Liver disorders are very common. Gastroenterologists trained in liver diseases are known as Hepatologists.Symptoms of liver disease include jaundice, vomitting of blood(Hemetemesis), bleeding in the motions(also known as Melena or hematochezia),altered sensorium known as Hepatic encephalopathy(HE), Renal failure also known as Hepatorenal syndrome(HRS), Breathlessness (due to Hepatopulmonary syndrome and portopulmonary hypertension).

Let s understand the liver disease point by point: 

1. Hepatitis B: Hepatitis B is a virus which is usually acquired in four ways. Unprotected sexual intercourse with the infected partner, from infected to the child, infected needles, infected blood. It takes many years for the hepatitis B virus to cause liver damage. Once the liver is damaged it is called Cirrhosis or chronic liver disease. When liver is more then 80 percent damage, it causes blood vomiting also known as hematemesis, Ascites(water in the stomach), Jaundice, HE, HRS etc. Treatment depends on virus count which is calculated by HBV DNA PCR and other lab parameters. Once the treatment starts monitoring of viral count is done to document the effectiveness of the treatment. All the family members and sexual partners must get HbsAg screening done to detect early silent infection. All those who test negative, Hepatitis vaccination should be done, by three injections which provide them with 100% protection against the HBV infection.

2. Hepatitis C: Hepatitis C is a virus which is acquired by injection drug abuse and infected needles and blood. Transmission by unprotected sexual intercourse is possible but chances are very low. Hepatitis C virus damages the liver slowly and takes years before clinical symptoms of liver failure appear. Once the liver is damaged it is called Cirrhosis or chronic liver disease. When the liver is more than 80 percent damage, it causes blood vomiting also known as hematemesis, Ascites(water in the stomach), Jaundice, HE, HRS etc. All hepatitis C virus infected patients must be treated irrespective of virus count. Baseline virus count by HCV RNA  is done to measure the effectiveness of the treatment. HCV Genotype is done for patients with cirrhosis. Vaccination is not available for hepatitis C but newer medicines(Direct acting antivirals DAA) for Hepatitis C can cure it with more than 95% certainty.

3. Acute viral Hepatitis: Sudden infection in the liver can be due to multiple causes but commonly is due to Hepatitis A and Hepatitis E, which are caused due to eating or drinking contaminated food and water. Rarely Hepatitis B and Hepatitis C can cause Acute hepatitis including Acute liver failure. Acute hepatitis presents with Jaundice, loss of appetite, generalised fatigue, vomiting and abdominal pain.  Patients are usually treated on an outpatient basis but if they have severe vomiting, abdominal pain or altered sensorium, they are admitted for inpatient care and monitoring. Drugs or complementary and alternative medicines (CAM) such as herbal or bodybuilding protein supplements which contain steroids and heavy metals can cause acute hepatitis.

4. Liver transplant: Removing the damaged liver and to put a new liver in the patients is called Liver transplant. Liver transplant is major surgery and costs around 20 to 30 Lacs. Indications of liver transplant are an acute liver failure due to hepatitis viruses such as hepatitis A, Hepatitis B, Hepatitis C and Hepatitis E, decompensated cirrhosis due to any cause including chronic hepatitis B and C, Drug-induced liver failure such antitubercular drugs(ATT). The donor for liver transplant is either a close relative (Living donor liver transplant LDLT) or a brain dead donor (deceased donor liver transplant DDLT).

5. Chronic liver disease or Cirrhosis: It is the end result of slow damage to the liver, where many liver cells are damaged and replaced by fibrosis. Apart from viruses such as Hepatitis B and Hepatitis C, Alcohol is one of the most common causes of cirrhosis.

Drinking alcohol for years together causes irreversible liver damage causing cirrhosis. Alcohol can cause acute severe hepatitis, acute liver failure and chronic liver disease.  Patients with suspected heavy alcohol drink must-visit Hepatologist (Liver doctor ) for proper diagnosis of stage of liver damage and deaddiction programme. USG Abdomen, blood tests, endoscopy and Fibroscan is usually done to know the liver health.

Fatty liver is also known as non-alcohol fatty liver disease(NAFLD) is a lifestyle disorder due to lack of exercise, high fat diet, obesity and due to drugs. Fatty liver causes silent liver damage and if not recognised in time can cause irreversible liver damage and cirrhosis. The evaluation includes Liver function tests, Ultrasound abdomen, Fibroscan. Treatment includes daily moderate-intensity aerobic exercise, drinking coffee and a low-fat diet. Few medicines are available which help in the reversal of fatty liver.

What Should You Know About Liver Disorders?

Sugar is the trigger to most of the diseases an adult faces in present times. Sugar is not only harmful for adults, but can pose severe threats to the health of a child as well, if not administered in monitored proportions. But again, sugar is indispensable when it comes to sweetening your drinks and desserts. In order to prevent yourself from the health hazards of sugar, you should know more about its scope and effects.
1. Sugar can lead to a fatty liver: Fatty liver is a troubling issue faced by many across the globe. It is wrong to think only alcoholics are subjected to this health condition. People who exercise little and consume huge amounts of fructose are also exposed to the threat of this disease. When a person doesn't do enough to burn up the existing amount of glycogen in his or her liver and take in fructose repeatedly, the liver turns that fructose into fat, impairing one's liver capabilities to a great extent.

2. Sugar may make you resistant to Leptin: Leptin is a hormone released by your fat cells. The hormone is particularly necessary as it sends signals to your brain telling it you are full and won't be requiring any more food. Fat people have more number of fat cells and thus additional Leptin too. The Leptin becomes inactive due to the effects of heightened blood triglycerides and insulin, both of which counter its functioning.

3. It is addictive and there lies the key to temptation: Sugar is enormously addictive. If you like sweetened products, you will find it hard to resist your cravings for cakes, cookies or chocolates. Sugar accelerates dopamine secretion; this hormone makes a person feel good. Dopamine is the hormone released on the consumption of drugs such as cocaine.

4. Calories in sugar are not balanced out with any mineral or vitamin: Because of its lack of nutrient value, sugar is said to have empty calories. Food items rich in sugar tend to make a person lethargic and slackened while depriving them of essential minerals and vitamins. It is therefore, best to not allow children to have pastries, chocolates or puddings in excess.

5. Sugar leads to extensive tooth decay: Sugar can accumulate on your teeth if you are having too many sweetened food items. This causes your teeth enamel to wear away, making it more prone to cavities and dental caries.

Why You Should Stay Away From Sugar?

Tummy tuck also known as an abdominoplasty, a tummy tuck surgery is a form of cosmetic surgery, which is used to remove excess fat and skin from the abdomen as well as tighten the muscles in your abdominal regions. Similar to 'mommy makeovers' (a procedure applicable after pregnancy, which helps women restore their figure). 


Tummy tuck surgery is used to help patients treat that loose and sagging skin who have experienced excessive weight loss within a relatively short period of time. Although, it is usually done for cosmetic reasons, it does provide a large number of medical benefits, such as:


1. Reduction in stress urinary incontinence: Stress Urinary Incontinence is a bladder control problem that is characterized by involuntary urination because of exercises or normal bodily functions such as sneezing or coughing which might put pressure on the bladder. In some women, (SUI) can develop after a vaginal birth. The condition does not generally require a surgery. However, research has shown that in severe cases, abdominoplasty is helpful in patients who do not have a caesarean section. A slight bladder obstruction is made during the procedure using soft tissue which reduces the incontinence.


2. Better posture and improved abdominal tone: Strong muscles tend to become weak after multiple pregnancies and extreme weight loss. In these cases, diet and exercise are not enough. Abdominoplasty surgically removes excess fat and skin thereby, tightening weak muscles and flattening the abdomen. It is noticed that after the surgery, the patients develop an improved posture due to the tightened muscles supporting the spine. This helps in relieving a variety of back pains.


3. Correction of ventral hernia: Ventral Hernia is the bulging out of tissues through a defect, opening or past incisions within the wall muscles of the abdomen. In such a case, the surgeon may opt for Abdominoplasty to support the abdominal wall and prevent recurrences.


Medical Benefits of Tummy Tuck Surgery 

Ulcerative colitis is a disorder that causes inflammations and ulcers inside your colon, affecting the entire digestive system. The disease grows over time and symptoms start to worsen over a prolonged period, rather than the problem showing up suddenly. Severe cases of ulcerative colitis may even be fatal if treatment does not resolve some of the complications arising from the condition.

Causes of Ulcerative Colitis-
The exact cause for the inflammatory bowel disease is unknown. Improper diet and lifestyle can aggravate the symptoms, but do not cause the condition. Some possible causes for the disease include-

Improper functioning of the body s immune system causes it to recognize the colon as a foreign body.
Genetic factors and hereditary may also be held accountable in some instances.
Risk factors for the condition include old age and family history of the condition.

Symptoms of Ulcerative Colitis-
Here are some common symptoms associated with the condition-

Bloody diarrhoea
Rectal pain
Weight loss
Pain in the abdominal region along with cramping
Fever
Urgency to defecate
Inadequate bowel movement despite the feeling of urgency
How can you prevent ulcerative colitis?
Ulcerative colitis cannot be prevented as the exact cause for the condition is unknown. However, there are simple steps that will help manage the symptoms.

Diet change- You need to stop eating certain foods, such as, dairy products, beans, broccoli, cabbage and anything spicy. Instead, fibre intake must be increased drastically.
Exercise- Mild exercise or activities have a profound impact on managing the condition.
Avoiding stress
Drinking plenty of fluids
Role of Homeopathy in Managing Ulcerative Colitis-
Homeopathy follows a natural and holistic approach to deal with the condition. It does not merely treat the symptoms, but looks to cure the underlying cause for those symptoms. Homeopathic remedies will greatly bolster the overall condition of the body s immune system. Furthermore, the bloody diarrhoea accompanying the disease will also stop with proper homeopathic treatment.

Ulcerative Colitis - Does Homeopathic Treatments Work?

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!

A liver transplant surgery involves surgically substituting a problematic liver with a healthy liver from a different person. Usually, the healthy liver is taken from a person who has recently passed away. In some cases, a living person may also give away part of the liver. Usually, living donors are members of the family or someone who has a good blood type match. The liver regenerates lost tissues after a surgery; hence, the donor s liver becomes normal within a few weeks of surgery.

You may require a liver transplant if your liver does not function optimally, owing to the below mentioned conditions:

    Cirrhosis: This is a chronic disease of the liver wherein, scar tissues replace healthy tissues in the liver, thus, not allowing the liver to function optimally.
    Metabolic disease: Disorders that modify the activity of the chemicals in the body
    Acute hepatic necrosis: This is a disorder that causes the healthy tissues in the liver to die
    Autoimmune disorders or liver cancer: Autoimmune disorders can cause healthy tissues in the liver to die as the immune system in the body starts attacking healthy tissues. Formation of malignant tumors in the liver can impair liver functioning.

Procedure
You have to undergo certain procedures before the surgery is conducted; a general health exam, imaging tests, blood tests and a psychological exam are conducted before the surgery. Based on the functioning of the liver and some other factors, your suitability for the transplant will be determined.
The procedure begins with general anesthesia, following which an incision is made in the abdomen. The liver is then removed and replaced with a healthy one. Once the procedure is completed, the surgeon closes the incision with stitches.

Aftercare
Once the procedure is done with, you are kept in the intensive care unit for a few days. The doctor will monitor your progress and put you on medications. After the recovery, you will have to undergo check-ups at regular intervals. You may also have to take medications such as immunosuppressant to prevent your immune system from attacking the liver.

Liver Transplant Surgery - How Best To Care for it Post Surgery?

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