Most of the drugs have issue with the efficacy as well.

Some targeted therapies only work in people whose cancer cells have certain genetic mutations. Your cancer cells may be tested in a laboratory to see if these drugs might help you.

Immunotherapy

Immunotherapy uses your immune system to fight cancer. Your body's disease-fighting immune system may not attack your cancer because the cancer cells produce proteins that blind the immune system cells. Immunotherapy works by interfering with that process.

Immunotherapy treatments are generally reserved for people with advanced liver cancer. This therapy is very expensive in Indian settings as compared to its outcomes.

Chemotherapy

Chemotherapy uses drugs to kill rapidly growing cells, including cancer cells. Chemotherapy can be administered through a vein in your arm, in pill form or both.

Chemotherapy is hardly used to treat advanced liver cancer.

Supportive (palliative) care

Palliative care is specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness. Palliative care specialists work with you, your family and your other doctors to provide an extra layer of support that complements your ongoing care. Palliative care can be used while undergoing other aggressive treatments, such as surgery, chemotherapy or radiation therapy.

When palliative care is used along with all of the other appropriate treatments, people with cancer may feel better and live longer.

Palliative care is provided by a team of doctors, nurses and other specially trained professionals. Palliative care teams aim to improve the quality of life for people with cancer and their families. This form of care is offered alongside curative or other treatments you may be receiving.

Liver abscess

A liver abscess is a pocket of infected fluid (pus) that forms in the liver. It is caused by infection from germs such as bacteria, parasites, or fungus. It must be treated right away to prevent serious problems.

Why Liver abscess treatment is done.

A liver abscess is a severe infection. It can lead to serious problems and cause death. It can harm tissue in the area where it’s found. It can also cause symptoms such as fever, pain, nausea, diarrhea, and loss of appetite. Treatment is done to cure the abscess, stop symptoms, and prevent death.

How liver abscess treatment is done.

The type of treatment you have depends on what caused the abscess. It also depends on how many abscesses you have, and how big they are. Treatment may include:

• Taking medicine. An abscess is first treated with antibiotic or antifungal medicine. You will need to take medicine for a few weeks. You may take it by mouth as a pill or liquid. Or the medicine may be put into a vein through an IV (intravenous) tube.

• Draining the abscess. This may be done in addition to taking medicine. Or it may be done if medicine doesn’t work or the infection causes other problems. There are several ways to drain a liver abscess. The healthcare provider may put a syringe needle through your skin into the abscess. He or she then uses the syringe to drain the fluid. This is called aspiration. Or the provider may put a thin wire may through your skin. The provider uses CT scan or ultrasound to help place the wire in the right spot. A thin, flexible tube (catheter) is then placed over the wire and into the abscess. The tube is left in place for 5 to 7 days to drain the fluid. In some cases, surgery may be done to cut into the liver abscess and drain it.

After treatment, you may have follow-up imaging tests of your liver. This is often done by ultrasound, CT scan, or MRI.

Risks of Liver abscess treatment.

• Bleeding

• A second infection

• Failure to cure the abscess

• Need for more treatment