Cirrhosis of liver is slow and gradual replacement of normal healthy liver tissue with scar tissue which results in poor liver function and blockage of flow of blood through liver which comes from intestines. As more scar tissue replaces normal healthy liver, liver begins to fail.

What causes cirrhosis?

Alcohol: Amount of alcohol which can cause liver damage varies from person to person, however those who consume alcohol for long in significant amount are more prone to develop liver damage.
Hepatitis B or hepatitis C: Caused by hepatitis B and C viruses, respectively, which are acquired by contact with contaminated blood (like needlestick injury, blood transfusion, injection drug abuser), sexual contact with infected person and from mother to child during childbirth.
Non-alcoholic fatty liver disease (NAFLD): Caused by presence of extra fat in liver (after excluding significant alcohol intake) which causes inflammation and scarring leading to cirrhosis. Usually seen in patients who are overweight or obese, having diabetes, high fat in blood, high blood pressure or metabolic syndrome.
Drugs causing liver injury.
Others: Autoimmune hepatitis (body`s own immunity acting against liver), Wilson disease (build up of copper in body), hemochromatosis (excess of iron in body), certain bile duct disorders, etc.
What are the symptoms of cirrhosis?

Early disease can present with nonspecific symptoms like weakness, fatigue (loss of energy), decrease wish to take food, vomiting or nausea, weight loss, etc.
Advanced disease can present with fluid accumulation in legs (edema) or abdomen (ascites), facial puffiness, yellowish discoloration of eyes or urine (jaundice), redness of palm (palmer erythema), decrease urine output, small red lesions on skin, easy bleeding following trauma, blood coming out of mouth/anus/other body site, black colored feaces, mental confusion, flapping tremors of hand, etc. In men it can cause impotence, breast enlargement and shrinking of testis.
What are the complication of cirrhosis?

Portal hypertension: It is a common complication of cirrhosis which is due to increased pressure in portal vein. Portal vein is main blood vessel which carries blood to liver from stomach, intestines, spleen, gallbladder and pancreas. Because of scar formation in liver the normal flow of blood from these organs to liver is hampered. As a result of blockage of blood flow to liver there are few complications which can arise like accumulation of fluid in abdomen (ascites) and legs (edema), formation of enlarged veins (varices) in food pipe (esophagus), stomach, etc., enlargement of spleen (splenomegaly), mental confusion/altered behavior/altered sensorium (hepatic encephalopathy), respiratory discomfort (hepatic hydrothorax or hepato-pulmonary syndrome) or decrease urine output/rise in creatinine (hepato-renal syndrome).

Increase risk of infection because of immune system dysfunction.
Development of liver cancer (Hepatocellular carcinoma)
Easy brusibility or bleeding following light trauma.
Gall bladder stone formation
Metabolic bone disease
What are the stages of cirrhosis?

Compensated cirrhosis: Liver damage is damaged but no abdominal swelling (ascites), blood in vomiting or black/red color feaces (variceal bleed), altered behavior/sensorium (hepatic encephalopathy), respiratory discomfort (hepatic hydrothorax or hepato-pulmonary syndrome) or decrease urine output/rise in creatinine (hepato-renal syndrome).
Decompensated cirrhosis: Presence of abdominal swelling (ascites), blood in vomiting or black/red color feaces (variceal bleed), altered behavior/sensorium (hepatic encephalopathy), respiratory discomfort (hepatic hydrothorax or hepato-pulmonary syndrome) or decrease urine output/rise in creatinine (hepato-renal syndrome).
How cirrhosis is diagnosed?

Your doctor will take good history and do proper physical examination. If there is suspicion of cirrhosis then he will subject you to some blood test, ultrasound abdomen, fibroscan/elastography, upper GI endoscopy and if needed CT scan or MRI of abdomen or liver biopsy.

Ultrasound of abdomen in cirrhosis may shows coarse liver echotexture, nodular liver surface, dilated portal vein or collateral, enlarged spleen or abdominal fluid (ascites).

How to prevent cirrhosis?

Best way to avoid development of cirrhosis from predisposing stage of liver illness is to recognize and treat early. Few advices to keep liver healthy are:

Dietary modification: Eat healthy balanced diet. Avoid high calorie food or drinks, saturated fat, sugar and refined carbohydrates. Keep yourself hydrated.
Lifestyle modification: Maintain healthy body weight. Avoid being overweight or obese. Aerobic exercise (like brisk walk 30-45min/day atleast 5days/week) regularly helps to lower liver fat.
Avoid: Avoid use of contaminated needles, sharing of items of personal hygiene (like shaving razors, toothbrush, nail clippers, etc), use of illicit drugs, self medication with over the counter drugs or using drugs beyond doctor`s advice.
Practice safe protected sex
Alcohol
Motivate others: to stop drinking and follow hand hygiene and doctor`s advice.
Hand hygiene: Wash hand with soap and water regularly before eating, after going to toilet and after touching dirty objects.
Vaccination: For hepatitis A or hepatitis B, if you are not vaccinated or not already infected or unsafe antibody titre. Transmission rate of hepatitis B from mother to child at birth can be reduced with vaccination and immunization of newborn starting within 12 hours of birth as well as by using antiviral drugs (if indicated).
Prevent others from getting infected from you if you harbor virus causing liver damage.

How to treat cirrhosis?

Treatment of cirrhosis is based on cause of cirrhosis and complication of cirrhosis. Main aim of treatment in early stage of cirrhosis is to slow the progression of cirrhosis and prevent complications development

Stop alcohol, antiviral drugs for hepatitis b or hepatitis C, proper sugar level if diabetes, steroid or other medications for autoimmune hepatitis, medications to reduce copper from body in patients with Wilson`s disease, etc.
Drugs to lower portal pressure (beta-blocker or nitrates), drugs to remove fluid from body (diuretics), drugs to lower ammonia level for encephalopathy (lactulose and others), drugs to improve kidney function (albumin, terlipressin and others).
Opt for liver ransplant, If cirrhosis is life threatening or treatment of cirrhosis complication is ineffective.
Low salt high protein diet
Stop alcohol intake even if you have other cause of cirrhosis.
Stop smoking
Avoid over the counter drugs (especially pain killers)
Vaccinate if not done already or infected

Cirrhosis Of Liver - A Complete Guide!

The liver is the engine of the human body. It is basically composed of 2 types of cells (a cell is the basic building block of the human body)   hepatocytes (liver cells) and cholangiocytes (bile duct cells). It also has other supporting tissue and their respective cells. The hepatocytes are by far the most numerous cell type, not surprisingly tumours (otherwise called mass or lump.  Tumor  means lump in Latin), of this cell form the majority of abnormal growths in the liver. Abnormal growths can be benign (that is, they do not grow rapidly, spread to other parts of the organ or to other parts of the body) or malignant (grow rapidly, spread to other parts of the organ and to other parts of the body, i.e. cancer). These abnormal growths from liver cells are Focal nodular hyperplasia (FNH), Adenomas (the benign variety) and hepatocellular cancer (otherwise called Hepatoma/HCC, the cancerous type). What we need to recognize is that certain adenomas can turn into HCC, over a period of time. The other type of growths in the liver are those that have originated elsewhere in the body and spread to the liver, for example a growth of the breast spreading to the liver. These are in fact the commonest tumours of the liver. I will discuss these at a later date.

Benign growths of the liver

Common benign growths are Haemangiomas, FNH and Adenoma. Most of these are identified when a scan is performed as investigation for some other problem. Accurate diagnosis of the nature of these lumps is important to determine the type of treatment needed. This can be ascertained by a carefully selected scan like an Ultrasound, CT scan or an MRI. The technology of these scans is continuing to evolve and get better year on year. There are different types of Ultrasound, CT and MRI scans with different applications, based on whether contrast is used or not, the different phases of scanning, the type of MRI scanning sequence etc. Therefore, these scans although commonly available and used very frequently, need to be performed under the supervision of a team involving Liver doctors and radiologist who is well versed in the diagnosis of liver lumps, for accurate diagnosis without the need for unnecessary tests (Box 1).

Haemangiomas are by far the commonest. It is estimated that 5% of the adult population harbor this lump in their livers! They occur in both sexes and at all ages but are commonest between 30 to 50 years in women. Most of them are small, less than 4-5 cms in diameter and are are identified on Ultrasound. MRI and its various applications is the scan of choice for accurate diagnosis. This is crucial as most of them do not need treatment.

Focal Nodular Hyperplasia (FNH) are the second most common liver lumps. They are usually single and small (less than 4 cms) and occur in women between 35   50 years of age. About 2.5-3% of population harbor this lump in their livers. Special MRI techniques using special contrast agents is diagnostic and the findings are quite distinct from haemangiomas. Again treatment is not recommended apart from selected circumstances. Assessment in a dedicated Liver team is recommended for accurate diagnosis and a proper management plan to be formulated.

Hepatic adenomas (Hepatocellular adenoma, HCA) are rare lumps and occur in 0.2 to 0.3% of the population, again occurring mostly in young women during their reproductive period. They are again solitary and most usually 3-4 ms in diameter.

There are a couple characteristics which make this lump different from the previous 2, there is a strong relation between hormones the development of HCA and some of these HCA can turn into the malignant Hepatocellular carcinoma (HCC). Therefore, accurate characterization and diagnosis of these HCA is essential. Sometimes biopsy of the lump, molecular and genetic tests maybe necessary to determine if the HCA has a high chance of progressing to HCC. Imaging tests are generally adequate, contrast MRI Liver and its different techniques is accurate in diagnosing HCA and sub-typing it, however CT and contrast-enhanced Ultrasound is sometimes necessary along with MRI.

Generally, a HCA in a male is recommended for surgical resection. While in women, discontinuation of the OCP pill/ any other such hormone is recommended for a period of 6 months, if the HCA does not have any worrying features and size is less than 5 cms. IF HCA is larger than 5 cms and has features suggestive of a high risk for change to HCC, surgery is advised. Again these decisions have to be made as a part of a Multi-disciplinary team (Box 1)

Malignant growths beginning within the Liver

As mentioned earlier, usually malignant growths which are seen in the liver spread to it from elsewhere in the body. Hepatocellular cancer/Hepatoma (HCC) is the commonest malignant tumour beginning within the liver, as apposed to those that spread to the liver from elsewhere. It occurs between 40-70 years of age and occurs commonly in men. It is estimated that 17000 new patients develop this tumour every year in India. The vast majority (> 80%) of these develop in patients who have chronic liver disease (cirrhosis). Importantly the number of HCC cases is increasing year on year as cirrhosis due to fatty liver disease, Hepatitis B (3% of Indian population carry this virus, ie nearly 40 million individuals) and alcohol are continuing to increase in India. Nearly overall it is the 4th or 5th most common cause of cancer and the second most common cause of cancer-related death. This is continuing to increase too. We do not have a national policy in India to screen and diagnose these lumps in the liver at an early stage. Most patients present at a late stage when effective treatment is not possible.

Hepatitis B is a vaccine-preventable disease, there are good drugs to treat it and decrease the risk of cirrhosis and HCC in HBV patients, therefore it is important to test for this virus infection. The fatty liver disease can cause chronic liver damage and HCC, regular exercise and consuming a balanced diet can reduce the risk of fatty liver disease.

The usual mode of detection of these growths is when a scan is done for some other reason. Occasionally patients can develop pain in the abdomen or jaundice which leads to an investigation. The treatment of HCC depends on the extent of tumour, the extent of the chronic liver disease (the stage of cirrhosis) and the overall condition of the patient. These patients are best seen, assessed and treated in a team (Box 1) which specializes in the treatment of Liver disease.

The best treatment for HCC is surgery. However, this is suitable only for certain carefully selected patients. This can take the form of liver resection (where a portion of the liver with tumour is removed) or liver transplantation (where the whole liver is removed and a donated liver (full or partial) is replaced into the patient. Indeed surgical has excellent survival rates; more than 75% of patients survive for more than 5 years after resection or transplantation making treatment for these cancers one of the most satisfactory.

Other treatments which can be combined with surgery in selected patients or can be combined with patients not suitable for surgery are different types of Interventional radiological therapy   chemotherapy or radiotherapy delivered through fine catheters introduced into the blood vessels of the liver (TACE: Transarterial chemotherapy, TARE: Transarterial radiotherapy) and or heat energy delivered to the tumour area by means of carefully placed needles/probes (RFA: radiofrequency ablation, MWA: microwave ablation).

HCC is unique cancer as its treatment should be tailored to the patient, the treatments are varied and range from catheter-based non-invasive treatment to major surgery and transplantation. This necessitates that HCC patients are best managed in a multidisciplinary team which is highly skilled in and specializes in the management of liver diseases.

Box 1: A liver tumour multidisciplinary team   Integrated Liver Care team

The team should be one with expertise in the management of benign liver lesions and should include a Hepatologist, a Hepatobiliary & Transplant surgeon, Diagnostic and Interventional radiologists, Medical oncologist and a Pathologist.

Each member of the team must hold specific and relevant training, expertise and experience relevant to the management of benign liver lesions.

The team should be one with the skills required not only to appropriately manage these patients but also to manage the rare but known complications of diagnostic or therapeutic interventions.

The Increasing Problem Of Liver Tumours In India!

In healthy individuals, the liver contains little or no fat. In overweight or obese people, gradual fat accumulation leads to significant liver disease. Interestingly, these individuals may be consuming minimal to no alcohol. So, alcohol, which is the main cause for liver damage, does not have a significant role to play.

The non-alcoholic fatty liver disease (NAFLD) has 4 significant stages as outlined below. It is a chronically progressive disease and may take years to reach the final stages of cirrhosis and fibrosis.

1. Simple fatty liver (steatosis): This is usually identified when diagnostic tests are done for some other suspected conditions. There are usually no symptoms obvious in this stage, other than the buildup of fat in the liver.

2. Non-alcoholic steatohepatitis (NASH): The second stage where the liver is inflamed to a greater extent due to fat accumulation.

3. Fibrosis: The next degree of inflammation where blood vessels may be narrowed leading to scarring in the liver with impaired liver functions.

4. Cirrhosis: This is the most severe stage that occurs due to years of cumulative inflammation. The liver shrinks in size, is scarred, and liver functions are markedly impaired and can also result in liver cancer.

Risk factors for NAFLD: The exact reason why a person develops NAFLD is not established, but some of the risk factors include

1. Obesity, with more weight concentrated around the abdomen

2. Type 2 diabetes

3. High blood pressure

4. High cholesterol levels

5. Age greater than 50

6. Smoking

Symptoms: This will depend on the stage in which it is identified. While there are no symptoms in the early stages, in some people there could be a dull, aching below the ribs, unexplained weight loss, weakness, and extreme tiredness. As it progresses to cirrhosis, there could be jaundice, fluid accumulation in the abdomen and feet, and itching of the skin.

Management: While there is no treatment aimed at curing the disease per se, there are ways to manage the symptoms, as noted below.

1. Weight loss: Reducing excess accumulated fat will help reverse symptoms and prevent further progression of the disease. A BMI of 18 to 26 is considered optimal.

2. Dietary changes: Modify your diet to a carbohydrates and protein rich and reduced fats and sugars. Increasing fiber through fruits and vegetables is highly recommended.

3. Exercise: Whatever your choice of workout, it will do wonders for NAFLD. Keep a target of an hour or two of moderate to intense exercise per day to reduce weight.

4. Smoking: This is another risk factor and can also help prevent other effects of NAFLD such as diabetes and heart disease.

NAFLD is highly controllable with these changes and other damages can be reversed too.

What is Nonalcoholic Fatty Liver Disease (NAFLD)?

Interstitial cystitis (IC), also known as painful bladder syndrome, is a difficult condition. It is difficult to diagnose and though there are treatments that can make life easier, there is no long-term cure. Interstitial cystitis is a lifelong bladder problem, that causes pressure and pain below the belly button. Symptoms can be constant, or they may fluctuate. It causes painful and urgent trips to the bathroom. In severe cases, you may need to urinate about 40 to 60 times in a day.

What causes interstitial cystitis (IC)?

The bladder is a hollow, muscular organ that holds the urine your body needs to dispose. The reason why IC occurs isn t that clear, but there a few ideas:
1. An issue with bladder tissue allows chemicals in your urine to irritate the bladder.
2. Chemicals that are released when there is an inflammation in your body can cause the symptoms.
3. The bladder can be attacked by your immune system
4. Substances in your urine can damage your bladder
5. Nerve problems can wreak havoc on your bladder

Signs and Symptoms
People suffering from IC don t display the same symptoms. The symptoms keep changing, be it every day, every week or every month. Sometimes, the symptoms may entirely disappear without treatment. Some common IC symptoms include:
1. Bladder pressure and pain that worsens after the bladder gets filled with urine
2. Pain in your urethra (the tube that drains the urine from your bladder), pelvis, lower back and lower tummy
3. Women experience vaginal pain (or the area behind it) or in the vulva
4. In men, a sensation of pain in the penis, testicles, scrotum or the region behind the scrotum
5. The urge to urinate, even if you had urinated a few moments ago
6. Women experience pain during intercourse
7. Men experience pain after sex or during orgasm

One common symptom shared by all people suffering from IC is a swollen bladder. There are certain things that can worsen your condition. These include:
1. Certain drinks or foods
2. Physical or mental stress
3. Menstrual cycles

Interstitial Cystitis (IC) - 5 Things That Can Cause it

The build-up of fat in the liver may lead to the development of a condition known as nonalcoholic steatohepatitis or NASH. This condition is not related to the consumption of alcohol and the inflammation is due to the buildup of fats in the liver. In most cases, there are no symptoms till the stage when the fat deposition causes inflammation and damages the liver cells. This also hinders the normal functioning of the liver and if not treated, it may lead to an extreme condition known as cirrhosis. However, NASH does not always get worse and with some precaution, it can be treated.

The cause behind the development of this disease is not alcohol consumption and it could be some environmental factor that triggers liver inflammation or heredity might be another reason. However, the risk of developing this disease is high for people who are obese, have metabolic syndrome, have high cholesterol or are resistant to insulin.

There are hardly any symptoms of NASH that are seen in the early stage of this condition. However, at a much-progressed stage, the following symptoms may be seen:

Weight loss
Fatigue and weakness
Upper abdomen pain
Diagnosing NASH requires undergoing several tests that include a blood test, a CT scan, an MRI scan and also an abdominal ultrasound.

Benefits of Ayurvedic remedies in managing NASH



There are remedies which help in detoxification of the liver. They also enhance the body s capacity to digest fats and prevent it from accumulating in the liver.
A few remedies are rich in vitamin C content as they are very effective in treating liver problems.
Some remedies are packed with the antioxidant and vitamin C. And, it is this vitamin C that helps the liver in producing the enzyme, glutathione, which neutralizes the toxins and detoxifies the liver of all of the toxins.
Some remedies contain catechins, which are known to enhance the functioning of the liver. They are great for blocking the fat stored in the liver and works wonder in fighting against diseases associated with the fatty liver disease.
There are some fruits that are effective in treating fatty liver diseases. These fruits burn the dietary fat rapidly and also improves the functioning of the liver if consumed regularly.
Some Ayurvedic remedies are a storehouse of the fat-soluble Vitamin E, and are known to protect your liver against the accumulation of fats and will keep your liver healthy.
Apart from including these natural ingredients in your diet, you will also have to reduce your body weight, reduce cholesterol level, control your diabetes, exercise regularly and stop consuming alcohol. However, home remedies are just supportive, but not a complete line of treatment for NASH so you cannot depend completely only on them. As mentioned NASH can disturb your normal liver functioning and if not treated it can lead to liver cirrhosis so take proper Ayurvedic treatment under the guidance of an Ayurvedic doctor.

In case you have a concern or query you can always consult an expert & get answers to your questions!

Nonalcoholic Steatohepatitis (NASH) - Home Remedies That Can Help Treat It!

Pregnancy is a blissful period, even with all the discomfort associated with it. And with proper awareness and caution, it is possible to keep pregnancy-related complications at bay to have a smooth sailing experience till you deliver the little bundle of joy.

Some women have health issues during pregnancy, while others suffer from disorders before pregnancy, leading to complications at the time of the pregnancy. It is very crucial for women to receive proper health care, both before and during pregnancy to reduce the risks of complications. Here are some common pregnancy complications that you should know about before you start planning a family.

Anemia: Anemia is a condition where you have lower than the desired number of healthy red blood cells. To deal with this condition, it is important to treat the underlying cause of anaemia. The most common symptom of this complication is feeling tired and weak even with the slightest physical exertions. You will have to eat a proper diet that consists of folic acid and iron supplements. Your healthcare provider will have to regularly monitor the iron levels during the time of pregnancy.
High blood pressure: Chronic high blood pressure before as well as during pregnancy puts the mother and the baby at risk. It is associated with increased maternal complications such as placental abruption, preeclampsia, and gestational diabetes. It puts you at risk of preterm delivery and even infant death. It is crucial to handle this condition before pregnancy to mitigate the complications.
Obesity: Recent studies suggest that the heavier a woman is before pregnancy, the greater are her chances of developing pregnancy complications. Research suggests that obesity during pregnancy is related to increased use of health care services along with longer hospital stay after the delivery. It may also cause complications like gestational diabetes and stillbirth.
Urinary tract infections or UTI: A urinary tract infection is a bacterial infection of the urinary tract. The common symptoms of this disease include fever and shakiness, pain and burning sensation at the time of passing urine, a pressure in the lower belly, an urge to use the bathroom often along with reddish and cloudy urine. If you think you have this complication, you should consult your doctor immediately. Your doctor will most likely prescribe treatment for the same.
Placenta previa: Placenta previa occurs when a baby's placenta partially or totally covers the mother's cervix   the outlet for the uterus. Placenta previa can cause severe bleeding during pregnancy and delivery. You'll need a C-section to deliver your baby if the placenta previa doesn't resolve.
Talk to your gynaecologist if you think there is even the slightest chance of suffering from one of these complications to avoid the further dire consequences.

5 Pregnancy Complications That You Should Not Ignore!

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