Cirrhosis of the liver
a collective term describing irreversible diffuse changes in the liver, characterized by death of liver cells, proliferation of connective tissue and the formation of abnormal blood vessels. Liver cirrhosis is the final stage of the course of many diseases and pathologies of the liver and other nearby digestive organs (gall bladder, biliary tract, pancreas).
Classification of liver cirrhosis depending on the cause
- Viral cirrhosis
- Alcoholic cirrhosis
- Metabolic cirrhosis
- Biliary cirrhosis (primary and secondary)
- Cirrhosis in congenital defects and diseases of the biliary organs
- Cirrhosis in disorders of the venous outflow
- Drug cirrhosis
- Cirrhosis of the immune origin
- Cryptogenic cirrhosis of the liver
- Other cirrhosis of the liver.
Classification of cirrhosis according to the nature of the changes in the liver (ICD-10)
- CKD (micronodular) cirrhosis of liver (alcoholic)
- SKD (macronodular) liver cirrhosis (viral)
- Mixed (micromanometry).
The main link in the development of liver cirrhosis is the destruction of liver cells (hepatocytes) any external or internal damaging factor. During the destruction (necrosis) of hepatocytes is a selection of various biological substances that trigger the local inflammatory process.
In turn, the inflammatory response stimulates excessive activity of the regenerative processes that manifests with the formation of walls (septa) of connective tissue, forming false hepatic lobules (the structural and functional unit of the liver) and the side branches of the blood flow that connects the Central hepatic vein with the portal venous network (the vessels of the mucous membrane of the stomach, the anterior abdominal wall, rectum).
For newly formed vessels blood from a Central vein goes directly to the hepatic vein, bypassing the main tissue of the liver, which is why there is oxygen starvation of the body and the death of its cells, which is launching a new inflammatory process and the formation of regeneration sites (fibrotic areas) in the liver. These nodes grow and compress the blood vessels of the liver, causing them the pressure increases, impeding the flow of blood occurs portal hypertension.
Depending on the type of cirrhosis in its development involved the relevant damaging factors.
Viral cirrhosis develops due to lesions of interest by viruses hepatitis b, C, D, G.
Alcoholic cirrhosis occurs due to toxic effects on the liver of ethanol and its metabolite acetaldehyde.
Metabolic causes of cirrhosis are congenital, or acquired disorders of metabolism
- hereditary hemochromatosis
- cystic fibrosis
- illness Vestfalya – Wilson-Konovalov
- hereditary fructose intolerance
- hereditary tyrosinemia
- alpha betalipoprotein
- hereditary hemorrhagic teleangiectasia
Cirrhosis in congenital defects of the biliary organs may be the result of children’s cholangiopathy disease (Byler’s syndrome Zellweger, Aegina syndrome, Alagille syndrome).
Cirrhosis in disorders of the venous outflow
developing under such conditions as
- vein-occlusive disease
- severe right ventricular failure of the heart
- disease or Budd-Chiari.
Medicinal cirrhosis is a consequence of prolonged treatment with hepatotoxic medications (tetracycline antibiotics, estrogens, antipsychotics, antifungal, antitubercular, cytotoxic agents, non-steroidal anti-inflammatory drugs).
Cirrhosis of the immune origin are the result of liver cells by his own immune system with various violations of its work, as well as after transplantation (transplant) of the body caused by the reaction of the transplant against the host.
Separately there are primary and secondary biliary cirrhosis resulting from inflammation of small bile ducts, leading to their destruction. The causes of primary biliary cirrhosis is not fully established, and secondary biliary cirrhosis develops on the background of concomitant diseases of biliary excretion (biliary disease, tumors, cysts, primary sclerosing cholangitis, etc.).
Also the causes of cirrhosis can serve as infectious diseases, sarcoidosis, obesity, malnutrition, hypervitaminosis of vitamin A, etc.
Cirrhosis of the liver of unknown etiology referred to as cryptogenic cirrhosis, the existence of which is explained by the insufficient diagnosis of the disease. It should be noted that every year, thanks to the improvement of laboratory and instrumental diagnostic methods, the number of cases of cryptogenic cirrhosis is reduced.
Cirrhosis of the liver occurs in three stages (scale Child-Drink)
- Stage A (latent, compensated), is characterized by the absence or weak expression of clinical manifestations of disease
- Stage In (subcompencirovanna), characterized by further progression of portal hypertension and impaired liver function
- Stage C (decompensated), characterized by the increase of the phenomenon of portal hypertension and hepatic insufficiency.
Depending on the stage of the disease may exhibit the following symptoms of liver cirrhosis
- the weight loss for no apparent reason
- a feeling of heaviness in the right hypochondrium
- pain in the right upper quadrant
- loss of appetite
- anorexia (refusal to eat)
- flatulence (flatulence)
- jaundice (ikterichnost skin and sclera)
- dark urine
- discoloration of feces
- swelling of the legs
- bleeding gums
- spider veins (telangiectasia)
- decreased sex drive (libido)
- redness of palms (Palmar erythema or liver palms) persistent redness of the palms, disappearing when pressed
- hair loss in the groin area and underarms
- head of Medusa – blue veins of the abdominal wall
- eyelid retraction (eyelid tension)
- the lag of the upper eyelid from the eyeball.
When subcompencirovanna and compensated stages of liver cirrhosis symptoms of hepatic encephalopathy (brain disorders)
- tremor (twitching)
For patients with alcoholic cirrhosis of the liver the most characteristic features, not counting the above I am
- parotid salivary glands
- contracture Dumitrana (the gradual loss of the ability to bend and straighten the fingers)
- deformation of fingers in the form of drum sticks
- white color nail plate.
In the absence of proper treatment, or advanced stage of disease for cirrhosis of the liver may be complicated with the development of the following violations
- ascites (accumulation of fluid in the abdominal cavity)
- abdominal hernia
- bleeding from varicose veins of the stomach and esophagus (it is the leading cause of death in patients with cirrhosis of the liver)
- renal failure
- bacterial peritonitis and sepsis
- hypersplenism (an enlarged spleen, accompanied by an increased destruction of blood cells (platelets, erythrocytes)
- liver cancer (hepatocellular carcinoma).
For the diagnosis of cirrhosis required
or a hepatologist.
- General blood analysis (anemia, thrombocytopenia, leukopenia)
- biochemical blood analysis (levels of transaminases, direct and indirect bilirubin, albumin)
- the General analysis of urine ( increased urobilinogen, bilirubin definition)
- analysis of blood for markers of viral hepatitis.
- Ultrasound of the liver
- computed tomography
- magnetic resonance imaging
- angiography of the liver and spleen
- spleno-, hepato – and portmannatalie (measurement of pressure in vessels of the spleen, liver and portal vein)
- fibrogastroduodenoscopy (EGD) for gastrointestinal bleeding
- elastography (assess the degree of liver fibrosis)
- needle biopsy of the liver.
The key to successful treatment is adherence to the prescribed regime, abstinence from alcohol and Smoking.
Specific (aimed at eliminating the causes of disease)
- in viral cirrhosis stage A (child-Pugh) prescribed interferon in stage b and C antiviral drugs (lamivudine, ribavirin, etc.)
- autoimmune cirrhosis of the liver and the detection of splenomegaly prescribe corticosteroids immunodepressant
- in alcoholic cirrhosis prescribe ursodeoxycholic acid
- in primary and secondary bilirem cirrhosis prescribe choleretic and cholekinetic (choleretic)
- when Wilson disease-Konovalova assign penicillamine (a drug that gets the copper from the body).
Symptomatic therapy (aimed at fixing the symptoms and complications of the disease)
- medications vitamins and nucleic acids (Riboxin)
- hepatoprotectors (Essentiale, lipoic acid)
- drugs of amino acids (Heptral)
- detoxification therapy (glucose 5%, reosorbilakt)
- solutions of amino acids (infezol) and albumin intravenous
- preparations of pancreatic enzymes (CREON, Pancreatin)
- diuretics (veroshpiron, lasix) to correct ascites
- antibiotics to prevent bacterial peritonitis
- vasopressin and its synthetic analogs to reduce pressure in the portal Vienna
- intravenous plasma, aminocaproic acid, inhibitors of fibrinolysis (contrical) to stop bleeding from the digestive tract.
- Transjugular vnutripechenochny portacaval bypass surgery (for removal of ascites, hemorrhage from the vessels of the digestive organs) installation of a shunt between hepatic vein and main branch of the portal vein
- Endovascular reduction of splenic arterial blood flow (to reduce portal hypertension) the introduction of a special spiral in the splenic artery to reduce the venous outflow into the portal vein
- Gastrostomy with flashing veins of the stomach and esophagus
- Percutaneous endovascular embolization of the gastric veins
- Electrocoagulation of blood vessels of the stomach and esophagus.
Meals in accordance with diet 5 by Pevsner, reducing salt intake (salt-free) diet, 4-5 meals a day to improve the quality of the outflow of bile.