Liver Disease / Hepatic Disease

Liver Disease / Hepatic Disease

What is liver disease?

Liver disease, also known as hepatic (i.e. relating to the liver) disease, is a comprehensive term that refers to any condition that causes damage to the liver and prevents the organ from functioning effectively and performing its designated roles. Normally, more than three-quarters of the liver tissue is affected before the decrease of the liver functioning occurs.

The role of the liver is to maintain a number of crucial functions in the body, if your liver is damaged, injured or diseased, then the loss of its functioning ability can result in significant and severe damage to your body.

What is the role of the liver?

Being the largest solid organ in the body, the liver is also considered to be a gland due to the fact that it secretes bile. Bile is a fluid containing water, bile acids (these are made from the cholesterol that is stored in the liver) and chemicals, amongst other substances. The gallbladder stores bile when food enters the small intestine (more specifically the duodenum), and bile is then secreted into the small intestine which helps the food to be digested.

Found in the upper right area of the abdomen, and with the rib cage for protection, the liver contains two main rounded portions (lobes) that consist of tiny lobules (i.e. small lobes). The cells of the liver have two blood supply sources that are different to each other. The liver’s hepatic artery is responsible for supplying blood that is oxygen-rich to the liver from the heart and the liver’s portal vein is responsible for supplying nutrients from the spleen and intestine to the liver. Veins will normally have the role of returning blood from the body to the heart, however, in the case of the portal vein, this allows chemicals and nutrients to be delivered to the liver from the gastrointestinal tract in order for them to be filtered and processed before entering the body’s overall circulation.

The portal vein also allows for proteins and chemicals to be delivered to the cells of the liver needed for producing the cholesterol, protein and glycogen that the body needs to function.

When hearing the word ‘cholesterol’ it is common to think that it is bad for our bodies and is unhealthy. However, this soft, waxy substance that is found in the bloodstream as well as every single cell in the body, aids in producing hormones, cell membranes, bile acids and vitamin D in order to help our bodies to digest fat. Cholesterol is important for our neurological functioning, aiding in learning and memory. Cholesterol only becomes a risk to our health when we eat too many bad kinds of cholesterol found in the form of high-fat foods.

An interesting fact is that the liver is the only organ in the body that is able to replace the cells that have been damaged, however, if too many cells have been lost then the liver is not always able to meet the many needs of the body as it does not function effectively.

The liver has been considered 'the factory' of our bodies as it performs a number of vital functions necessary for life.

The liver is responsible for the following:

  • Producing bile needed for food to be digested (fats in particular)
  • Storing any extra sugar or glucose as glycogen (a form of energy storage) and then converting this back into sugar (glucose) when the body needs this for energy.
  • Producing factors for blood clotting
  • Producing amino acids, these are building blocks needed for the production of proteins (these are molecules made up of amino acids that form the basis of our living tissues), as well as manufacturing the amino acids needed to help fight off infection. Simply put, the protein we eat in food is broken down into amino acids by the liver, which is then used by the body for a number of purposes.
  • Processing and storing the iron that is needed for the production of red blood cells
  • Manufacturing cholesterol and a number of other chemicals needed to transport fat
  • Converting waste products that are excreted in urine
  • Metabolising (i.e. changing) medications into their active form to be used by the body.

When the liver is permanently damaged or scarred, this is described as cirrhosis. This is a condition wherein the healthy cells of the liver are replaced by tissue that cannot perform any of the functions of the liver, this is known as scar tissue (scarring of the tissue is known as fibrosis). Cirrhosis is simply described as end-stage liver disease and is pronounced “si-roh-sis”.

Human Liver Anatomy

What are the causes/types of liver disease?

Infection

Viruses and parasites can infect the liver which results in the reduction of liver function as a result of the inflammation caused by the infection. The viruses causing damage to the liver can spread through semen, blood, contaminated water or food, or coming into close contact with an infected person. Hepatitis viruses, which cause inflammation of the liver, are the most common form of liver infections.

These infections include:

  • Hepatitis A This infection is a result of the hepatitis A virus. Patients usually contract this infection through the consumption of contaminated food and drinks. The items are often contaminated by an infected person’s faeces. This infection is common in places where there is poor sanitation and hygiene practice. The virus infects the liver and causes symptoms that are flu-like as well as jaundice (often evident by the yellowing of the skin and whites of the eyes).
  • Hepatitis B -  This infection is a result of the hepatitis B virus and is spread within the infected person’s blood. This infection is commonly seen worldwide, usually spreading from an infected woman to her baby in the womb (in utero transmission), through the sharing of needles, sexual contact or accidently coming into contact with infected blood. The virus is transmitted via blood, saliva, semen and other bodily fluids. The symptoms are typically the yellowing of the person’s eyes, dark urine and abdominal pain. Most cases disappear on their own whereas the more severe cases can result in liver tissue scarring and may even require a liver transplant. 
  • Hepatitis C – This infection is a result of the hepatitis C virus and is spread through contact with contaminated blood. The majority of patients do not have any symptoms, if symptoms do develop they may include nausea, fatigue, loss of appetite and jaundice.

Abnormalities of the immune system

Autoimmune diseases, conditions where the immune system mistakenly recognises the body’s healthy cells as invaders and attacks them, are disorders that can have an effect on the liver. Some examples of these diseases include the following:

  • AIH (Autoimmune hepatitis) – This is a chronic disease of which the exact cause is still unknown. This condition involves the immune system attacking the liver directly and can eventually lead to cirrhosis which can progress causing liver failure.
  • Primary sclerosing cholangitis – This condition was formerly known as PBC (Primary biliary cirrhosis) and is a disease that progressively destroys the bile ducts which become inflamed and collapse as the disease takes its course. The inflammation of the bile ducts causes scarring which will narrow the ducts resulting in damage to the liver and

Genetics

Gene mutations that are inherited from parents can result in the build-up of a number of substances in the liver, this will eventually lead to liver damage. Liver diseases that are genetic include:

  • Hemochromatosis – This is a condition that causes an overload of iron in the body. This excess amount of iron can be toxic to the organs and can even lead to various conditions such as an irregular heartbeat, cancer and severe liver damage (cirrhosis).
  • Primary hyperoxaluria with oxalosis – Hyperoxaluria is condition also referred to as Bird’s disease after the first person to describe it. The disease occurs when the levels of oxalate in the urine are too high. Oxalate is one of the body’s natural chemicals that is also found in some kinds of food. In this type of hyperoxaluria, being primary hyperoxaluria, the liver does not create enough of the enzyme needed to break down the oxalate levels. When oxalate combines with calcium, creating kidney stones, this can result in renal failure (kidney failure), which is known as oxalosis. In oxalosis, the oxalate forms crystals which start to build-up in a number of organs, causing damage and inflammation. 
  • Wilson's disease – This is a rare condition that is inherited and results in excessive amounts of copper accumulating in the brain, liver and a number of other important organs.

Growths and cancer

Some examples of growths and cancer that can lead to liver disease are:

  • Bile duct cancer
  • Liver cancer
  • Liver cell adenomas – also known as hepatic adenomas or hepatocellular adenomas, these are tumours on the liver that are benign (non-cancerous) and may result in haemorrhaging of the liver.

Other liver disease causes

Some additional and common liver disease causes may include:

  • NAFLD (Non-alcoholic fatty liver disease) – Simply put, this is the accumulation of fat in the liver. This cause of this condition is still unknown. This disease can lead to scarring of the liver and eventually cirrhosis. Risk factors tend to include obesity, type 2 diabetes and high cholesterol.

Fatty Liver

  • Prolonged alcohol abuse (chronic) – Chronic abuse of alcohol can lead to alcoholic liver disease due to the liver having to constantly process a number of toxins from the abuse of alcohol. This can result in scarring and over time, cirrhosis.

What are the stages of liver disease from initial inflammation to liver failure?

To put everything into perspective, it would help to explain the difference between liver disease and liver failure. Liver disease refers to the initial inflammation of the liver that can sometimes be repaired naturally by the liver itself or through effective medical treatment.

Liver disease that does not heal or is not treated can lead to liver failure when the liver is unable to perform its normal functions. Simply put, liver failure is the end-stage of liver disease and requires immediate treatment.  If any functioning parts of the liver cannot be saved, then often the only alternative is a liver transplant which can be a long and complicated process of organ transplant waiting lists, evaluations and hospital visits.

The damage done to the liver and the stages of liver disease remain consistent if the condition is not treated or does not heal initially. This consistency remains the same regardless of the cause or type of the liver disease.

These stages are described as follows:

Stage One - The first stages of liver disorder/disease

The first stage of liver disease involves inflammation of the individual’s bile duct or liver. Abdominal pain is often the first symptoms of this inflammation as the person’s body attempts to fight off the disease or infection. If this inflammation is left untreated, it can result in the liver being damaged, thus worsening the condition. During stage one, the symptoms and inflammation are often treatable and can prevent liver disease from progressing to stage two.

Stage Two: Inflammation leads to scarring (fibrosis) of the liver

In a number of people with liver disease, the condition only becomes evident at stage two or during stage three as the initial symptoms often go unnoticed. Stage two consists of the scarring or inflammation (damage) starting to block the natural flow of blood in the liver. This results in the liver not being able to function correctly, however, through treatment, the liver may still be capable of healing, thus preventing any further damage from being done and halting the progression of the liver disease.

Stage Three: Cirrhosis

Cirrhosis, pronounced “si-roh-sis”, is a result of liver disease progression, usually due to lack of treatment, wherein the scar tissue of the liver replaces healthy tissue. This process occurs when the healthy liver cells have been damaged over time (normally a number of years) from a progressive disease or infection. This results in the permanent scarring of the liver making it hard and lumpy. Eventually the liver will not be able to function as the new scar tissue will make is difficult for blood to pass through the portal vein and into the liver. When this blood is blocked from entering the portal vein, it can flow into the spleen which can result in further issues.

At this stage of liver disease, damage is irreversible and a doctor will tend to focus on treatment that will protect any existing functional liver tissue and manage the symptoms so as to slow down the progression of the condition and possibly prevent the disease from advancing to complete liver failure. Cirrhosis does not have a cure and in severe cases, the patient will require a new liver entirely.

Cirrhosis

Cirrhosis stages

Cirrhosis has two key phases, these are:

  • Compensated – This phase does not cause any symptoms as the healthy liver cells are still able to meet the needs of the body and compensate for the scarred tissue and damaged cells. Treatment is required at this stage in order to stop the condition from progressing to liver failure as the body will be unable to rid itself of toxins effectively.
  • Decompensated – This kind of cirrhosis does cause a number of symptom and may lead to issues including:
    • Bleeding of varices – Varices are blood vessels that are dilated in the stomach or oesophagus and are a result of portal hypertension from the portal vein to the liver being blocked. The increase in pressure of the liver’s portal vein results in the blood moving to other, smaller blood vessels, which are unable to hold the increased volume of blood and can rupture putting the patient at risk of a blood infection. Variceal bleeding is considered a medical emergency and requires immediate attention and treatment.
    • Hepatic encephalopathy – Pronounced “en-sef-uh-lop-uh-thee”, this is the loss of functioning in the brain due to the liver being unable to remove the toxins from the patient’s blood. The symptoms are often confusion and forgetfulness.
    • Ascites – Pronounced “ah-SIGH-tees”, this condition refers to the build-up of fluids, specifically the fluid containing protein known as ascetic, in the abdominal cavity (peritoneum) due to an increase in blood pressure of the blood vessels in the liver forcing fluid to accumulate in the belly.
    • Jaundice – This is a condition that refers to the yellowing of the eyes and skin as a result of the elevated levels of yellow pigment existing in the body known as bilirubin. It is the responsibility of the liver to produce and process this bile pigment, if the liver and bile ducts are not functioning correctly due to scarring and damage done, this pigment accumulates.
    • Gallstones – The gallbladder is found right under the liver. Gallstones are hard digestive fluid deposits and often result in the gallbladder needing to be removed if the patient suffers from the symptoms. Cirrhosis can lead to the bilirubin chemical accumulating (this is needed to break down the red blood cells) which is a contributing factor to the formation of gallstones.

Stage Four: Liver failure / advanced liver disease / hepatic failure

During the disease’s final stage, the failure of the liver will signal the termination of the functioning of the liver. This will require immediate medical attention in order to prevent fatality. The symptoms associated with liver failure may include:

  • Diarrhoea
  • Vomiting
  • Fatigue
  • Stage three symptoms
    • Jaundice
    • Weakness
    • Itching
    • Loss of appetite
    • Bruising easily due to the decrease of the blood clotting components being produced by the damaged liver

It can take a number of years for cirrhosis to progress to liver failure, however the damage that has been done at this stage is irreversible and fatal.

The goal is for liver disease to be diagnosed and treated as early as possible in order for the prognosis to be improved and liver failure to be prevented.

Acute (sudden) liver failure

This type of rare liver failure rapidly progresses and liver failure occurs within a number of days or weeks. Acute liver failure tends to affect those who do not have any existing liver disease. The condition often occurs suddenly without symptoms or warning. The causes typically include drug overdose from ingesting a high amount of Tylenol (acetaminophen/paracetamol). 

Chronic (gradual) liver failure

The more gradual type of liver failure is known as chronic liver failure as it can occur over a number of months or years (usually over a period of six months or more) before any symptoms are shown. This condition is normally the end result of severe liver damage/disease known as cirrhosis.

What are the symptoms of liver disease?

The symptoms of liver disease are often dependent on the type of condition causing the disease. Some patients in stage one may not progress to the next stage due to their liver’s ability to naturally heal itself or if an accurate, early diagnosis of liver inflammation or liver disease is made and appropriate treatment is administered. Other patients may only notice the symptoms when it is too late to ensure a positive prognosis during stage three or four.

The following are considered the early warning symptoms and signs of liver disease and can include:

  • Jaundice (Yellowing of the eyes and skin)
  • Dark-coloured urine
  • Itchy skin
  • Abdominal swelling and pain
  • Swelling of the ankles and legs from fluid build-up, this is known as oedema and can also result in breathing issues
  • Bloody, pale or very dark coloured stool
  • Chronic fatigue
  • Nausea
  • Vomiting
  • Loss of appetite
  • Personality changes due to altered chemicals or a build-up of toxins in the brain
  • Bruising easily due to loss of blood clotting factors made by the liver

The above symptoms and signs are often confused with a number of other disorders and problems, thus making a liver failure diagnosis difficult. The patient may be dizzy, drowsy or disorientated at this stage and may go into a coma.  

If liver disease is related to alcohol abuse, then the patient may develop jaundice or battle with their mental abilities and concentration due to the build-up of toxins in the brain. The spleen may also become enlarged, the stomach may bleed or the patient may suffer from renal (kidney) failure. It is also possible for the individual to develop liver cancer.

When to see a doctor

Should you notice any of the above symptoms persisting and they become bothersome, then you should consult with your doctor, particularly if you suffer from severe abdominal pain.  

What are the risk factors of liver disease?

There are a number of factors that can increase an individual’s risk of developing liver disease. These can include:

  • Alcohol abuse
  • Sharing needles
  • Having unprotected sex
  • Body piercings or tattoos (as with sharing needles and having unprotected sex, this increases the risk of spreading hepatitis infections)
  • Diabetes
  • Being exposed to toxins or chemicals
  • Obesity
  • High levels of fatty acids (triglycerides) in the blood

How is liver disease diagnosed?

In order for the doctor to find the exact cause, as well as the extent of the damage done to the liver, both of which are vital factors as these, will guide the treatment plan, he or she is likely to begin with running through a complete health history of the patient as well as a physical examination.

Once this has been completed, the doctor is likely to recommend the following:

  • Blood tests – Blood tests conducted when the liver is concerned are known as liver function tests and are able to diagnose the presence of liver disease. A number of other blood tests are also able to detect any other liver issues as well as genetic disorders and conditions.
  • Imaging/screening tests – The doctor may conduct an MRI (magnetic resonance imaging) which is a scan that uses radio waves and magnetic fields in order for detailed visuals to be made of the liver. A CT (computed tomography) scan may also be conducted which uses specialised X-ray devices to create cross-sectional visuals of the liver.
  • Biopsies (tissue analysis) – A biopsy involves the removal of a sample of tissue taken from the liver in order for it to be examined. This kind of biopsy is done while the patient under local anaesthetic while the doctor inserts a long and thin needle into the skin and into the liver to obtain a sample which will be sent to the lab for analysis.

How is liver disease treated?

The diverse types of liver diseases will each have their own treatment regimen that is specific to the disorder. For example, in the treatment of hepatitis A, the plan will need to include supportive care in order for hydration to be maintained while the patient’s body fights off and resolves the infection. Those who suffer from gallstones may need to have surgery done to remove their gallbladder. Other conditions may require more long-term treatment in order for the infections to be controlled and the complications reduced.

Patients who have cirrhosis or the end stages of liver disease may need medications to aid in controlling protein absorption in their diet. Proteins create waste products through their process of absorption, when the liver is cirrhosed, its ability to metabolise and process waste products is hindered, this results in ammonia levels in the blood being elevated which causes confusion, lethargy and the potential for the patient to slip into a coma, this is known as encephalopathy. Water pills, known as diuretics and a low-sodium (salt) diet may be needed in order to reduce a person’s water retention resulting from the excess fluid being trapped in the body’s tissues.

For patients who have a large amount of fluid that has accumulated in their abdominal cavity (i.e. ascites fluid), this fluid can sometimes be removed through the use of paracentesis. This method uses a hollow needle or a catheter that is inserted into the abdominal cavity (peritoneum) to remove the excess fluid. This is done while the patient is under local anaesthetic. This fluid is also able to become infected, therefore a paracentesis can also be used to detect any infection. 

**Just to recap on ascites:

  • Ascites – Pronounced “ah-SIGH-tees”, this condition refers to the build-up of fluids, specifically the fluid containing protein known as ascetic, in the abdominal cavity (peritoneum) due to an increase in blood pressure of the blood vessels in the liver forcing fluid to accumulate in the belly.

In cases of portal hypertension (high blood pressure), operations are sometimes performed in order to minimise the patient’s risk of internal bleeding. These methods often include a blood transfusion combined with medication to reduce the blood pressure.

The final treatment option is for those who suffer from liver failure to receive a liver transplant. This is a surgical procedure wherein the infected liver is removed and replaced with a healthy liver from a donor.

Can liver disease be prevented?

The majority of cases of liver disease can be prevented. Roughly 5% of liver disease deaths are as a result of genetic and autoimmune disorders, with more than 90% being due to the three main risk factors.

These risk factors are:

  • Viral hepatitis – This is a highly contagious condition and is a result of a hepatitis A infection.
  • Obesity – This is the leading cause of fatty liver disease which is the most common type of liver disease. Obesity can lead to the accumulation of fat in the liver which causes strain and damage.
  • Alcohol – A number of cases of fatty liver disease will progress to alcoholic hepatitis amongst heavy drinkers, and eventually to alcoholic cirrhosis. Alcohol contains a number of toxins that are harmful to several organs in the body. The liver has to process these toxins which can damage the liver cells and result in inflammation. The prognosis of this condition, as with most liver diseases, will depend on the severity of the damage done.

The following are factors that are able to significantly reduce liver disease developing:

  • Not drinking alcohol in excessive amounts – For normal adults, an acceptable amount of alcohol use is one unit a day for women and elderly men (over 65 years old), and healthy men younger than 65 can have as many as two units a day. For drinking to be classified as high-risk or heavy, this means that a person consumes more than a total of three drinks a day, for women and elderly men, this means to more than seven drinks in total over a period of a week and for younger men this will be more than 14 drinks per week. If you think you may suffer from alcoholism, then speak to your doctor about a rehabilitation program. 

Alcohol abuse to liver

  • Avoiding dangerous behaviour – Using drugs intravenously or sharing needles is considered risky behaviour and will significantly increase one’s chances of contracting an infection that may lead to liver disease. This also includes having unprotected sex.
  • Using medications with care – Taking drugs, whether prescription or over-the-counter should be done with care and within the recommended dosage. Medications should not be mixed with alcohol.
  • Getting vaccinated – There are vaccines available for hepatitis (A and B). These will help control the risk of infections that cause liver disease for those who are most likely to contract these infections.
  • Maintaining a healthy diet and weight – Non-alcoholic fatty liver disease can often stem from obesity. This disease can be prevented through controlling one’s weight through a proper exercise regime and nutritional diet.
  • Avoiding contact with someone else’s blood and their bodily fluids - The hepatitis viruses are easily spread and often in areas where sanitation and hygiene is poor.

The liver disease diet

A specialised diet has been advised for some patients with liver disease as this can aid in assisting the liver to function and prevent it from further strain. It is best to always speak to a medical professional regarding any dietary changes before making them.

The liver disease diet recommendations are as follows:

  • The amount of protein eaten will need to be limited as this consumption aids in the build-up of toxins. Proteins typically help to repair tissue in the body, they are also able to prevent the build-up of fat. However, in those who have liver disease, the liver is not able to process the protein properly which results in waste products building up and affecting the brain.
    • Protein intake should be aimed at roughly 1g (0.035oz) per 1kg (2.2lb) of a person’s total body weight. This is not including the protein found in vegetables and starches. If liver disease is more severe, then protein intake may need to be further reduced. It is vital not to limit proteins too much as this can reduce the availability of amino acids needed by the body for a number of functions as amino acids are found in a number of tissues in the body and aid in muscle growth, strength and recovery.
  • Carbohydrate intake should be in proportion to the amount of protein eaten, if not more. Carbohydrates will aid in the digestion of proteins.
  • Sodium (salt) intake should be limited as salt can worsen the build-up of fluid as well as liver inflammation, this is specifically vital for those suffering from water retention.
  • Medications that have been prescribed must be taken along with vitamin B as this aids in the production of red blood cells and cognitive functioning.

What is the outlook for liver disease?

The prognosis for liver disease will be dependent on the cause of the disease and the extent of the damage and scarring done to the liver. Acute liver failure is often fatal as it occurs instantly, whereas chronic liver failure or severe cirrhosis is sometimes able to be treated long enough for the patient to undergo a liver transplant.

As stated, the liver is the only organ in the body that is capable of healing itself. Therefore, should the extent of the damage be manageable, the symptoms and damage can be treated which may result in a positive prognosis for the patient should he or she stick to their treatment.

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