Prevention of Liver Disease is Easier and More Effective Than its Treatment

Functions of liver

Liver is a solid organ, located in the right upper part of the abdomen just below the rib cage. It is a complex organ both structurally and functionally. Liver is a pivotal organ for metabolic functions of our body. The function of liver can be categorized into two major groups: excretory function and synthetic function. Most foreign substances and waste product made in body are metabolized within the liver before being excreted via bile or kidney. Excretion of bilirubin from liver is important as defect in bilirubin excretion leads to jaundice. Liver is the site of synthesis of all major proteins in body. These proteins are building blocks for all important functions in body. Bile is synthesized in liver and which helps in digestion of fat in body. Liver also plays an important role in fat and carbohydrate metabolism.

Symptoms of liver disease

Early or mild form of liver diseases may give rise to non-specific symptoms like fatigue or weakness. Significant liver injury can cause jaundice, which means yellow discoloration of sclera of eye ball and is associated with dark yellow urine. Liver cirrhosis results from persistent damage to liver due to any cause (alcohol, hepatitis B & C). Common manifestations of liver cirrhosis are ascites (accumulation of fluid in the abdomen), loss of consciousness (coma) and bleeding from gastrointestinal tract in form of vomiting of blood.

Contrary to popular belief, liver diseases are not associated with problems of digestion. Many people attribute any upper abdominal discomfort to liver related problem, which is fallacious.

Causes of liver diseases and their prevention

Liver diseases are of two types: (a) Short lasting and self limiting which resolves completely without causing any permanent damage or functional impairment and (b) Smoldering slow diseases which cause a permanent damage to liver which is manifest as “liver cirrhosis”.

The major causes of liver diseases are viral hepatitis (A, B C, D & E), alcohol intake, Fatty liver disease, inherited and metabolic diseases and drugs. Liver can in addition be involved in any generalized disease process like infection (eg: Typhoid, malaria, Dengue) or various malignancies.

Among the hepatitis viruses, Hepatitis A and E causes jaundice, which is self-limiting. Hepatitis A and E are spread by contaminated food and water. Thus if we have safe drinking water supply and pay attention to hygiene these diseases can be prevented. There is vaccine available for hepatitis A and can be used safely at any age. There is no vaccine available for hepatitis E at present but safe drinking water could be the most effective measure to control hepatitis.

Hepatitis B and C cause chronic infection of liver, which can be cause cirrhosis of liver. Hepatitis C is the leading cause of cirrhosis worldwide. In our country hepatitis B is a major challenge. Both hepatitis B and C are spread by blood transfusion, needle sharing, sexual contact and from mother to child. Thus to a large extent these things are preventable by simple measures like improving our testing in blood bank, increasing awareness for voluntary blood donation, educating people against reuse or needle sharing and safe sex practices. In addition we have a very effective vaccine against hepatitis B. There is no vaccine against hepatitis C is as yet.  Hepatitis C has a very high prevalence in parts of India where intravenous drug abuse is rampant. Public awareness is the most important tool in preventing the spread of this disease.

Alcohol is very important cause of liver disease. Alcohol consumption has increased across all social, age and gender groups. Awareness about alcohol consumption is of paramount importance in preventing liver disease. Lack of self help groups and social stigma in approaching them prevents people in need of help from coming out in open. We need a massive public awareness campaign to educate people about safe and responsible alcohol consumption.

Fatty liver is a condition usually picked up incidentally on routine ultrasound and investigation for deranged liver function tests. It is a slowly progressive disease but in a significant number of subjects can lead to liver cirrhosis over years to decades. The most common causes for fatty liver are obesity and diabetes. The epidemic of fatty liver has grown with rise in these lifestyle diseases. In western world it is already the second most common cause of liver cirrhosis after hepatitis C. Prevention remains the cornerstone of treatment of treatment of fatty liver. Adopting a healthy lifestyle with dietary precautions are more effective than medication in early course of this disease.

Measures for keeping liver healthy

The concept of prevention of liver diseases has still not caught up. As highlighted in previous section most liver diseases can be avoided by simple interventions. Following these simple measures will go a long way in decreasing the burden of liver cirrhosis.

1. Keeping alcohol intake in moderation
2. Hepatitis B vaccination
3. Avoiding reuse of needles, sharing needles.
4. Promoting voluntary blood donation and improving surveillance of blood products
5. Control of obesity
6. Safe drinking water
7. Avoiding unprescribed medications

Common Liver Diseases and Their Symptoms

Symptoms of liver disease depend on the disorder, but can include:

• Jaundice (the skin or whites of the eye turn yellow)
• Dark urine
• Nausea
• Vomiting
• Diarrhoea
• Appetite loss
• Weight loss
• General malaise
• Fever
• Bloated abdomen, swollen ankles
• Abdominal pain in the upper right side
• Anaemia, vomiting blood or passing black stools (denoting altered blood)
• Changes in mental state – altered sleep pattern (awake at night), confusion, and drowsiness.

Common Liver Diseases

• Fatty liver – this is the most common of the alcohol-induced liver disorders. Fat accumulates inside the liver cells, causing cell enlargement (steatosis) and sometimes cell damage (steatohepatitis), and can lead to cirrhosis. Similar changes are also seen in people who do not drink excessive amounts of alcohol but are overweight, obese or have diabetes. The liver becomes enlarged, causing discomfort on the upper right side of the abdomen.

• Cirrhosis – this has many causes but is commonly due to hepatitis infection or excessive alcohol intake. The cells of the liver are progressively replaced by scar tissue, which seriously impairs liver functioning.

• Hepatitis – a general term meaning inflammation of the liver. It is also used to refer to infections of the liver by specific viruses (hepatitis A to E).

• Haemochromatosis – this inherited disease makes the body absorb and store higher than normal amounts of iron. This damages many organs including the liver, pancreas and heart.

• Autoimmune liver disorders – an abnormal increase in immune cells damages the liver cells. These rare conditions include autoimmune hepatitis and primary biliary cirrhosis (mostly women affected) and primary sclerosing cholangitis (more common in men).

• Cancer – primary cancers can arise in the liver, most often from chronic hepatitis with cirrhosis. Stray cancer cells from a tumour elsewhere in the body may cause a secondary tumour in the liver.

• Galactosaemia – the body’s reaction to particular milk sugars damages the liver and other organs. This is a rare inherited disorder.

• Alpha 1-antitrypsin deficiency – another rare inherited disorder that can cause cirrhosis of the liver.

• Wilson’s disease – the liver can’t excrete copper. Various organs of the body, including the liver and brain, are affected by the excessively high copper levels.

       

         Complications of liver disease

        Without treatment, a person with liver disease is susceptible to a wide range of complications,               including:

• Hepatic Encephalopathy – scar tissue prevents the proper flow of blood through the liver, so that toxins remain. These circulating toxins, particularly ammonia, affect brain functioning and can lead to a coma.

• Ascites – liver disease can cause a build-up of body sodium (‘salt’), which leads to fluid retention in the abdominal cavity (ascites) and in the legs, feet and back (oedema).

• Liver failure – the liver cells are destroyed faster than the liver can replace them, until the organ can no longer function adequately.

• Cancer – cirrhosis or some forms of hepatitis can make the liver more susceptible to primary cancer (cancer that originates in the liver).

• Gastrointestinal bleeding – the veins that normally travel through the liver may be blocked because of cirrhosis. These veins then bypass the liver and may travel along the stomach or oesophagus lining, where they may rupture and bleed.

Precautions to Protect Liver

• Avoiding alcohol and any drugs that might damage the liver
• A well-balanced, nutritious diet – some people require a modified diet (for example, low salt)
• Medications, such as antiviral drugs to treat viral infections
• Specific medications to manage Wilson’s disease 

Role and Functions of a Liver

The liver is situated on the upper right side of the abdomen, just below the diaphragm. It is the largest internal organ of the human body and weighs around 1.5kg in the average adult. Blood from the digestive system must first filter through the liver before it travels anywhere else in the body. 

The principal roles of the liver include removing toxins from the body, processing food nutrients and helping to regulate body metabolism. A range of conditions can prevent the liver from performing its vital functions. Culprits include fat accumulation, alcohol misuse, viral infection, iron or copper accumulation, toxic damage and cancer.

 

Functions of the liver

Some of the many functions of the liver include:

• Drugs, including alcohol, are filtered through the liver and neutralised or converted into other forms by special enzymes.
• Bile, produced by the liver, is stored in the gall bladder and used to help break down dietary fats.
• Fat soluble vitamins A, D, E and K need bile in order to be absorbed by the body.
• The liver converts carbohydrates into glucose for instantly available energy and converts glucose into its storable form (glycogen). When blood sugar levels drop, glycogen is converted back into glucose.
• Amino acids from protein are sent to the liver for the production of body proteins such as hormones.
• The liver changes ammonia (a toxic by-product of protein metabolism) into urea, which is then excreted in urine. 

Advances in Gastrointestinal Endoscopy

Endoscopy is a procedure where a flexible instrument is passed through mouth or anus (known as upper endoscopy and colonoscopy respectively), to examine the internal lining of the gastrointestinal tract. In Upper GI endoscopy the food pipe (esophagus), stomach and initial part of small intestine (duodenum) are examined while in colonoscopy the entire large intestine and also a part of most distal small intestine (Ileum) is examined. This procedure is done under conscious sedation and is usually an office procedure.

As endoscopy has evolved its role and emphasis has changed from being a diagnostic tool to a therapeutic mean. One of the earliest applications of therapeutic endoscopy was in controlling bleeding from various sources in the GI tract. Peptic ulcer is the commonest cause of gastrointestinal bleeding and surgery was the standard therapy for this condition till about two decades ago. But the success of endoscopic treatment has marginalized the role of surgery to one of rescue therapy. An endoscopist has various means in his armamentarium to control bleeding , starting from injection to application of clips and to direct coagulation of bleeding vessel there are many means to effectively and quickly stop bleeding. The biggest advantage of endoscopy is that it requires much less time and no general anesthesia in critically sick patients. Endoscopic banding and glue injection has proven to be very effective in control of bleeding in patients with cirrhosis of liver. These patients are very high risk for any kind of surgical procedures and the surgeons would not like to operate upon these patients unless pushed to the wall.

Endoscopic dilatation is a procedure where a narrowing in the GI tract can be opened up by the help of certain accessories. The commonest cause of such narrowing is ingestion of corrosive agents. In addition to simple dilatation stents, which are like spring coils made of metal, can be placed in the GI tract. This restores the patency of the GI tract and avoids surgery in such patients. These patients are usually moribund patients with terminal malignancy and stenting provides adequate palliation for them. Patients who are unable to take food due to cancers of esophagus and stomach can start food intake very rapidly after this procedure.

Foreign bodies accidentally ingested by children can be easily retrieved by endoscopy. Polyps are commonly found benign tumors of GI tract which can cause bleeding or even be a precursor of malignancy. These can be removed by cutting through cautery and thus obviating surgery.

Heart burn is one of the most commonly encountered GI symptom which requires a long term medical therapy in substantial percentage of patients. Endoscopic suturing of the junction of food pipe and stomach is now done endoscopically to prevent acid reflux in patients with heartburn. This is undertaken only in patients not responding to drugs and when the only option is surgery.

Endoscopic retrograde cholangio-pancreatography (ERCP) is a procedure where one can enter bile duct and pancreatic duct at the site where these ducts open in the gastrointestinal lumen. This procedure, which was started, nearly three decades back has made giant strides. The most common applications are to remove stone in the bile duct and pancreatic duct. Apart from this any obstruction in these ducts can be by-passed by placing stents. All these procedures hitherto were done by surgical procedures, which are fairly complicated. By doing these procedures endoscopically the hospital stay and costs has been shortened to a great extent.

Efforts are on to do surgeries of internal organs like gall bladder and uterus through a small hole made into the stomach. This would even make the button-holes of laparoscopic surgery a thing of past. 

Apart from the strides in therapeutic endoscopy great strides have been made in imaging characteristics of endoscopes. Narrow band imaging and optical coherence tomography are now available and in near future will play a vital role in early diagnosis of malignancy..

Endoscopic ultrasound (EUS) is fusion of endoscope with ultrasound probe. This allows much better imaging of walls on internal organ and their adjacent organs. This adds tremendously to the diagnostic capabilities and in addition is very useful as therapeutic tool.

Thus endoscopy has come a long way in last two or three decades. In the near future the advances are likely to make it more useful and the role of endoscopist is likely to expand in providing non-surgical treatment of various condition of gastrointestinal tract.