Chronic Liver Disease

Chronic Liver Disease: Liver Cirrhosis

The liver is the largest organ in the body and holds 25% of the body’s blood supply. This organ is important in the maintenance of many body functions. Often if the liver fails, other organs will soon follow. It is the only organ in the body that can regenerate itself, although only in some intances.

What does the liver do?

-Metabolizes drugs and toxins
- Synthesizes substances necessary for blood clotting
 -½- 1 liter of bile is produced daily for fat digestion
- Stores excess sugar for reserves when blood sugar is low (such as sleep)
- Produce substances that aid in the immune response 
- Recycles old red blood cells  (stores iron from the hemoglobin)

Liver Disease: Stages and Symptoms
pic:(http://www.herbalprovider.com/imgs/yahoo/fatty-liver-cirrhosis.jpg)

Fatty liver is the first stage of liver disease. This stage is characterized by inflammation, a sign that the body is attempting to heal an injury. While this stage is relatively harmless it can progress quickly if a healthy diet and exercise are withheld.

Fibrosis is one of the more damaging stages of liver disease. Fibrosis is the formation of liver scarring. The scars impede blood flow to the rest of the liver. The scars also cannot perform the functions that liver cells do. If diet and lifestyle changes are made, over time there is a chance the liver can repair.

Cirrhosis is the chronic stage of liver disease involving extensive scarring and hardening of the liver. At this stage, the scarring can no longer be repaired.

Causes of Cirrhosis
Alcoholism is the number one cause of liver cirrhosis in the United States. Alcohol is extremely toxic to living cells. When the liver cells are repeatedly exposed to this toxin, they begin to scar.

Hepatitis B – (HBV) is a virus is spread through blood and body fluids contact. The severity of the infection ranges for mild, to long term, to chronic. A vaccine is available that is usually given to children at a young age. Hepatitis D (HDV) can only occur along with HBV

Hepatitis C- (HCV) is a virus that is spread through blood contact that leads to chronic infection of the liver and eventually leads to cirrhosis.  No vaccine is available.

Autoimmune Hepatitis- this occurs when someone’s body mistakens the liver cells as a pathogen (like a bactera, or a virus). The body then lauches an immune response against the liver.

Less common causes of cirrhosis include direct liver injury from inherited disease such as cystic fibrosis, alpha-1-antitrypsin deficiency, hemochromatosis, Wilson’s disease, galactosemia, and glycogen storage disease.  (http://www.gastro.org/wmspage.cfm?parm1=681)

(Note: there is a Hepatitis A Virus although it is not a risk for chronic illness. A vaccine is also available.)

Symptoms of Cirrhosis:
-fatigue
-weakness
-anorexia (loss of appetite)
-itchiness of the skin
-naseau
-weightloss
-jaundice (yellowing of the skin, and eyes)
-ascites(water accumulation in abdomen and legs)
-easy bruising
-odor from the skin and mouth
-memory loss and difficulty concentration
-sensitivity to medications

What exactly is Jaundice?
When the body is overwhelmed with toxins inside the body that it cannot neutralize or excrete in urine, the body uses the skin and the lungs to help eliminate toxins. This why patients may exert a foul odor from their skin or breath. Just the same, the yellowing of the skin and sclera of the eyes is actually the build up of bilirubin, the biproduc of old redblood cells.

Learn more about Jaundice:
Jaundice Health Video — powered by http://www.livestrong.com

Detection and Diagnosis:

If liver disease is suspected the physician will run a series of tests. The first of these will be a blood test. An ultrasound or a computerized axial tomography (CAT) scan may be used when blood tests are returned. If necessary, a biopsy of the liver tissue may also be collected.

Blood Tests:

• Serum Bilirubin Test
  -Elevated bilirubin indicates a disruption in the processing of bile in the liver
• Serium Albumin Test
  - Albumin is an protein produced by the liver that is important in the metabolism of drugs. Drugs are inactivated when bound to albumin. Lower than normal albumin levels can cause drug toxicity, and is associated with many liver diseases. 
• Prothrombin Time (PTT)-
  - PTT tests the how long it takes for blood to clot. If the amount of clotting factors is reduced due to liver damage, the prothrombin time will increase.
• Serum Aminotransferases (transaminases)
  -This enzyme is released by a damaged liver
• Alanine Transaminase (ALT) Test
  -This  enzyme is released by a damaged liver
• Aspartate Transaminase (AST) Test
  - is an enzyme found in patients with fatty liver disease
• 5-Nucleotidase Test-
  - This test detects liver damage due to bile duct obstruction
• Mitochondrial Antibodies Test -
  -This test searches for he presence of these antibodies which indicate chronic active hepatitis and other liver diseases.

Treatments:

The literature on liver disease is unified in its assessment that “Cirrhosis is a progressive liver disease, and damage sustained to the liver is irreversible.” You may be asking, if the liver can regenerate itself, then how is the damage irreversible? The answer is an unhealthyliver regenerates itself in an abnormal way, often in ball-like nodules and fibroids. This regeneration damages the liver’s ability to perform its normal functions. (http://www.umm.edu/liver/chronic.htm).

 

The main goal is to prevent the damage from getting worse through lifestyle modification.Patients should not consume alcohol, which easily damages liver cells. Food high in fat, protein, and simple sugars should be reduced or removed from the diet. A variety of fruits and vegetables high are encouraged to maintain a healthy blood sugar. The goal of treating cirrhosis is to prevent the accumulation of toxins and overall strain on the liver. Many antioxidant herbals as well as liver detox regiments to “clean” the liver have become increasingly popular.

 

Although there are no medications that can cure liver cirrhosis, there are perscriptions that can treat the symptoms and prevent complications.

Potassium Sparing Diuretics: spironolactone (Aldactone)
- This drug is used for CHF and cirrhosis to block the production of aldosterone, which is often oversecreted in patients with cirrhosis. Aldosterone is a hormone that tells the kidneys to conserve salt and water when there is a fluid volume deficit. In cirrhosis, the oversecretion of aldosterone can lead to ascites (accumulation of water in the abdomial cavity).  This diuretic helps reduce the amount of excess fluid in the body.
This drug should be used under physician supervision as it has many side effects.

-It is a highly albumin bound drug and causes drug interactions with Ace Inhibitors and other antihypertensive drugs and decreases the clearance of Lithium.  
-Since this drug is steroidally based it can cause endocrine like side effects: facial hair and menstrual irregularities in women, and breast growth in men.
-Causes hyperkalemia (high potassium levels). This can cause tremors, twitching, numbness in extremities, and cardiac dysrythmias. Patients should be taught to limit their intake of potassium when on this drug.
-Increases Blood urea nitrogen and creatinine, seen in patients with kidney problems.

Antivirals:

http://www.fda.gov/downloads/Drugs/DrugSafety/ucm089017.pdf

Herbals: Benefits and Risks

Milk Thistle
According to Health and Human services milk thistle may have liver protective properties through antioxidant properties. A study was conducted on varying liver diseases including alcohol induced and viral hepatitis. The results show some improvement improvment in liver fuction including aminotransferases, but were not consistent. There were also improvement on gastroinstestinal bleeding and mental function.
(http://www.ahrq.gov/clinic/epcsums/milktsum.htm)

Dandilion
The stalk of the dandelion is thought to have antioxidant properties and is used medicinally as a diuretic. Common uses are for liver disorders, gastrointestinal upset, an appetite stimulant, and and immune system stimulant. Studies on mice have shown that dandilion lowers LDL cholesterol and triglycerides, while increasing HDL.

Interacts with Lithium, antibiotic Quinolone, and antiacids. Those with allergies to ragweed, iodine, yarrow, daisies, marigold, or chamomile should not take dandilion. 

If you are on medications it is important to discuss taking herbals with your health care provider.

http://www.umm.edu/altmed/articles/dandelion-000236.htm

Licorice Root
The active ingredient Glycyrrhiza glabra has been used for respiratory problems as an expectorant, stomach problems such as heartburn and gastric ulcers, inflammatory diseases, skin problems, liver disorders, and as a stress reliever.  It is also used enterically and topically to reduce body fat. It has also been known to supress the hormone aldosterone in the body that normally retains water.

A major drug interaction that is it increases digoxin levels. Digoxin is a heart medication with a very narrow therapuetic index!

http://www.umm.edu/altmed/articles/licorice-000262.htm

Coffee:
- In a  four year study,  766 people infected with hepatitis C virus (HCV) were asked to record their intake of coffee, green tea, and black tea. The study found that of “those who drank 3 or more cups of coffee per day were 53 percent less likely to have liver disease progression than those who didn’t drink coffee.”
Read the whole article at http://health.usnews.com/articles/health/healthday/2009/10/23/coffee-may-slow-liver-disease.html

Drug interactions:

As we’ve seen herbals are thought of as “all natural” they can interact with some medications.

Patients with liver disease and high cholesterol:

Since cholesterol is synthesized in the liver, most of these drugs act on the liver. Most lipid lowering drugs such as Lipitor, Crestor, niacin, Zetia, etc. cause an increased risk of hepatotoxicity and should not be taken by patients with liver disease!

Liver Transplants:

As you know, in liver Cirrhosis the liver becomes damaged beyond the point of repair. Scarring from cirrhosis replaces functional cells that perform the necessary work of the liver. When scarring from cirrhosis progresses throughout the liver, the organ can go into End Stage Liver Failure where it has lost all of its function. This is an urgant state of illness where a liver transplant is urgent as life expectancy is low.  

pic:(http://www.hivandhepatitis.com/images2007/grex-liver-transplant.jpg)