lung disease



Overview

Definition

Liver disease is a collective term for all diseases that occur in the liver area.

Liver diseases include hepatitis, cirrhosis, and liver cancer.

Hepatitis is categorized by cause as chronic viral hepatitis, autoimmune hepatitis, drug-induced liver injury, and other chronic hepatitis of unknown cause.

Various kinds of liver diseases can develop individually or co-exist.

In China, viral hepatitis B is a common liver disease.

In recent years, the incidence of fatty liver disease and drug-induced liver disease is increasing year by year.

Classification

Classification according to disease progression

Common types of liver diseases include hepatitis (acute or chronic), cirrhosis and liver cancer.

Classification according to the cause of disease

Hepatitis can be categorized into viral liver disease and non-viral liver disease.

Viral liver disease:Usually refers to infectious diseases of the liver caused by different hepatophilic viruses. They include viral hepatitis A, viral hepatitis B, viral hepatitis C, viral hepatitis D, and viral hepatitis E.

Non-Viral Liver Diseases:Mainly includes fatty liver disease, autoimmune liver disease, drug induced liver injury, hereditary liver disease.

Morbidity

Most Asian regions are areas of moderate to high prevalence of hepatitis B virus (HBV).

The prevalence of hepatitis B surface antigen (HBsAg) in China is 5-6%, and the population with chronic HBV infection is about 70 million.

Chronic Hepatitis B (CHB) is a persistent HBV infection resulting in chronic inflammation of the liver, with a population of about 20-30 million.

In China, fatty liver disease has replaced CHB as the most common chronic liver disease.

Fatty liver disease, including alcoholic liver disease and non-alcoholic fatty liver disease (NAFLD).

With the increase in the number of drug classes, the annual incidence of drug-induced liver disease is about 1-10 per 100,000 people.

Etiology

Some of the more common types of clinical liver disease are hepatitis, cirrhosis, and hepatocellular carcinoma. There are many causes of these liver diseases, including viral infections, alcohol, drugs, obesity, immunologic factors, and genetic factors.

Causes

Viral infection

Hepatophilic viruses are categorized into hepatophilic viruses and non-hepatophilic viral infections.

Hepatophilic viruses are categorized as hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis D virus (HDV), and hepatitis E virus (HEV), and when attacked by these viruses, they can lead to viral hepatitis A, B, C, D, and E, respectively.

Hepatophilic viral hepatitis is contagious. Viral hepatitis A and E are transmitted by the fecal-oral route. Viral hepatitis B, viral hepatitis C, and viral hepatitis D are mainly transmitted through blood, mother-to-child, and sexual transmission.

Non-hepatophilic viruses including cytomegalovirus (CMV), herpes simplex virus (HSV), and Epstein-Barr virus (EBV) can also cause hepatitis.

Bacterial or amoebic protozoan infections

Migration of pathogenic bacteria from other organs or tissues to the liver or invasion of amoebas into the liver can result in the formation of a liver abscess.

Alcohol

Chronic heavy drinking can lead to alcoholic liver disease. Initially, it usually presents as fatty liver, which can progress to alcoholic hepatitis, liver fibrosis and cirrhosis.

Drugs

Various kinds of western drugs, biological agents, health products, traditional Chinese medicine, dietary supplements and their metabolites can induce drug liver injury.

Immune factors

Autoimmune liver disease is a kind of non-purulent inflammatory liver disease with autoimmune basis whose etiology is still unclear. Genetic and autoimmune function abnormalities are the main causes of this disease.

Depending on the type of hepatocyte involved, it is divided into two categories: autoimmune hepatitis with hepatocyte involvement and autoimmune cholangiopathies with cholangiocyte involvement, such as primary biliary cholangitis, primary sclerosing cholangitis, and IgG4-associated sclerosing cholangitis.

Genetic and metabolic diseases

Hepatomegaly such as hepatomegaly due to copper metabolism disorders, hemochromatosis due to iron metabolism disorders, hepatic glycogen accumulation, hyperthyroidism, etc. can cause liver inflammation.

Blood circulation disorders

Such as chronic right heart failure, constrictive pericarditis and hepatic venous obstruction syndrome (including Buga syndrome and hepatic sinusoidal obstruction syndrome) caused by various etiologies can also lead to liver involvement.

Others

The etiology and pathogenesis of primary liver cancer have not been completely clarified. According to relevant investigations and studies, primary liver cancer is related to viral hepatitis, aflatoxin, metabolic factors and genetic factors.

Secondary liver cancer mainly refers to cancers that metastasize to the liver from other organs of the body.

Fatty liver disease, also commonly known as fatty liver, is characterized by excessive storage and fatty degeneration of liver cells. It is mainly caused by alcohol, obesity, diabetes, pregnancy and other factors.

Chemical poisons such as phosphorus, arsenic, carbon tetrachloride, etc., and biological toxins can also cause liver injury.

Predisposing Factors

The following factors may trigger or cause liver disease to worsen.

Poor living habits, excessive alcohol consumption.

Bad eating habits such as unhygienic diet and irregular diet.

Prolonged late nights, overwork, and decreased resistance.

Poor nutrition.

Trauma, mental stimulation.

Frequent exposure to poisons, radiation or chemicals such as spray cleaners, pesticides, paints.

Symptoms

There are many causes of liver disease, but ultimately they all impair liver function, so most liver diseases behave similarly in terms of symptoms. Early symptoms may not be obvious and often fail to attract the attention of the patient; it is only when the disease continues to progress that more typical digestive symptoms and systemic manifestations appear.

Main Symptoms

Digestive symptoms

It is the most common symptom of liver disease, and most patients with liver disease will experience it, such as nausea, anorexia, poor appetite, generalized fatigue, etc. Vomiting, diarrhea, splenomegaly and other symptoms may also occur.

Discomfort in liver area

Among all the symptoms of liver disease, hepatic discomfort and hepatic pain are more specific and related to hepatomegaly compressing the hepatic envelope. When such symptoms occur, without a history of trauma, liver disease should be suspected as the first cause.

Occasionally, normal people may also experience temporary pain and discomfort in the liver area.

Systemic manifestations

Generalized weakness and easy fatigue are the most common systemic manifestations.

Jaundice

Some patients with liver disease may be accompanied by different degrees of jaundice, manifested by yellow urine, yellow sclera, yellow itchy skin, etc. It is the most specific symptom of liver disease.

Liver palms and spider nevus

Liver palms, spider nevus and liver disease face will appear in many chronic liver diseases, especially in cirrhosis patients.

Ascites

Hepatic ascites usually occurs in the advanced stage of liver disease, or when the condition is extremely serious, such as cirrhosis with the appearance of hepatic ascites indicates that the cirrhosis has entered the decompensated stage.

Bleeding tendency

Bleeding in liver disease is caused by decreased synthesis of coagulation factors due to decreased liver function.

It is easy to cause gum bleeding, gastrointestinal bleeding, subcutaneous petechiae, etc., and it is difficult to stop bleeding.

Portal hypertension

Portal hypertension often causes esophagogastric fundus varices, which is the main cause of gastrointestinal bleeding.

Once bleeding occurs, the condition is often more dangerous, and it is one of the main causes of death in the advanced stage of liver cirrhosis and liver cancer.

Hepatic encephalopathy

Hepatic encephalopathy occurs when liver function is obviously impaired in the decompensated stage of liver cirrhosis, portal shunt is abnormal, and the metabolism of various substances is seriously disturbed.

Neuropsychiatric abnormalities of different degrees of severity appear, including anxiety, apathy, amnesia, drowsiness, slurred speech, coma or abnormal behavior.

Complications

Splenomegaly and hypersplenism: anemia symptoms such as pallor, dizziness, and fatigue, as well as decreased resistance manifestations such as susceptibility to infection, may occur.

Spontaneous peritonitis: there may be different degrees of fever, abdominal distension and poor mental status.

Rupture and bleeding of esophagogastric fundal varices: mainly manifested by sudden vomiting of blood, which is bright red or dark red, and shock may occur when the bleeding is large.

Hepatorenal syndrome: there may be sudden onset of oliguria, anuria, jaundice and ascites with varying degrees of yellowing of the skin and mucous membranes, and increase in abdominal circumference.

Hepatopulmonary syndrome: dyspnea, cyanosis of skin and mucous membranes may occur.

Consultation

Department of Medicine

Gastroenterology, Hepatology

For symptoms such as fatigue, obvious yellowing of skin and sclera, dark urine, decreased energy, poor appetite, and pain in the liver area, it is recommended to consult a gastroenterologist or hepatologist in a general hospital.

Emergency Department

Severe vomiting, vomiting blood, change of consciousness, coma and other symptoms, it is recommended to seek medical treatment immediately.

Preparation for medical treatment

Preparation for medical consultation: registration, preparation of documents, common problems

Tips for seeking medical treatment

Try to keep a record of symptoms, duration, and information about previous treatments so that you can give your doctor more information.

Preparation Checklist

Symptom list

Pay particular attention to the time of onset of symptoms, special manifestations, etc.

Do you have fatigue or loss of energy?

Do you have a good appetite?

Do you have an aversion to oily foods?

Any bleeding gums, nosebleeds, petechiae or ecchymosis of the skin?

Is there any change in the color of stool or urine?

Any yellowing of the skin or eyes?

Any bloating, abdominal distension, leg edema?

How long have the above symptoms lasted?

Do the above symptoms recur?

Have any of the above symptoms worsened?

List of medical history

Is there any positive Hepatitis B surface antigen (HBsAg)?

Any history of blood transfusion or intravenous drug use?

Has there been chronic heavy drinking or recent alcohol abuse?

Is the family, especially the mother, a hepatitis B hepatitis patient?

Does anyone in the family have hereditary liver disease?

Are you taking various western medicines, health supplements, or herbal remedies?

Have you been exposed to toxic and harmful substances recently?

Checklist

Test results in the last six months, which can be carried to the doctor

Laboratory tests: viral hepatitis markers, liver and kidney function, coagulation indexes, etc.

Imaging tests: abdominal ultrasound, abdominal CT or MRI, liver transient elastography.

Liver puncture examination.

Medication list

Medication used in the last 3 months, if available, bring the box or package with you to the doctor’s office

Hepatoprotective medications: liver protection tablets, silymarin.

Antimicrobials: cefuroxime, amoxicillin, vancomycin.

Glucocorticoids: dexamethasone, prednisone acetate.

Diuretics: furosemide, spironolactone.

Diagnosis

Diagnosis is based on

Medical History.

The following medical history may be present:

Family history of hepatitis B and hepatocellular carcinoma.

History of blood transfusions or drug use.

History of prolonged heavy alcohol consumption.

Recent use of western medicines, health supplements, Chinese herbs, etc.

Clinical manifestations

Symptoms

Weakness, decreased energy, poor appetite.

Pain in the liver area or right upper abdomen.

Visible yellowing of skin and eyes, dark urine color.

Skin petechiae and ecchymosis, bleeding gums, bleeding from the nose.

Abdominal distension, bloating, low urine output, bilateral lower extremity edema.

Physical Signs

Visualization: yellowing of skin sclera, spider nevus, liver palms, distended abdomen.

Palpation: tenderness to percussion in the liver area, bilateral lower extremity edema.

Percussion: positive mobile turbidities suggesting the presence of peritoneal effusion.

Laboratory tests

Viral hepatitis markers

Serologic markers of HBV infection, also known as “Hepatitis B two halves,” include HBsAg, anti-HBs, HBeAg, anti-HBe, and anti-HBc.

HBsAg positivity indicates HBV infection. Anti-HBs positive indicates immunity to the virus. Anti-HBc positivity indicates infection with HBV and is mostly positive whether or not HBV is cleared.

HBV-DNA reflects the level of viral replication and guides antiviral therapy.

HAV and HEV test: If IgM antibody is positive, it suggests the presence of current infection; if IgG antibody is positive, it suggests previous infection or recovery from infection.

HCV test: anti-HCV positivity suggests existing HCV infection, and HCV-RNA should be further tested to determine whether it is a current infection.

HDV test: serum may detect HDVAg or HDV-RNA, or anti-HD, anti-HDDIgM.

Liver function

Elevated alanine aminotransferase (ALT), menthionine aminotransferase (AST), and glutamyl transpeptidase (γ-GT) are seen.

Total bilirubin and direct bilirubin are elevated.

Albumin is decreased.

Coagulation

Prolonged prothrombin time (PT) and decreased serum coagulation factor levels are seen in severe hepatitis and liver failure.

Alpha Fetoprotein

Alpha-fetoprotein (AFP) test:Significant and persistent elevation should be considered for possible hepatocellular carcinoma.

Others

Stool routine:Positive fecal occult blood test when liver disease is combined with rupture and bleeding of esophagogastric fundic varices.

Urine routine:Positive urine bilirubin and urobilinogen suggest that the patient has jaundice.

Autoantibody test: it can assist in determining whether autoimmune hepatitis exists.

Imaging examination

Ultrasonography

Ultrasonography has diagnostic value for liver disease. It is used to diagnose fatty liver, liver cirrhosis and liver parenchyma occupying lesions.

CT or magnetic resonance imaging

Helps in the differential diagnosis of fatty liver, cirrhosis and hepatocellular carcinoma.

Transient elasticity scan of the liver

Allows assessment of liver fibrosis and grading of the degree of fibrosis.

This test is one of the preferred modalities currently used to monitor the progression of cirrhosis. It is fast, convenient and safe.

The normal reference value is 2.8-7.4 kilopascals (kPa), with a value of more than 17.5 kPa suggesting cirrhosis.

Liver puncture biopsy

It is an invasive examination, which can distinguish and diagnose different types of liver diseases, and judge the treatment effect and prognosis.

Differential Diagnosis

Liver disease is a collective term for all diseases that occur in the liver area, mainly including hepatitis, cirrhosis, liver cancer and other diseases. Differential diagnosis is mainly based on symptoms, only some of which are listed here as there are many disease symptoms.

Malaria

Similarities: Both may present with hepatosplenomegaly, and both may be preceded by a history of blood transfusion.

Differences: malaria may be preceded by a history of living in a malaria-endemic area or being bitten by mosquitoes, etc.; typical intermittent chills and profuse sweating may also be present, and the intermittent episodes have a certain regularity; malaria parasites may be detected in the laboratory tests.

Cardiogenic ascites

Similarity: both can present with ascites.

Differences: Patients with cardiogenic ascites may present with symptoms associated with heart failure, i.e., sedentary breathing, coughing up pink foamy sputum, etc.

Treatment

Aim of treatment: mainly targeting different aspects of the pathogenesis, blocking the vicious cycle of disease development, promoting remission, improving symptoms and preventing complications.

Treatment principle: antiviral treatment, protection of liver function, prevention of liver fibrosis, cirrhosis and complications.

General treatment

Hospitalization or home rest in the acute stage, appropriate rest in the chronic stage, can increase activities and avoid exertion.

Strictly abstain from alcohol.

Appropriately reduce or stop using drugs that are damaging to liver function.

Do not listen to the so-called prescriptions and health products that can cure liver disease.

Patients with fatty liver disease who are overweight or obese should control the total amount of dietary calories, give low-carbohydrate and low-fat diet, and do moderate aerobic exercise such as cycling, fast walking, swimming and dancing, so as to make their weight decrease by 5-10% within half a year.

Pay attention to give high nutrition and easy to digest and absorb food.

Maintain a regular diet and pay attention to water and food hygiene.

Symptomatic treatment

The principle of treatment is to protect the liver, lower the enzyme, reduce the yellow color, resist liver fibrosis, and promote the regeneration of liver cells.

Adenosylmethionine, diammonium glycyrrhizinate, bicyclic alcohol, reduced glutathione, silymarin, polyene phosphatidylcholine and other drugs can be chosen.

If necessary, intravenous infusion therapy, such as hepatocyte growth promoter, reduced glutathione, glycyrrhizic acid-based preparations.

Traditional Chinese medicine can be chosen as Fu Zheng Hua Yu capsule, He Luo Hua Fibre Pill, Compound turtle shell soft liver tablets, silymarin-like drugs.

Etiologic Treatment

Viral hepatitis

Chronic hepatitis B

Nucleoside analogs: recommend entecavir, tenofovir or propranolol tenofovir, but also tibivudine, adefovir, lamivudine, etc.

Interferon: Polyethylene glycol interferon can be chosen cautiously for compensated cirrhosis, or common interferon therapy. Interferon is prohibited in decompensated cirrhosis.

Hepatitis C

Currently, direct antiviral drugs (DDAs) are mostly used in clinical treatment.

Commonly used drugs include prozac (a combination of sofosbuvir and viplatasvir, also known as gizandia), asurevir, simeprevir, dalatasvir, lediprevir, and sofosbuvir.

Antiviral drugs should be selected based on viral genotyping. With a course of treatment of 8 to 12 weeks, more than 95% of hepatitis C can be completely cured.

Alcoholic liver disease

Abstinence from alcohol is the key to treatment, and do not consume any food containing alcohol.

Patients with severe symptoms can take glucocorticosteroids such as prednisone to suppress the inflammatory response of liver cells.

Non-alcoholic fatty liver disease

There is no effective treatment for non-alcoholic fatty liver disease. It mainly relies on weight control, dietary modification and improvement of metabolism.

Patients with type 2 diabetes mellitus can be treated with metformin, which can improve insulin resistance, lower blood glucose and assist weight loss.

Autoimmune liver disease

Can use glucocorticoids, immunosuppressant therapy, such as prednisone combined with azathioprine, cyclosporine and so on.

Drug-induced liver injury

The primary measure of treatment is to stop the drug causing liver injury in time.

Hepatomegaly

Copper repellent treatment, commonly used copper repellent drugs include penicillamine, sodium dimercaptopropanesulfonate, calcium sodium edetate, etc.

Reduce the consumption of oysters, animal liver, walnuts and soybeans, which are rich in copper.

Liver Cancer

Treat the cause of liver cancer, such as using antiviral drugs.

Depending on the size, stage and metastasis of liver cancer, surgical resection, chemotherapy, radiotherapy and immunotherapy may be chosen.

Complications treatment

Ascites

Use diuretics, such as spironolactone, furosemide, etc. as prescribed by doctor.

If diuresis is not effective, it may be gradually increased. Diuretic treatment is appropriate to lose no more than 0.5 kg of weight per day to avoid inducing hepatic encephalopathy and hepatorenal syndrome.

Diuretics may be tapered down gradually if ascites subsides.

Intravenous infusion of albumin can also be used to increase colloid osmotic pressure and reduce ascites production.

For refractory ascites can be treated with repeated draining of the peritoneal fluid, plus intravenous infusion of albumin.

For refractory ascites, or with hypovolemic state, hyponatremia, hypoproteinemia, and hepatorenal syndrome, as well as large amounts of peritoneal fluid due to various causes in urgent need of symptomatic relief, ascites concentrating reflux can be used.

Bleeding from ruptured esophageal-fundal varices

Requires rehydration, blood transfusion, reduction of portal hypertension, hemostasis, acid suppression, triple lumen tube compression for hemostasis, endoscopic sclerotherapy or sleeve therapy, gastric coronary vein embolization, surgery, and transjugular intrahepatic portal vein stenting bypass (TIPS).

Spontaneous peritonitis

The doctor may use antibacterial drugs such as cefoperazone and ciprofloxacin.

Antimicrobial drugs will also be adjusted during the course of treatment, based on drug sensitivity results and response to treatment, for 1 to 2 weeks.

Hepatorenal syndrome

Transfusions of albumin, plasma, whole blood, and concentrated reflux of one’s own peritoneal fluid are usually given.

Concurrent treatment with spironolactone, furosemide diuretics, and vasoactive drugs such as dopamine and terlipressin may also be received.

Sometimes they may also receive dialysis treatment, which includes hemodialysis and peritoneal dialysis.

Liver Transplantation

Patients with severe hepatitis, liver failure, or liver cancer may be considered for liver transplantation depending on their condition.

Prognosis

Cure

The prognosis of liver disease is related to the type of disease, and patients with hepatitis have a better overall prognosis. Some hepatitis such as chronic hepatitis B can evolve into cirrhosis or even liver cancer with poor prognosis.

Most of the fatty liver diseases can be reversed or even completely recovered if they are detected and treated at an early stage.

The prognosis for most drug-induced liver disease is good after stopping medication, and the prognosis for patients with severe liver damage is poor.

Drug therapy can slow down, or keep cirrhosis from worsening further, but there is no way to reverse cirrhosis. Current anti-fibrotic drugs also cannot completely reverse liver fibrosis and cirrhosis, so medical treatment is not able to cure cirrhosis.

Surgical treatment of cirrhosis with liver transplantation can reverse cirrhosis from the root and is the only way to cure cirrhosis at present. The development of liver transplantation has significantly changed the prognosis of cirrhosis, and the 1-year survival rate after transplantation is about 90%, and the 5-year survival rate is about 80%, and the quality of life has been greatly improved.

The prognosis of liver cancer patients is affected by tumor stage, physical condition, treatment method and other factors. Early stage liver cancer patients have a better prognosis with a 5-year survival rate of 40%~70% as they can receive radical surgery. The survival time of advanced liver cancer patients is often only six months to one and a half years.

Daily

Daily Management

Dietary management

Diet should be light, fine and soft, easy to digest, non-stimulating, small and frequent meals, chewing and swallowing slowly.

Cooking should be processed finely and avoid hard and rough foods, such as fried foods and hard fruits; if there is upper gastrointestinal bleeding, the above foods are strictly prohibited.

Staple food should be chosen softer, rice and noodles should be softer than normal, buns, steamed buns, wontons, dumplings can be (pay attention to the filling of wontons or dumplings to choose less fiber).

Recommended high-quality protein diet, such as soybeans and their products such as tofu, tofu brain, soy milk, milk and dairy products, a variety of lean meats.

Eat more vegetables and fruits with lower fiber content to supplement vitamins and minerals, such as winter squash, pumpkin, cauliflower, apples, oranges, etc. Chopping, juicing and pureeing are preferred for cooking.

Short-term intravenous nutritional support therapy for patients with significant nausea and vomiting and difficulty in eating.

Life management

Stop smoking and drinking.

Eliminate the use of unreasonable medication, and do not use drugs that may harm the liver as well as health care products.

Ensure sufficient rest and sleep.

Maintain regular exercise, taking walking as the main activity, which should not be more than half an hour each time and not more than twice a day, taking into account your physical condition. Avoid heavy physical labor.

Psychological support

Keep a positive and good mindset.

Family members should give comfort and psychological guidance to advanced cirrhosis, as well as patient company and good care.

Prevention

Newborns and high-risk groups should be vaccinated against hepatitis B, which can effectively prevent infection.

Avoid contact with blood and body fluids of HBV-infected people and pay attention to sexual hygiene.

Avoid unregulated use of syringes and blood products, which can cause medical transmission.

Quit smoking and drinking.

Reasonable weight control, diversification of food types, dietary exercise phase balance, prevent the occurrence of non-alcoholic fatty liver.

Workers with long-term exposure to hepatotoxic substances such as arsenic and carbon tetrachloride need to pay attention to the environmental pollution of the workplace and, if necessary, need to carry out certain occupational protection.

Adequate intake of nutrition is conducive to liver cell regeneration.

Keep a happy mood, open mind, less angry.