Overview
A clinical syndrome in which various factors damage the liver, resulting in abnormal liver function.
Symptoms include fatigue, poor appetite, abdominal pain, nausea and jaundice.
Mainly related to biological factors, hepatotoxic substances, immunologic factors, nutritional factors.
Treatments can be taken to treat the cause, supportive therapy, surgery, and complications.
Definition
Hepatic insufficiency refers to the damage to hepatocytes caused by various factors, resulting in dysfunction of hepatic synthesis, degradation, detoxification, storage, secretion and immunity [1-5].
It is a clinical syndrome characterized by symptoms such as fatigue and poor appetite, accompanied by abnormalities of liver enzymes and bilirubin.
Classification
Classification according to the course of the disease
Acute hepatic insufficiency: the onset of the disease is acute and progresses rapidly, jaundice or even coma can appear in a short period of time, and there is often a tendency to hemorrhage.
Chronic hepatic insufficiency: the course of the disease is longer and progresses slowly.
Causes
Causes
Liver insufficiency can be caused by a variety of causes, generally believed to be caused by the following factors.
Biological factors
Bacteria, viruses, parasites, etc. can cause liver injury, especially hepatitis virus is the most common.
Bacteria such as Escherichia coli can cause liver abscess. Various viral infections can lead to viral hepatitis. Certain parasites such as amoebas, trematodes, and nematodes can involve the liver and cause liver injury [6-7].
Hepatotoxic substances
Overdose or failure of detoxification function of certain drugs can cause liver damage, such as acetaminophen, rifampicin, and certain traditional Chinese medicines.
Long-term heavy drinking, alcohol or its metabolite acetaldehyde can directly damage liver cells.
Aflatoxin, nitrite and poisonous mushrooms ingested with food can also lead to liver insufficiency.
Immunologic factors
Autoimmune liver diseases such as autoimmune hepatitis, primary biliary cirrhosis, and primary sclerosing cholangitis can lead to liver cell damage.
Nutritional factors
Nutritional deficiencies can promote the occurrence and development of liver disease, such as when starvation occurs, energy substances such as hepatic glycogen and glutathione in the liver are reduced, which lowers the detoxification function of the liver.
With the improvement of people’s living standard and the change of life style, the intake of fat and other high-calorie food gradually increases, the incidence of fatty liver gradually increases, and severe fatty liver can cause liver insufficiency.
Hereditary factors
This kind of etiology is less common, due to genetic or inborn enzyme deficiency, such as copper metabolism disorder, α1-antitrypsin deficiency, etc. can lead to metabolite deposition in the liver, causing hepatocellular damage and promoting the occurrence of hepatic insufficiency.
Other factors
Other factors such as biliary obstruction caused by cholelithiasis, hepatic stasis and hypoxia caused by heart failure can promote the occurrence and development of hepatic injury and cause hepatic insufficiency.
Severe diseases such as hemorrhagic shock, hepatic stasis, and fatty liver in acute pregnancy can trigger hepatic insufficiency and even cause acute liver failure.
High risk factors
The following factors are closely related to the increased risk of hepatic insufficiency and are high risk factors for the disease.
Obesity.
Emotional abnormalities, adverse emotions can lead to liver dysfunction.
Long-term staying up late and lowered immunity.
Long-term intake of too much high-cholesterol food.
Lack of exercise.
Pregnancy [8].
Symptoms
Symptoms of liver insufficiency are varied, and the severity of symptoms is closely related to the degree of liver insufficiency. Early stage patients may not have any symptoms, and with the gradual decline of liver function, poor appetite, nausea, and fatigue appear; in the terminal stage, bleeding, infection, hepatic encephalopathy, hepatic and renal syndrome, and other serious manifestations may occur.
Main Symptoms
Fatigue
It is common in patients with mild hepatic insufficiency.
It is mostly intermittent and often occurs after exertion, mental stress, or with other diseases, and can be relieved after rest.
Abdominal discomfort
Mostly occurs in the right upper abdomen.
It may be accompanied by abdominal pain, which is often intermittent and can be relieved by rest.
Poor appetite and indigestion
May be manifested as poor appetite, nausea, abdominal distension.
It is often aggravated after meals, and diarrhea is easy after meat and greasy food.
When the synthesis function of the liver is severely impaired, it is unable to synthesize albumin, and lower limb edema or ascites may occur.
Jaundice
In mild jaundice, there is no obvious abnormality.
Typical manifestations include yellowing of the skin and sclera, and the color of the urine may deepen.
In addition to jaundice, itching of the skin is also present.
Other symptoms
Bleeding and anemia
Decreased synthesis of coagulation factors by the liver and hyperfunction of the spleen lead to a decrease in red blood cells, white blood cells and platelets in the blood, resulting in petechiae on the skin and gums, as well as bleeding from internal organs, especially the most serious internal bleeding.
Anemia may be manifested by dizziness, fatigue, pale skin and mucous membranes and eyelids.
Liver palms and spider nevus
Related to the increase of estrogen, patients with liver palms often show blood congestion and redness in both hands.
Spider nevi are often found on the face, neck and chest. Spider nevus is a kind of red vascular lesion, which is called spider nevus because it is characterized by a central protrusion and a large number of capillaries sticking out in all directions in the shape of a spider’s leg.
Others
Acute viral hepatitis patients mainly show digestive symptoms, but may also be accompanied by fever, muscle and joint pain, upper respiratory tract infection and other manifestations.
Alcoholic hepatitis patients may be accompanied by malnutrition and chronic alcoholism.
Complications
If left untreated, liver function continues to deteriorate, which may lead to serious complications such as cirrhosis, hepatic encephalopathy and liver cancer.
Cirrhosis
It is mainly caused by different etiologic factors continuously damaging the liver, resulting in chronic liver injury and progressing to cirrhosis.
The compensated stage is usually asymptomatic or mildly symptomatic, while the decompensated stage will show liver insufficiency with portal hypertension.
Hepatic encephalopathy
Occurs on the basis of liver disease such as cirrhosis. High protein diet, hypoglycemia, uremia, surgical infections, and massive release of ascites can further increase the chances of occurrence [9].
The metabolism of blood ammonia is weakened in hepatic insufficiency, and blood ammonia enters the brain, causing changes in the patient’s demeanor and personality.
Hepatocellular carcinoma
Long-term irritation and damage to the liver, progressive decline in liver function, the development of these liver diseases can easily cause malignant changes in the normal tissues of the liver, leading to the development of hepatocellular carcinoma.
Consultation
Department of Medicine
Gastroenterology
If you experience symptoms such as fatigue, poor appetite, abdominal distension, jaundice, itchy skin, etc., you should consult a doctor promptly.
Department of Infectious Diseases
If you have a history of viral hepatitis and experience symptoms such as fatigue, bloating, jaundice, itchy skin, etc., it is recommended to consult the Department of Infectious Diseases.
Emergency Medicine
If there are critical symptoms such as vomiting blood, black stool, confusion, impaired consciousness, coma, etc., it is recommended to go to the Emergency Department immediately.
Preparation for medical treatment
Preparation for medical consultation: registration, preparation of documents, common problems
Tips for seeking medical treatment
If you have vomited blood or have black stools before visiting the doctor, you can take photos of the vomit and the color and nature of the stools with your cell phone, which may give the doctor more information.
Preparation Checklist
Symptom list
Pay special attention to the time of onset of symptoms, special manifestations, etc.
When did you experience weakness, nausea, vomiting, and yellowing of the skin?
Has there been any blood in the vomit, blood in the stool?
Medical History Checklist
Is there any history of liver disease in the family?
Any previous liver disease?
Any long-term use of hepatotoxic drugs such as rifampicin, isoniazid?
Has alcohol been consumed? How long has alcohol been consumed? What is the amount of alcohol consumed per day?
Checklist
Test results of the last six months, which can be brought to the doctor’s office
Laboratory tests: blood biochemistry, coagulation function.
Imaging examination: abdominal ultrasound, CT, MRI examination, etc.
Medication list
Medication used in the last 3 months, such as medicine box or package, can be brought to the doctor
Antiviral drugs: entecavir, tenofovir, telbivudine, lamivudine, interferon, etc.
Liver-protecting drugs: glutathione, polyene phosphatidylcholine, vitamin E, etc.
Lipid-lowering drugs: simvastatin, benzofibrate, acyclovir, colesevelam, etc.
Diagnosis
Diagnosis is based on
Medical history
Possible past history of associated liver disease such as viral hepatitis, autoimmune hepatitis, etc.
There is chronic drug and alcohol abuse.
There are risk factors such as obesity, prolonged late night.
Clinical manifestations
Symptoms
Patients may experience weakness, loss of appetite, abdominal distension, jaundice, itchy skin and other symptoms.
Symptoms such as bleeding and anemia may also occur.
Signs
Signs such as abdominal distension, spider nevus, and liver palms may be present.
Laboratory Tests
Routine blood tests
Routine blood tests can determine the presence of anemia.
If the hemoglobin is decreased, it suggests the presence of anemia.
Blood biochemistry tests
Elevated values of alanine aminotransferase and glutamic aminotransferase suggest abnormal liver function and possible biliary obstruction.
Serum total protein, albumin, and globulin measurements may reflect the reserve function of liver parenchymal cells.
Increased blood ammonia is common in severe liver damage (e.g., cirrhosis, hepatocellular carcinoma, severe hepatitis, etc.), upper gastrointestinal bleeding, uremia, and extrahepatic portosystemic shunt formation.
Lipid metabolism function test: including cholesterol, triglyceride, high-density lipoprotein, low-density lipoprotein and so on, which can be used to reflect the level of lipid metabolism.
Bilirubin metabolism examination: clinically, through the detection of serum total bilirubin, conjugated bilirubin, unconjugated bilirubin, in order to diagnose the presence of hemolysis and determine the functional status of the liver and biliary system in the metabolism of bile pigment.
Alkaline phosphatase, γ-glutamyltransferase, lactate dehydrogenase and isoenzyme measurements can reflect the pathological state of the liver, and have certain significance in the differential diagnosis of different liver diseases.
Measurement of coagulation function
Including prothrombin time, activated partial thromboplastin time, prothrombin time measurement, etc., can determine whether the patient’s coagulation function is normal.
Alpha-fetoprotein test
Checking alpha-fetoprotein helps to make diagnosis and differentiation of liver insufficiency caused by liver cancer, hepatitis and other liver diseases.
Virology
Screening for viral hepatitis A, B, C, D, and E markers can assist in the diagnosis of hepatic insufficiency caused by viral hepatitis.
Serum Immunology
Serum immunology test can further exclude autoimmune liver disease.
Imaging test
Abdominal ultrasound
It is often used as the first choice for diagnosing liver diseases.
It can clearly show the size, shape, edge and parenchymal echogenicity of the liver and make localized diagnosis of the lesion.
Abdominal CT examination
It includes scanning examination and enhancement examination.
Scanning examination can find most of the liver diseases, such as fatty liver, cirrhosis and hemorrhagic, calcified lesions, etc. Combined with CT value, a clear diagnosis can be made.
Enhanced examination: it is used to observe the blood vessels and occupations in the liver and make further differential diagnosis of the disease.
Abdominal MRI examination
It is usually used as a supplementary examination technique, mainly for the differential diagnosis of diseases.
It also includes scanning and enhancement examination.
For early liver cancer, MRI examination can provide more diagnostic information.
Pathologic examination
It is mainly liver puncture biopsy, which can directly understand the histopathological changes of liver and make accurate diagnosis.
Differential diagnosis
Hepatic insufficiency is a group of clinical manifestations such as weakness, jaundice, poor appetite, etc. caused by various factors that lead to liver function injury. It is necessary to further clarify the primary etiology such as cirrhosis, viral hepatitis, autoimmune liver disease, hepatocellular carcinoma and so on.
Symptoms of portal hypertension can be seen in the decompensated stage of cirrhosis, and the degree of liver fibrosis can also be assessed by liver puncture biopsy.
Viral hepatitis has a clear history of hepatitis virus infection and can be further diagnosed on the basis of epidemiology, liver biochemistry, pathogenesis and serology.
Autoimmune liver disease can present extrahepatic manifestations such as roving large arthritis and erythema nodosum in addition to primary liver lesions.
Serum AFP examination in patients with hepatocellular carcinoma may reveal significant elevation. Definitive diagnosis can also be made by imaging and pathology.
Treatment
Aims of treatment: eradicating the primary disease, relieving the symptoms, controlling the development of the disease, preventing and reducing the complications.
Treatment principle: according to the different causes of the disease, liver-protecting, yellow-lowering, antiviral, antibacterial and other medications, supportive therapy and surgical treatment are used.
For liver insufficiency caused by viral hepatitis, antiviral drugs can be given.
For bacterial liver abscess, antibiotic treatment is given.
For liver insufficiency caused by chemicals, alcohol and drugs, first stop using all substances that damage the liver and give liver-protecting drugs.
For autoimmune liver disease, treatment with hormones and/or immunosuppressants is required.
As for liver insufficiency caused by severe infection and hemorrhagic shock, active treatment of the original disease, rehydration and anti-infection should be carried out.
General treatment
Prohibit alcohol consumption to prevent further liver injury or aggravation.
Try to avoid further use of relevant drugs that cause liver injury to reduce liver damage [10].
Patients with mild disease can get out of bed and walk around appropriately; patients with significantly decreased liver function should rest in bed.
In terms of diet, nutritional support therapy mainly based on sugar is given to reduce the decomposition of fat and protein and ensure that blood glucose is at the normal level, which is conducive to the repair of liver cells.
Drug treatment
It mainly includes liver-protecting drugs, antiviral drugs, antibacterial drugs, yellow-lowering drugs, lipid-lowering drugs and so on.
Hepatoprotective drugs
They mainly include hepatocyte membrane protectors such as polyene phosphatidylcholine; detoxification and hepatoprotective drugs such as glucuronolactone, thiopronin, penicillamine, etc.; and anti-inflammatory drugs such as glycyrrhizic acid preparation compound glycyrrhizic acid amine, glycyrrhizic acid diamine and so on.
The main effects are anti-inflammatory, choleretic, antioxidant, hepatocyte protection and hepatocyte repair, thus improving liver function.
Antiviral drugs
They are mainly used to treat liver insufficiency caused by hepatitis virus.
Including nucleoside analogs (such as tenofovir, entecavir, tibivudine, etc.) and interferon.
They can inhibit viral replication and have the advantages of being potent antiviral and not easily resistant to drugs.
Ursodeoxycholic acid
It has stabilizing cell membrane, immunomodulatory and mitochondrial protective effects, and promotes the transport of bile acids in intracellular and small bile ducts, and can be used in patients with primary biliary cirrhosis to reduce cholestasis.
Glucocorticoids, immunosuppressants
Autoimmune liver disease requires the application of hormone and immunosuppressant therapy.
They can inhibit the body’s production of abnormal immunoglobulins to avoid damage to the liver.
The main drugs are prednisone, dexamethasone, azathioprine and so on.
Adverse effects of glucocorticoids include osteoporosis, hyperglycemia, hypertension, increased nervous system excitability, and susceptibility to infection.
Long-term use of azathioprine should alert the risk of bone marrow suppression and tumorigenesis.
Surgical treatment
Surgical treatment is mainly for early hepatocellular carcinoma, cirrhosis combined with esophageal varices rupture and bleeding.
For patients with chronic hepatic insufficiency, liver transplantation can be considered when there is a continuous deterioration of liver function that cannot be relieved.
Prognosis
Cure
Mild hepatic insufficiency is usually asymptomatic. Symptomatic supportive treatment can relieve symptoms such as fatigue, loss of appetite, dyspepsia, nausea and vomiting.
Combination of other liver diseases, such as viral hepatitis, fatty liver disease, drug-induced liver injury, etc., may affect the therapeutic effect.
The prognosis is poor for older people, people with other systemic organ diseases, and people with poor nutritional status.
Long-term undiagnosed and untreated patients may lead to further development of the disease and jeopardize health.
Daily
Daily Management
Dietary management
Adjust a good diet structure, focus on light diet, avoid spicy and stimulating food.
Prohibit drinking and smoking.
When consuming proteins, it is better to use plant proteins so as not to induce hepatic encephalopathy by consuming other proteins; at the same time, attention should be paid to giving a diet high in sugar to ensure sufficient energy supply.
Avoid eating food with long preservation time and mold, and don’t drink river and ditch water, polluted water and so on.
Exercise management
Exercise can be strengthened appropriately with physical exercise and weight control.
Avoid bumping, so as not to cause bleeding.
Psychological support
Keep positive and optimistic mood to reduce the impact of bad mood on the organism.
You can consult the doctor about the scientific knowledge of related diseases and strengthen the understanding of liver insufficiency and other related diseases, so as to facilitate the self-management of emotions.
You can use methods such as diverting attention, appropriate physical exercise, watching movies and other methods to divert attention and keep your mood happy.
You can confide in relatives and friends and listen to their opinions to change the situation of unstable and depressed mood. If necessary, consult a psychiatrist to adjust the bad mood.
Follow-up and review
Regularly review liver function, blood routine, blood ammonia.
Pay attention to whether edema worsens, the degree of abdominal distension, whether petechiae and ecchymosis appear on the skin, etc. Go to the hospital promptly if there is any discomfort.
Prevention
For patients with hepatitis B, when the first attack must follow the doctor’s instructions to take medication regularly, so as not to cause repeated episodes of hepatitis.
Do not take traditional Chinese medicine, prescriptions, etc., in order to prevent liver function damage.
Avoid drinking a lot of alcohol, alcohol can cause fatty liver, leading to liver function decline.