Cirrhosis

• Excessive alcohol intake
• Hepatitis B
• Hepatitis C
• Non alcoholic fatty liver disease (Which occurs mostly in overweight individuals).
• Wilson disease
• Autoimmune hepatitis
• Hemochromatosis.

Symptoms of cirrhosis are

• Individuals with cirrhosis may be totally asymptomatic, and diagnosed on imaging on blood tests
• Weakness and fatigue
• Fluid in abdomen (ascites) and swelling of feet (pedal edema)
• Vomiting of blood
• Black stool
• Altered behavior or unconsciousness
• Decreased urine output

Diagnosis

• LFT
• Ultrasonography
• Fibroscan
• Liver Biopsy
• CT scan and MRI

• Diet rich in calories and protein for the nutritional build up
• Diuretics and salt restriction for fluid overload
• Beta blockers, Endoscopy and banding for variceal bleed
• Laxatives and L-ornithine L-Aspartate in patients with hepatic encephalopathy
• Liver transplant may be only options in patients with advanced liver disease

Reversal of disease with the treatment of underlying etiology

• Stopping alcohol
• Antiviral for hepatitis B and C
• Steroids for autoimmune Hepatitis
• Copper chelation for wilson disease
• Iron chelation for Hemochromatosis

Chronic Hepatitis B

Hepatitis B is a virus affecting the liver and can lead to acute and chronic hepatitis
Hepatitis B infection can be treated effectively with the available new antiviral medications
Untreated Hepatitis B can lead to liver cancer/cirrhosis and liver failure
Family members of the patients should be screened for Hepatitis B infection
Transmission routes and risks

• Vertically, between a mother with chronic infection and her baby
• Close person-to-person contact, usually in childhood (through open cuts or sores)
• Sexually from male to female or vice versa
• Parenteral route, transfusion of contaminated blood products
• Sharing of needle amongst drug abusers

Risk factors

• Household contacts of people who are 
HBsAg positive
• Intravenous drug abuse
• Contaminated blood products transmission
• Contaminated surgical equipment usage
• Tattoos
• Haemodialysis.

Hepatitis B virus can lead to both acute and chronic hepatitis

Acute hepatitis is sudden onset severe inflammation of the liver

• Usual symptoms are fever, bodyache, nausea and vomiting followed by jaundice
• Liver function test usually reveals increased bilirubin, markedly elevated SGOT/SGPT.
• HBsAg and IgM anti HBc are positive
• Acute hepatitis is mostly self limiting, and body clears the virus in more than 90% of cases, however 5 % of patients may develop chronic hepatitis
• 1 % of patients may develop features of liver failure and may requires ICU admission and liver transplantation

Chronic hepatitis B is characterized by low grade inflammation of the liver, which manifest as tiredness, and slightly elevated liver enzymes

• Four stages of Chronic hepatitis B are immune tolerance phase, immune clearance, immune control and state of immune escape
• 30 % of patients with chronic hepatitis B are at risk for cirrhosis and liver cancer
• Treatment strategy is to identify the patients who are at high risk for progressive liver disease and treating these patients with potent antiviral agents

Chronic Hepatitis C

• Transfusion of contaminated blood prodcuts
• Sharing of needle by untrained health care workers
• Sharing of needle amongst drug abusers

• Patient may be totally asymptomatic, diagnosed on screening blood tests
• Patient with chronic hepatitis may complain of fatigue
• Patients with advanced liver disease may complain of ascites (fluid in abdomen), feet swelling, vomitinig of blood, change in behavior

• LFT
• Anti HCV antibody
• HCV RNA, quantitative and qualitative

• Genotype 1 usually requires treatment for 48 weeks with PEG IFN and Ribavarin, Efficacy of treatment is around 50%
• Genotype 2 and 3 are easy to treat, treatment response is 70-90%, and the duration of treatment is 24 weeks
• Response rate in previously non responders has improved with addition of Telaprevir and Boceprevir to the Peg Interferon and Ribavarin
• Recently trail for Sofosbuvir and Ribavarin had shown that injection free treatment without side effect will be available in near future

Non alcoholic fatty liver disease (NAFLD)

• Obesity
• Diabetes
• Dyslipidemia
• Starvation

• Fatty liver
  • Fatty liver is the deposition of fat in liver, without inflammation and is the most benign disease of the spectrum with low risk of progression to severe disease
• NASH (fatty liver with inflammation)
  • NASH is fat deposition with liver inflammation
  • These patients are at high risk for developing progressive liver disease
• Cirrhosis
  • Cirrhosis is the end stage manifestation of NAFLD

• LFT
• USG abdomen showing enlarged liver and hyperechoic liver
• FBS/serum insulin
• Thyroid profile
• Lipid profile
• Liver biopsy in patients with persistent liver enzyme elevation

• Gradual weight reduction
• Life style modification
• Restricted calorie intake
• Ursodeoxycolic acid and Vit E had shown the benefit in clinical trials

Alcoholic liver disease

• Fatty liver
• Steatohepatitis
• Cirrhosis

• Heaviness in upper abdomen
• Jaundice
• Abdomen distension
• Pedal edema
• GI bleed
• Altered behavior

• Stopping alcohol
• Food rich in calories and proteins
• Multivitamins
• UDCA, silymarin, steroids and pentoxifylline have shown benefit in appropriately selected patient population

Ascites

Ascites is collection of fluid in abdominal cavity

Common causes of ascites are

• Liver failure
• Tuberculosis
• Peritoneal malignancy
• Heart failure
• Nephrotic syndrome
• Systemic lupus erythmatosis

Diagnosis

• Confirmed by ultrasonography.

Underlying etiology is diagnosed by various tests such as

• CECT abdomen
• Peritoneal biopsy
• Laparoscopy
• Ascites fluid evaluation
  • ADA
  • TLC/DLC
  • CytologyProtein/albumin
  • AFB and TB culture

Management
Management depends upon the underlying cause.

• Ascites in a patient with chronic liver disease is an indicator of advanced diseases, these patients are treated with diuretics and salt restriction, and many of these patients are candidate for liver transplantation.
• Infection of ascites in liver disease patients is defined as Spontaneous Bacterial Peritonitis (SBP), and is trated by IV antibiotics, albumin followed by oral antibiotics. Patients with SBP are the candidates for liver transplantation.
• Tubercular ascites is treated by ATT
• Malignant ascites requires chemotherapy

Liver tumors

Benign tumors of the liver are

• Hemangioma
• Fibrous nodular Hyperplasia
• Hepatic adenoma
• Biliary cystadenoma
• Infantile hemangioendothelioma

Malignant primary tumor of liver are

• Hepatocellular carcinoma (HCC)
• Cholangiocarcinoma
• Biliary cystadenocarcinoma
• Fibrolamellar carcinoma

Hepatocellular carcinoma (HCC) is the most common primary malignant tumor of the liver

Risk factors are

• Cirrhosis
• Hepatitis B
• Hepatitis C
• Hemochromatosis
• Membranous obstruction of IVC
• Wilson disease

Hepatocellular carcinoma are diagnosed by raised Alfa-fetoprotein in liver, and CT or MRI findings of arterial enhancing lesion with venous washout in the liver

Treatment of HCC depends upon stage of disease and includes

• Radiofrequency ablation
• Percutaneous acetic acid injection
• Transarterial chemoembolization
• Transarterial Radioembolization
• Liver transplantation
• Oral sorafinib