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?

Liver cirrhosis is characterized by the replacement of normal liver tissue with fibrous tissue. This condition occurs when the liver has been exposed to certain causative factors for a prolonged period of time. Liver cirrhosis can be compared to  Kumbhakaamla  as stated in Ayurveda.

In Ayurvedic terms, liver cirrhosis is through to result due to an extreme aggravation of the pitta dosha. The liver is considered as the seat of pitta and therefore, an aggravated pitta dosha affects the functioning of this vital organ that helps eliminate toxins from the body. It can lead to problems such as anemia, jaundice, hemorrhage, ascites, and liver and spleen enlargement. This may end up aggravating and dis-balancing other doshas as well.

Because of aggravation of the pitta dosha, all the functions of the pitta such clarity of skin complexion, hunger, digestion, and production of blood are seriously affected. Because of the aggravation, the rasa and rakta dhatus are severely affected followed by other dhatus.

Ayurvedic treatment for liver ailments is highly recommended as it is completely natural and does not result in any side effects. It helps reverse all of the symptoms of liver cirrhosis and other diseases while restoring the normal functioning of the liver. There are several Ayurvedic remedies that you can practice to relieve the symptoms of liver cirrhosis.



The following are some of the most common Ayurvedic tips for liver cirrhosis:

Patient must take expert opinion of an Ayurveda for the right treatment of liver cirrhosis
Cirrhosis is a complicated and serious situation thus, home remedies or any single herb treatment is not recommended.
Quit alcohol
Eat a well balanced and nutritious diet that contains a lot of fresh fruits and vegetables
Opt for sources of good fats such as nuts, seeds, avocado, soy and olives
Avoid packaged food items with added preservatives, including pickles
Ayurvedic treatment varies from person to person and therefore one must consult an expert and not try any home remedies.

Liver Cirrhosis Treatment With Ayurvedic Remedies 

In modern day societies of intense stress and work pressure, the average diet mostly comprises of street foods, packaged fast foods and processed foods. Such stress and overexposure to a lot of toxins (present in the processed food, fast foods, and street foods) disable the liver from performing its primary function of cleansing the toxic materials through the skin, the respiratory and the digestive system. Besides, this overexposure to toxins also disrupts bile formation, which hinders the absorption of necessary nutrients, resulting in a severe disruption in health. Also, liver is responsible for the proper functioning of the eyes, the brain, the kidneys and the joints in the body. Thereby, it is necessary to include these 7 foods in your diet which help to detoxify your liver from the excessive toxins and allow it to function properly.

    Avocado: Avocados contain a rich amount of the antioxidant glutathione, which helps the liver to fight against the toxins.
    Garlic: Garlic contains a rich amount of selenium and allicin, which helps to cleanse the liver. A little amount of garlic helps in the activating liver enzymes which in turn helps to eliminate the toxins from the body.
    Green tea: Green tea contains a rich amount of the plant antioxidant known as Catechin, which help the liver to function properly. It also helps to protect the liver from the toxins.
    Beets and Carrots: Beets and carrots contain a rich amount of beta - carotenes and plant flavonoids which help to regulate the overall function of the liver.
    Turmeric: A little amount of turmeric in your daily meal helps in the cleansing the liver by helping the enzymes to get rid of the toxic carcinogens.
    Green Vegetables: Green Vegetables like spinach, bitter gourd and chicory contains a rich amount of detoxifying components, which helps in the neutralization of heavy metals which in turn regulates the cleansing ability of the liver. Green vegetables also help in the simulation of the flow of bile.
    Grape Fruit: Grape fruit contains a rich amount of vitamin C and antioxidants which initiates the cleansing process of the liver. Grape fruit also help in the formation of enzymes that destroys toxins like carcinogens.

Cleanse Your Liver - 7 Natural Foods that Will Help You 

The term cirrhosis refers to liver scarring due to various diseases and conditions such as chronic alcoholism and hepatitis. Each time the liver gets injured, it tries to repair itself, resulting in the formation of the scar tissue. With the progression of cirrhosis, a number of tissues generate making the task of liver difficult. Since the liver is an important organ of the body due to its functionalities such as detoxification and nutrient generation, reduced function of liver poses a serious threat to the body.

Symptoms of liver cirrhosis:
Unfortunately, cirrhosis doesn t portray any conspicuous symptoms that can be easily identified until the scarring has reached a level of threat. Some of the common signs and symptoms of this disease include fatigue, nausea, itchy skin, drowsiness, enlarged breasts, testicular atrophy, fluid in the abdomen, bleeding from the mouth, leg swelling, redness in palms etc.

Causes of liver cirrhosis:
There could be an array of reasons for the occurrence of liver cirrhosis. The major causes include an accumulation of fat in the liver, chronic alcoholism and chronic hepatitis. Some of the other reasons include cystic fibrosis, bile duct deformation, Wilson s disease, hemochromatosis, schistosomiasis, continuous consumption of medicines such as methotrexate, a disease involving glycogen storage and Aalagille syndrome.

Complications involved in liver Cirrhosis:

High blood pressure: Cirrhosis results in slow blood movement through the passage of the liver resulting in an increased pressure on the vein that is responsible for carrying blood from the intestine to the liver. This increases the blood pressure in the body.
Swelling of abdomen and legs: Portal hypertension can result in accumulation of fluid in the leg and the abdomen due to the liver s inability to producing an important protein known as the albumin.
Spleen enlargement: Portal hypertension is responsible for changing the shape of the spleen. Decreased count of WBC and the platelets indicate towards portal hypertension and cirrhosis.
Bleeding: Portal hypertension doesn t let the blood flow in its normal path. It directs the blood to flow through smaller veins. The veins, in turn, swell and burst to cause a massive amount of bleeding.
Apart from these some of the other complications involve jaundice, liver cancer, infections, bone diseases and liver failure.

Diagnosis:
Liver cirrhosis doesn t get detected easily. It is often diagnosed with a routine blood test. Some of the lab tests that can help to identify cirrhosis include blood work to check organ function of liver and kidney. Your doctor might suggest other tests such as MRI scan, CT scan or liver biopsy.

Treatment:
Treatment for the underlying cause of liver cirrhosis is done to keep the disease under control. A doctor might treat you for weight loss, alcohol dependency, complications related to hepatitis, portal hypertension and hepatic encephalopathy. For advanced cases where the liver stops functioning, a doctor might suggest a patient go for a liver transplant.

Liver Cirrhosis - What You Must Know About It?

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)?

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!

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