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Herckleperckle
Member
11-20-2003
| Tuesday, July 04, 2006 - 2:05 pm
Source: ADAM Healthcare Center Cirrhosis An in-depth report on the causes, diagnosis, treatment, and prevention of cirrhosis Alternative Names Alcoholism; Liver Transportation; Primary Billing Cirrhosis Causes There are several processes that can lead to cirrhosis. Alcoholism The liver is particularly endangered by alcoholism. Alcoholic cirrhosis (also sometimes referred to as portal, Laennecs, nutritional, or micronodular cirrhosis) is the primary cause of cirrhosis in the US. It is estimated to be responsible for 44% of deaths from cirrhosis in North America. Some experts believe this estimate is low; one Canadian study found alcohol to be the major contributor to 80% of all cirrhosis deaths. The relationship between alcohol and cirrhosis is generally as follows: * Alcohol is absorbed from the small intestine, and the blood carries it directly into the liver, where it becomes the preferred energy source. * In the liver, alcohol converts to toxic chemicals, such as acetaldehyde (AcH), which trigger the production of powerful immune factors called cytokines. These molecules in large amounts can cause inflammation and tissue injury and are proving to be major culprits in the destructive process in the liver. AcH is particularly being researched because it plays a role in most actions of alcohol, including damaging effects on the liver that may lead to cirrhosis. * The injured liver eventually is unable to breakdown fatty acids, compounds that make up fat. Over time, then, fat accumulates, further impairing the livers ability to absorb oxygen and increasing its susceptibility to injury. During the initial phase, the fat-laden liver becomes greatly enlarged, but it eventually shrinks as cirrhosis develops. Chronic Hepatitis The second leading cause of cirrhosis in the US is chronic hepatitis, either hepatitis B or hepatitis C. Chronic hepatitis C is the more dangerous form and accounts for one-third of all cirrhosis cases. Overall, between 10% and 15% of patients with chronic hepatitis C develop cirrhosis. The risk varies widely, however. About 5% to 10% of hepatitis B patients eventually develop cirrhosis. Viruses or other mechanisms that cause hepatitis produce inflammation in liver cells, resulting in their injury or destruction. If the condition is severe enough, the cell damage becomes progressive, building a layer of scar tissue over the liver. In advanced cases, as with alcoholic cirrhosis, the liver shrivels in size, a condition called postnecrotic or posthepatic cirrhosis. Hepatitis C Hepatitis C is a virus-caused liver inflammation which may cause jaundice, fever and cirrhosis. Persons who are most at risk for contracting and spreading hepatitis C are those who share needles for injecting drugs and health care workers or emergency workers who may be exposed to contaminated blood. Autoimmune Liver Disease Autoimmune liver diseases include autoimmune hepatitis and primary biliary cirrhosis. Like other autoimmune disorders, these conditions most likely develop because a genetically defective immune system attacks the body's own cells and organs. People who have one of these liver diseases also often have other autoimmune conditions, including systemic lupus erythematosus, rheumatoid arthritis, Sjogren's syndrome, scleroderma, inflammatory bowel disease, glomerulonephritis, and hemolytic anemia. Autoimmune Hepatitis Autoimmune chronic hepatitis occurs when an abnormal immune response causes an attack on the liver cells. It accounts for about 20% of all chronic hepatitis cases. Autoimmune chronic hepatitis typically occurs in women between the ages of 20 and 40 who have other autoimmune diseases. Some research indicates that the postmenopausal period may be another peak in incidence of AIH among women. About 30% of patients are men, however, and in both genders there is often no relationship to another autoimmune disease. In general, no major risk factors have been discovered for this condition. Suspects for triggering this hepatitis include the measles virus, a hepatitis virus, or the Epstein-Barr virus, which causes mononucleosis. It is also possible that a reaction to a drug or other toxin that affects the liver also triggers an autoimmune response in susceptible individuals. Infectious mononucleosis Infectious mononucleosis Swollen lymph nodes, sore throat, fatigue and headache are some of the symptoms of mononucleosis, which is caused by the Epstein-Barr virus. It is generally self-limiting and most patients can recover in 4 to 6 weeks without medications.
Primary Biliary Cirrhosis Up to 95% of primary biliary cirrhosis cases occur in women, usually around age 50. In the case of primary biliary cirrhosis, the cells under attack from the aberrant immune system are in the bile ducts. Liver cells are destroyed as the disease progresses. In some cases, the disease also has features that resemble autoimmune hepatitis, but these features do not appear to affect the long-term outlook. Some research indicates that this autoimmune process may be triggered by a virus or an unknown intestinal microorganism. People with celiac sprue appear to have a higher risk. This is an intestinal disorder associated with an inability to metabolize gluten, which is found in wheat and other common grains. Genetic factors are involved, but the inheritance pattern is unclear. A 1999 English study suggested that the disease is on the rise, although it is unclear if this reflects an actual increase or simply a greater awareness of the disorder. Celiac sprue Celiace Sprue--Foods to Avoid Celiac sprue is an inflammatory condition caused by intolerance to gluten, a substance found in wheat and other grains. The inability to digest and process this substances may lead to inflammation of the intestines, vitamin deficiencies due to lack of absorption of nutrients, and bowel abnormalities. Gluten may be found in many foods, especially processed foods and baked goods. Breads, cakes, desserts that use thickeners, alcoholic beverages (except wine), cereals and pastas may all contain gluten.
Nonalcoholic Fatty Liver Disease Nonalcoholic fatty liver disease, also called nonalcoholic steatohepatitis (NASH), has features similar to alcohol-induced hepatitis, particularly a fatty liver, but it occurs in individuals who do not consume significant amounts of alcohol. Severe obesity and type 2 diabetes are the major risk factors for NASH, as well as for complications from NASH. NASH may occur in about half of people with diabetes and up to 75% of obese people, depending on how severe the obesity is. (It can occur in overweight children as well as adults.) Some evidence suggests that insulin resistance (the primary problem in type 2 diabetes) is a major factor in development of a fatty liver in the first place. Although NASH is generally considered to be a benign and slowly progressive disorder, the fatty liver is vulnerable to injury from oxidants (damaging particles produced by chemical processes in the body). Excessive oxidation can lead to progression to advanced liver disease. In one study of patients with NASH, about 20% had some liver damage over a period of 3.5 to 11 years, with only about 6% of all patients showing severe liver damage. Another study reported that eventually 15% to 20% of patients develop advanced liver disease. Hemochromatosis and Iron Overload Hemochromatosis is a disorder of iron metabolism that is characterized by excess iron deposits throughout the body, including the liver, where they can cause cirrhosis. Once believed to be rare, hereditary hemochromatosis is now considered to be one the most common genetic diseases among Caucasians. Between 2% and 4% of people of European ancestry are believed to carry the gene, and the disease itself is estimated to occur in between 1.5 and three Caucasians per 1,000. Early symptoms of hemochromatosis include: * Fatigue * Joint pain (arthralgia) * Impotence in men * Arthritis. A 2000 study further suggested that both hemochromatosis patients and their relatives who carry the trait are at higher risk for cirrhosis. Elevated iron levels, even in the absence of this disease, have been associated with liver scarring, particularly when accompanied by other risk factors for cirrhosis, including hepatitis, NASH, and alcoholism. Other Causes of Cirrhosis Inherited Diseases Cirrhosis can be caused by a number of inherited diseases including: * Cystic fibrosis. * Alpha-1 antitrypsin deficiency. * Galactosemia. * Glycogen storage diseases. * Wilsons disease. Other Rare Causes. Rare causes of cirrhosis include: * Schistosomiasis, caused by a parasite found in the Far East, Africa, and South America. * Small intestine bypass surgery (rarely, if ever, performed anymore). * Long-term or high level exposure to certain chemicals and drugs can cause cirrhosis, including arsenic, methotrexate, and toxic doses of vitamin A. Changes That Resemble Cirrhosis Cancers that have metastasized to the liver, blood clots in the hepatic or portal vein, or obstructions in the bile duct can cause changes that resemble cirrhosis.
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Herckleperckle
Member
11-20-2003
| Tuesday, July 04, 2006 - 2:30 pm
Source: Adam Healthcare Center Cirrhosis Risk Factors Risk Factors Cirrhosis affects about three million Americans a year. However, because an estimated 2.7 million to 4 million people harbor hepatitis C, experts expect the rates of cirrhosis to dramatically increase over the next few years. (Cirrhosis rates will then decline as the current fall in the prevalence of hepatitis C starts to take effect.) Risk Factors in People with Alcoholism Only 10% of heavy drinkers develop advanced liver disease. Not eating when drinking and consuming a variety of alcoholic beverages are factors that increase the risk for liver damage. Still, the amount of alcohol consumed and the patterns of drinking are only weak predictions of risk. Other risk factors have been identified that may increase the danger to the liver: * Obesity is a major factor for all stages of liver disease. * Women develop liver disease at lower quantities of alcohol intake than men. The reason for this may be due to women's inability to metabolize alcohol as quickly as men, so it stays in the bloodstream longer. * Genetic factors that regulate the immune responses in the intestine also play role in increasing the risk for liver injury from alcoholism. Risk Factors in People with Chronic Hepatitis Risk Factors for Developing Cirrhosis from Hepatitis C. Overall, between 10% and 15% of patients with chronic hepatitis C develop cirrhosis. The risk varies widely, however. The following conditions put people with hepatitis C at higher risk for liver damage: * Overall the risk for progression is highest in men -- particularly African Americans -- who were older at the time of infection. The risk is much lower in women and children (2% to 4%). * Moderate to heavy alcohol users. (Even one or two alcoholic drinks a day increase the risk for liver injury in HCV patients.) * Having a specific genetic type of the virus. There are six main genetic types and more than 90 subtypes, which can differ significantly in their effects and response to treatment. Genotype 1 is the most serious and is the cause of up to three quarters of the cases in the US. The other common forms are types 2 (15%) and 3 (7%), which are pose less danger. (Some evidence suggests that the genetic type is not a primary factor in disease progression, however.) * Co-infection with hepatitis B. Co-infection with B significantly affects the outcome of these patients and may be more common than previously believed. This co-condition may cause superinfections with very serious consequences, reduce these patients responses to interferon therapy, and increase their risk of liver cancer. Patients with hepatitis C should be immunized against hepatitis B. * Co-infection with HIV * A history of transfusions. (In one report, the risk in middle-aged patients with a history of transfusions was 20% to 30%). * Being diabetic and overweight, particularly if fat is distributed in the abdomen (an apple-shape). This condition poses a higher risk for nonalcoholic fatty liver disease (NASH), which in turn is apt to become scarred and cirrhotic. Different types of weight gain Weight gain in the area of and above the waist (apple type) is more dangerous than weight gained around the hips and flank area (pear type). Fat cells in the upper body have different qualities than those found in hips and thighs.
* Having large iron stores in the liver. * High exposure to toxic chemicals or environmental contaminants. Because there are millions of Americans now infected with chronic hepatitis C, experts have been justifiably concerned that there will be a significant number of cases of liver failure and liver cancer in the coming years. Computer analyses have suggested that mortality rates from HCV-related cirrhosis or liver cancer will double or triple over the next twenty years. Fortunately, improved therapies may significantly reduce these discouraging estimates. Risk Factors for Developing Cirrhosis from Hepatitis B The great majority of people with chronic persistent hepatitis B have a good long-term outlook. Between 5% and 10%, however, become carriers of the virus and 5% to 10% of these individuals eventually develop cirrhosis. The addition of hepatitis D is a particular danger and increases the risk for cirrhosis. Seven genetic types of hepatitis B virus (designated A to G) have now been identified, which may help researchers determine which patients may have a better outlook than others. Genotype C is the most common and is more aggressive than genotype B, which also responds better to treatment. Risk Factors for Cirrhosis in Autoimmune Liver Diseases Primary biliary cirrhosis accounts for only 0.6% to 2% of deaths from cirrhosis. And in patients with chronic persistent autoimmune hepatitis, the outlook is very favorable and survival rates are equal to the general population. If it becomes active, it must treated, since untreated the five-year survival rates are 50%. Obesity and Other Risk Factors for Cirrhosis A 2003 study of more than 11,000 patients, published in the journal Gastroenterology, revealed that obesity increased the risk of death from cirrhosis in those who drank little or no alcohol, but not in alcoholics. Previous evidence has suggested that severe obesity and diabetes are major risk factors for cirrhosis in nonalcoholic steatohepatitis (NASH) patients. (Severe obesity in any case is a risk factor for liver damage and in one study, 2.3% of patients with severe obesity had signs of cirrhosis.) Men are at higher risk than women and African Americans have a higher risk than Caucasians. Patients with NASH-associated cirrhosis generally do better than patients with alcohol-related liver damage, however.
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Herckleperckle
Member
11-20-2003
| Tuesday, July 04, 2006 - 2:44 pm
Source: Adam Healthcare Center Symptoms of Cirrhosis Initial Symptoms Many people experience few symptoms at the onset of cirrhosis. Early symptoms include the following: * Fatigue and loss of energy * Loss of appetite and nausea * Spider angiomas may develop on the skin; these are pinhead-sized red spots from which tiny blood vessels radiate Later Symptoms Patients in later stages may develop the following symptoms: * Jaundice. This is a yellowish cast to the skin and eyes, which occurs because the liver cannot process bilirubin for elimination from the body. Jaundice Jaundice is a condition produced when excess amounts of bilirubin circulating in the blood stream dissolve in the subcutaneous fat (the layer of fat just beneath the skin), causing a yellowish appearance of the skin and the whites of the eyes. With the exception of normal newborn jaundice in the first week of life, all other jaundice indicates overload or damage to the liver, or inability to move bilirubin from the liver through the biliary tract to the gut.
* The palms of the hands may be reddish and blotchy, a condition known as palmar erythema. * Loss of body hair. * Abnormalities in hormone-affected organs. In men with alcoholic cirrhosis, the testicles may atrophy and their breasts may become swollen, sometimes painfully. * Ascites. A swollen belly is a sign of ascites, the most common major complication of cirrhosis, which occurs when fluid accumulates in the abdomen. Fever, abdominal pain, and tenderness when the belly is pressed indicate that the fluid is infected, but infection can occur without any symptoms. * Fluid buildup and swelling (edema) in legs. Symptoms of Primary Biliary Cirrhosis People with primary biliary cirrhosis are subject to severe generalized itching and often develop small fatty yellow lumps called xanthomas on the eyelids, hands, and elbows. They may have an unpleasant condition called steatorrhea, in which the feces contain excessive fat, causing them to float and to be very foul smelling. Xanthoma Closeup Xanthomas are raised, waxy-appearing, frequently yellowish-colored skin lesions. They may be associated with an underlying lipid (cholesterol/triglyceride) abnormality.

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Herckleperckle
Member
11-20-2003
| Tuesday, July 04, 2006 - 3:24 pm
Source: Adam Healthcare Center Complications of Cirrhosis Complications Cirrhosis is the eleventh leading cause of death by disease in the US, killing more than 25,000 people each year. A damaged liver affects almost every bodily process, including the functions of the digestive, hormonal, and circulatory systems. The most serious complications are those associated with so-called decompensation, which occur when cirrhosis progresses. They include the following: * Bleeding and fluid buildup (ascites) * Infections * Damage to the brain (encephalopathy). Impaired brain function occurs when the liver cannot detoxify harmful substances Liver cancer is also a long-term risk with cirrhosis. Cirrhosis is irreversible, but the rate of progression can be very slow, depending on its cause and other factors. Five-year survival rates are about 85% and can be lower or higher depending on severity. * For example, for alcoholics with cirrhosis who abstain, a survival rate of five years or more can be as high as 85%. For those who continue drinking, the chance for living beyond five years is no higher than 60%. * In patients with hepatitis B or C, the five-year survival rate after a diagnosis of cirrhosis ranges between 71% to 85%. * About two-thirds of patients with primary biliary cirrhosis never develop symptoms and can have a normal life span. Once symptoms of liver damage, such as jaundice, occur, however, the average survival time declines. In one study of women diagnosed with primary biliary cirrhosis, about 36% developed symptoms over an 11-year period, and 11% either died or required liver transplantation. Unfortunately, physicians are usually unable to determine when cirrhosis first occurred, which makes it difficult to determine prognosis. Portal Hypertension In cirrhosis, liver cell damage slows down blood flow. This causes a backup of blood through the portal vein, a condition called portal hypertension. The effects of portal hypertension can be widespread and serious, including fluid buildup and bleeding. Ascites and Fluid Buildup Ascites is fluid buildup in the abdomen. It is uncomfortable and can reduce breathing function and urination. Ascites is usually caused by portal hypertension, but it can result from other conditions. Swelling can also occur in the arms and legs and in the spleen. Although ascites itself is not fatal, it is a marker for severe progression. Once ascites occurs, only half of patients survive after two years. In fact, some experts refer to the phases of cirrhosis as preascitic and ascitic. Some physicians even believe that ascites signals the need for liver transplantation, particularly in alcoholic cirrhosis. Variceal Bleeding One of the most serious repercussions of portal hypertension is the development of varices, which are blood vessels that enlarge to provide an alternative pathway for blood diverted from the liver. In about two-thirds of patients they form in the esophagus (the "food pipe"). They pose a high risk for rupture and bleeding because of the following characteristics: * They are thin-walled * They are often twisted * They are subject to high pressure * Internal bleeding from these varices (variceal bleeding) occurs in 20% to 30% of cirrhosis patients. The risk of death from a single episode can reach 70%. Bleeding commonly recurs within two weeks of the first episode, but after six weeks, the risk for recurrence is the same as for patients who have not had a bleeding event. Factors that predict variceal bleeding in general include the following: * Ascites (fluid buildup) * Encephalopathy (altered mental state due to changes in the brain) * Large veins Factors that can increase the danger for a bleeding episode in high-risk individuals include the following: * Moderate to intense exercise * Bacterial infection * Certain times of the day. Eating increases portal pressure, and there is a greater risk for bleeding in the evening. A lesser but still significant risk occurs in the early morning. It is important for patients to be screened for esophageal varices and treated with preventive beta blockers if they show signs of risk. Between 30% and 40% of patients with cirrhosis experience bleeding, which carries a mortality rate of between 20% and 35%. Some experts recommend that all newly diagnosed patients be screened using endoscopy. Screening should also be considered for all previously diagnosed patients who have not been screened but would benefit from preventive treatments. Gastrointestinal Bleeding Gastrointestinal (GI) bleeding can occur from abnormal blood clotting, which can be result of a combination of complications associated with cirrhosis. They include vitamin K deficiencies and thrombocytopenia -- a drop in platelets (the blood cells that normally initiate the clotting process). Some research now suggests that thrombocytopenia itself may be associated with more advanced liver failure. Infections Bacterial infections are very common in advanced cirrhosis, and may even increase the risk for bleeding. Most bacterial infections, including those in the urinary, respiratory, or gastrointestinal tracts, develop when patients are in the hospital. Abdominal infections are a particular problem in cirrhosis and occur in up to 25% of patients with cirrhosis within a year of diagnosis. Mental Impairment and Encephalopathy Mental impairment is a common event in advanced cirrhosis. In severe cases, the disease causes encephalopathy (damage to the brain), with mental symptoms that range from confusion to coma and death. A combination of conditions associated with cirrhosis causes this serious complication: * Buildup in the blood of harmful intestinal toxins, particularly ammonia. * An imbalance of amino acids that effect the central nervous system. Encephalopathy is often triggered by certain conditions, including the following: * Gastrointestinal bleeding * Constipation * Excessive dietary protein * Infection * Surgery * Dehydration Alcoholics with cirrhosis are believed to be at higher risk for this complication than with nonalcoholic cirrhosis, but one study suggested that alcoholics simply tend to have more severe cirrhosis. Symptoms of Encephalopathy Early symptoms of hepatic encephalopathy include forgetfulness, unresponsiveness, and trouble concentrating. Sudden changes in the patients mental state, including agitation or confusion, may indicate an emergency condition. Other symptoms include bad fruity-smelling breath and tremor. Late stage symptoms of encephalopathy are stupor and eventually coma. Hepatorenal Syndrome Hepatorenal syndrome occurs if the kidneys drastically reduce their own blood flow in response to the altered blood flow in the liver. It is a life-threatening complication of late-stage liver disease that occurs in patients with ascites. Symptoms include dark colored urine and a reduction in volume, yellowish skin, abdominal swelling, mental changes (delirium, confusion), jerking or coarse muscle movement, nausea, and vomiting. Liver Cancer Cirrhosis greatly increases the risk for liver cancer, regardless of the cause of cirrhosis. Although few studies have been conducted on the risk for liver cancer in patients with primary biliary cirrhosis, one study reported an incidence of 2.3%. About 4% of patients with cirrhosis caused by hepatitis C develop liver cancer. In Asia about 15% of people who have chronic hepatitis B develop liver cancer, but this high rate is not seen in other parts of the world. (One Italian study that followed a group of hepatitis B patients for 11 years found no liver cancer over that period of time.) Osteoporosis About 30% of patients with chronic liver disease develop osteoporosis (loss of bone density), which is twice the usual incidence Primary biliary cirrhosis poses a particularly high risk for osteoporosis. Treating osteoporosis in patients with cirrhosis can be complicated. One study found that calcitriol (a form of vitamin D) is especially helpful in preventing bone loss in patients with cirrhosis. Osteoporosis Osteoporosis is a condition characterized by progressive loss of bone density, thinning of bone tissue and increased vulnerability to fractures. Osteoporosis may result from disease, dietary or hormonal deficiency or advanced age. Regular exercise and vitamin and mineral supplements can reduce and even reverse loss of bone density. Insulin Resistance Nearly all patients with cirrhosis are insulin resistant. Insulin resistance is a primary feature in type 2 diabetes and occurs when the body is unable to use insulin. This hormone is important for delivering blood sugar and amino acids into cells and helps determine whether these nutrients will be burned for energy or stored for future use. Other Complications One study reported that nearly a quarter of patients with cirrhosis had gallstones. Cholelithiasis Normally a balance of bile salts, lecithin and cholesterol keep gallstones from forming. If there are abnormally high levels of bile salts or, more commonly, cholesterol, stones can form. Symptoms usually occur when the stones block one of the biliary ducts or gallstones may be discovered upon routine x-ray or abdominal CT study.
They may also face a higher than average risk for certain abnormal heart rhythms. Peptic ulcers, sleep disorders, and respiratory problems are also more common in people with cirrhosis than in the general population.
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Herckleperckle
Member
11-20-2003
| Tuesday, July 04, 2006 - 4:10 pm
Source: Adam Healthcare Center Diagnosing Cirrhosis Diagnosis A physical examination may reveal the following findings in a patient with cirrhosis: * The cirrhotic liver is firm and often enlarged. The liver may feel rock-hard. (In advanced stages of cirrhosis, the liver may become small and shriveled.) * The left side can often be felt by the physician when pressing on the abdomen. If the abdomen is swollen, the physician will check for ascites by tapping the flanks and listening for a dull thud and feeling the abdomen for a shifting wave of fluid. Specific Tests Used to Diagnosis Hepatitis Measuring Liver Enzymes (Aminotransferases) Enzymes known as aminotransferases, including aspartate (AST) and alanine (ALT) are released when the liver is damaged. Measurements of these enzymes, particularly ALT, are the least expensive and most noninvasive tests for determining severity of the underlying liver disease and monitoring treatment effectiveness. Enzyme levels vary, however, and not always an accurate indicator of disease activity. (For example, they are not useful in detecting progression to cirrhosis.) Radioimmunoassays To identify a particular virus that may be causing hepatitis, blood tests called radioimmunoassays are performed. Typically, radioimmunoassays identify particular antibodies, which are molecules in the immune system that attack specific antigens. (Antigens are any molecules that the body considers threatening or dangerous and which can be targeted by antibodies.) Antigens An antigen is a substance that can provoke an immune response. Typically antigens are substances not usually found in the body. Some of these tests can pinpoint hepatitis antigens directly. These tests, however, have limitations: * There may not be sufficient numbers of antibodies to be detectable by blood tests for up to weeks or months after hepatitis develops. Blood tests that are taken too early, then, may miss these signs of infection. * Antibodies also persist after patients recover, so a positive antibody test can indicate a previous infection but does not necessarily determine if the infection is active. The assays for individual hepatitis viruses may differ. Polymerase Chain Reaction In some cases of hepatitis C, a polymerase chain reaction (PCR), may be performed. A PCR is able to make multiple copies of the genetic material (the RNA) of the virus to the point where it is detectable. Screening for HCV In the March 16, 2004 issue of the Annals of Internal Medicine, the U.S. Preventive Services Task Force recommended against routine screening for the HCV infection in the general population due to low prevalence of the disease. In addition, it "found no evidence that screening for HCV infection in adults at high risk leads to improved long-term health outcomes" and found insufficient evidence to recommend for or against such screening. However, the Task Force did advise testing in those with signs or symptoms of liver disease. The failure to recommend testing in the high-risk population goes against current recommendations made by CDC, NIH and other professional organizations. In response to the study, The American Association for the Study of Liver Diseases issued a statement saying that halting such screening would be a "terrible mistake with grave consequences," pointing out that the study itself underscored some key infection-related data which strongly emphasizes the need for screening in high-risk populations. Biopsy A liver biopsy is the only definite method for diagnosing cirrhosis. It also helps determine its cause, treatment possibilities, the extent of damage, and the long-term outlook. For example, hepatitis C patients who show no significant liver scarring when biopsied appear to have a low risk for cirrhosis. The biopsy may be performed using various approaches including the following: * Percutaneous Liver Biopsy. This approach uses a needle inserted through the abdomen to obtain a tissue sample from the liver. Various forms of needles are used, including those that use suction or those that cut out the tissue. If cirrhosis is suspected, a cutting needle is the better tool. This approach should not be used in patients with bleeding problems, and it must be used with caution in patients with ascites or severe obesity. Liver Biopsy
A liver biopsy is not a routine procedure, but is performed when it is necessary to determine the presence of liver disease and to look for malignancy, cysts, parasites, or other pathology. The actual procedure is only slightly uncomfortable. Most of the discomfort arises from being required to lie still for several hours afterwards to prevent bleeding from the biopsy site. * Transjugular Liver Biopsy. This approach uses a catheter (a thin tube) that is inserted in the jugular vein in the neck and threaded through the hepatic vein (which leads to the liver). A needle is passed through the tube and a suction device collects liver samples. This procedure is risky but may be used for patients with severe ascites. * Laparoscopy. This procedure employs small abdominal incision through which the physician inserts a thin tube that contains small surgical instruments and a tiny camera to view the surface of the liver. This is generally reserved for staging cancer or for ascites with unknown causes. Biopsies can be dangerous, so they cannot be performed on patients who have test results that indicate clotting problems, on those who have had previous liver biopsies, or who have ascites. Tests for Determining Liver Function Certain blood tests are used to determine liver function. They include the following: * Serum albumin concentration. Serum albumin measures protein in the blood (low levels indicate poor liver function). * Prothrombin time (PT). The PT test measures in seconds the time it takes for blood clots to form (the longer it takes the greater the risk for bleeding). * Bilirubin. One of the most important factors indicative of liver damage is bilirubin, a red-yellow pigment that is normally metabolized in the liver and then excreted in the urine. In patients with hepatitis, the liver cannot process bilirubin, and blood levels of this substance rise, sometimes causing jaundice. The results of these tests along with the presence of specific complications (ascites and encephalopathy) are used for calculating the Child-Pugh Classification. This is a staging system (A to C) that helps physicians determine the severity of cirrhosis. Specific Blood Tests for Primary Biliary Cirrhosis Very high levels of serum alkaline phosphatase, an enzyme produced in the liver, and high levels of immune factors called mitochondrial antibodies are usually present in blood tests of patients with primary biliary blood cirrhosis. Bilirubin measurements appear to be important factors in determining its severity. Imaging Tests A number of imaging tests can be used to diagnose cirrhosis and its complications. Imaging Techniques Magnetic resonance imaging (MRI), computed tomography (CT), and ultrasound are all imaging techniques that are useful in detecting and defining the extent of cirrhosis. Such tests can reveal ascites, enlarged spleen, irregular liver surface, reversed portal vein blood flow, and liver cancer. Sometimes they can even detect abnormally large blood vessels in the liver. In some cases, images from ultrasound and CT can be misinterpreted as cancer. MRI is most useful for ruling out or confirming cancer. MRI
MRI stands for magnetic resonance imaging. It is a relatively new technology that allows imaging of the interior of the body without using X-rays or other types of ionizing radiation. An MRI scan is capable of showing fine detail of different tissues. Its use is rapidly increasing while the use of standard X-rays is decreasing. CT Scans
CT stands for computerized tomography. In this procedure, a thin X-ray beam is rotated around the area of the body to be visualized. Using very complicated mathematical processes called algorithms, the computer is able to generate a 3-D image of a section through the body. CT scans are very detailed and provide excellent information for the physician. Liver Scans. Sometimes liver scans are performed using a small radioactive tracer and a special camera that records information provided by the tracer as it passes through the liver: * Arteriography uses dye injected into the hepatic arteries that show up on x-ray. * Splenoportography uses dye injected into the spleen, which allows the physician to measure portal vein pressure; this procedure is risky. Hepatic Vein Wedge Pressure Hepatic vein wedge pressure involves insertion of a catheter into the hepatic veins. The blood pressure in the veins of the liver is then measured. The result is an indicator of portal vein pressure. If pressure is high, cirrhosis is likely. A low measurement is a favorable sign. Other Tests Used to Detect Complications of Cirrhosis Endoscopy Some experts recommend endoscopy for patients newly diagnosed with mild to moderate cirrhosis in order to screen for esophageal varices. (These are abnormal blood vessels in the esophagus that increase the risk for bleeding). This test involve inserting a fiber optic tube down the throat. The tube contains tiny cameras to view the inside of the esophagus, where varices are most likely to develop. Endoscopy is the only procedure for detecting varices, but it is not clear if screening for varices in patients without severe cirrhosis is any more beneficial than simply putting them immediately on preventive drugs -- whether or not varices have been identified. Paracentesis If ascites is present, paracentesis is performed to determine its cause. This procedure involves using a thin needle to withdraw fluid from the abdomen. The fluid is tested for different factors to determine the cause of ascites: * Bacteria cultures and white blood cell counts. (These are used to determine the presence of infection.) * Protein levels. Low levels of protein in the fluid plus a low white blood cell count suggest that cirrhosis is the cause of the ascites. The appearance of the fluid is helpful in determining problems: * A cloudy fluid plus a high white blood cell count means an infection is present. * Bloody fluid suggests the presence of a tumor. Screening for Liver Cancer. Patients with cirrhosis are usually screened for liver cancer using ultrasound and tests for a substance called alpha-fetoproetin (AFP). It is not known whether such screening has much impact on survival, because it is not very sensitive and has a high rate of false positives (suggesting the presence of cancer when it is not actually present). Screening is not necessary in patients without cirrhosis.
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