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!

The liver is the largest internal organ in our body which performs multiple functions and it is the only gland that can regenerate quickly when it is healthy. The main role of the liver is to clean and filter blood coming via digestive tract previous to it flows to remaining body parts. Liver failure results in reduced ability of blood clotting, thereby causing severe problems in case of injuries. Apart from that, alcohol and viruses are also significant factors that stop the liver from functioning properly.

Liver Transplantation
Liver Transplantation enables even the people at the final stage of liver failure to lead longer and happier life. The success rate of Liver transplantation has increased drastically due to advanced surgical techniques. Liver transplant is the best option when the liver is damaged partially or entirely. It is a surgery that involves replacing a failed liver in a recipient with a healthy liver of a donor.

Who should go for it?
The main cause of liver failure in infants is Biliary Atresia. This occurs when bile ducts are absent or partially/fully blocked. Whereas in adults, liver disease is caused due to Cirrhosis - a condition in which liver is scarred and becomes dysfunctional in the worst case. Most common reasons for Cirrhosis are Hepatitis B and C, genetic disorders, alcohol consumption, toxic metals and obesity. One should immediately seek advice from a doctor when he/she suffers from following symptoms:

Fatigue
Nausea
Weakness
Weight loss
Jaundice
Fever
Abdominal Pain
Itchy Skin
Liver Transplantation Surgery
Two kinds of the liver transplant are available: 

Deceased donor transplant 
Living donor transplant
There are not enough deceased donor livers available to match all the liver transplant needs. Any living donor with a matching liver can donate a part of their organ to the person undergoing the liver transplant. As the liver can regenerate itself to its normal size in healthy people within a few months, there are no side effects of donating a part of the liver. A thorough physical and mental health examination will be performed for both the donor and the recipient to ensure that they can cope with the process and are aware of the risks involved. This includes psychological tests and blood tests. Patients are added to a waiting list as per their priority score. The score is assigned to a patient based on three blood samples creatinine, bilirubin and INR.

The priority score is termed as MELD (model of end-stage liver disease) in adults and PELD (pediatric end-stage liver disease) in children. The patient cannot undergo liver transplant if he/she has contracted cancer in any other part of the body or is suffering from heart disease or severe infections.

During the liver transplantation procedure, the surgeon removes some part of the liver from a donor and replaces damaged liver in the recipient with it. Both recipient's and donor's liver re-grow rapidly and reach normal size within months. As per statistics, recipients who receive the liver from living donor have a higher survival rate than those who receive it from deceased donors.

After surgery, both donor and recipient should maintain healthy and clutter-free life and follow strict diet rules and get vaccinated as per the chart provided by the doctor. They also need to avoid consumption of alcohol entirely and talk to a medical practitioner before taking any medications.

Liver Transplant Surgery - Who Should Go For It?

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?

Having some fat in your liver is legit. But, if you have too much of fat say more than 5%-10% of the organ's weight then you are at risk of getting fatty liver disease. At the onset, you can do one important thing to help your liver stop drinking. It causes fatty liver disease.

There are two main types of fatty liver disease

Alcoholic liver disease or ALD
Non-alcoholic fatty liver disease or NAFLD
If you are a woman who is pregnant, you can also get fatty liver disease.
Alcoholic Liver Disease (ALD)

You can get ALD from drinking lots of alcohol. ALD can also present itself after a short period of heavy drinking.
Genetics has a role to play in ALD. Genes can make you hit the bottle and increase your chances of becoming an alcoholic.
Genes can also impact the way your body breaks down the alcohol you drink.
Other root causes of ALD are:

Hep C doesn't cause ALD. it is one of the causes of fatty liver. 
Hep B is also a cause of fatty liver. There are certain medications which may be helpful from person to person besides lifestyle management.
Excess iron in your body
Obesity
Non-alcoholic Fatty Liver Disease (NAFLD)
The cause of NAFLD is not clear, but we know that it tends to run in families.
NAFLD is also more common in the middle-aged and the obese or, those who have high cholesterol and diabetes.

Other risk factors are:

Certain medicines
Viral hepatitis
Auto-immune or inherited liver disease
Gaining weight fast
Malnutrition
Acute Fatty Liver during Pregnancy
Fat can build up in your liver when you're pregnant, causing this kind of fatty liver disease.
It s a serious condition as it can be risky for both you and your baby. It can cause liver or kidney failure in you and your child, both.
Causes are unknown. But, hormones may play a role.
Symptoms of fatty liver disease
This disease can sometimes cause no symptoms for long. But, the things to look out for are-

Feeling tired all the time
Loss of appetite or weight
General weakness
Nausea
Confusion and trouble concentrating
Your liver can become larger
Pain in the centre or right upper part of your belly
In ALD, your symptoms get worse after bouts of heavy drinking. Fatty liver disease is diagnosed during routine exams when your doctor notices your enlarged liver. Ultrasound, blood tests to check for certain enzymes and biopsy of the liver are performed to confirm it.

Treatment

There is no specific treatment for the fatty liver disease.
You can manage it by managing your diabetes and giving up drinking. If you have ALD and you don t quit, you get complications like alcoholic hepatitis or cirrhosis.
Even if you have a non-alcoholic fatty liver disease, alcohol cessation helps.
Losing weight if you are overweight also helps to manage this disease and having a good balanced diet with exercise also shows benefits.

Fatty Liver Disease - Signs You Are Suffering From It!

In general, fatty liver is considered synonymous with alcoholic liver disease. However, in reality it is not so. Fatty liver just indicates the presence of fat in the liver. It may or may not be harmful for the patient. Fatty liver is harmful only when it starts to damage the liver cells. Simple fatty liver does not cause inflammation, but when it starts doing so, it does not remain a simple fatty liver anymore.

Types of Fatty Liver Disease

There are two types of Fatty liver disease: Alcohol Related Fatty Liver Disease and Non-alcoholic Fatty Liver Disease.

Alcohol Related Fatty Liver Disease

Fatty liver does not always beget symptoms, although the liver may be enlarged. One may also feel discomfort or pain in the upper right quadrant of the abdomen. However, one can prevent alcoholic liver disease, since fatty liver owing to alcohol consumption usually gets better after stopping alcohol abuse. However, if a person doesn t do that, ALD can progress to more serious stages, like alcoholic hepatitis and alcoholic cirrhosis.

Alcoholic Cirrhosis
Alcoholic Cirrhosis occurs when there is formation of scar tissue in the liver. It can cause symptoms like bleeding, confusion, changes in mood and enlargement of spleen. Scar tissue formation can even lead to fatal liver failure.

Alcoholic Hepatitis
Alcoholic Hepatitis occurs when there is a swelling of the liver. It can precipitate nausea, fever, abdominal pain, vomiting, jaundice etc.

Non-Alcoholic Fatty Liver Disease

This is of two types: Simple Fatty Liver and Non-alcoholic Steatohepatitis.

Simple fatty liver just indicates the presence of fat in the liver without inflammation. On the other hand, Non-alcoholic steatohepatitis is a much worse form of fatty liver. This indicates that there is fat as well as inflammation in the liver. Even some of the liver cells may have become damaged. It can cause the following problems:

Formation of scar tissue in the liver, called fibrosis.

Severe fibrosis can lead to cirrhosis in advanced stages. Cirrhosis can lead to liver failure

Liver cancer

Causes of Fatty Liver

In alcoholic fatty liver disease, the prime cause is consuming too much alcohol. Alcohol may precipitate fatty liver by promoting obesity, malnourishment and even chronic hepatitis.

For non-alcoholic fatty liver disease there may be a number of factors:

Obesity

Insulin resistance

High levels of LDL cholesterol or low levels of HDL cholesterol

Diabetes

Conditions that may precipitate Type 2 diabetes 

High blood pressure

High blood sugar

Symptoms of Fatty Liver

There is hardly any symptom of fatty liver disease. At most, one can feel pain or tiredness in the right upper quadrant of the abdomen. However, if fatty liver has advanced to cirrhosis, fibrosis or hepatitis, there can be a number of symptoms. Some of these symptoms are:

Swollen abdomen

Enlarged blood vessels under the skin

Abnormal breast size in men

Redness in palms

Yellowing of skin and eyes.

Treatment

For alcoholic fatty liver disease, the best treatment is cessation of drinking when the fatty liver has still not progressed to more serious forms. For non-alcoholic fatty diseases, weight loss is an effective treatment. If there is Cirrhosis or Liver Failure, liver transplant is the only option.

As the treatment may vary from patient to patient, it is important that one should always consult a doctor before going for any option.

Fatty Liver - Types & Treatment Of It!

Just like the name suggests, Non-Alcoholic Fatty Liver Disease (NAFLD) is a set of diseases that can affect the liver due to excess accumulation of fat. One common disease that arises from this condition is known as nonalcoholic steatohepatitis. This can lead to cirrhosis as well. NAFLD is very common in the Western Countries affecting close to 100 million people annually. Although it can occur in any age group, the most affected age group being the one between 40-50 million. With this condition, the risk of getting other diseases such as cardiovascular problems and type 2 diabetes increases considerably.

Symptoms: Non-alcoholic fatty liver shows symptoms such as fatigue, enlarged liver, and pain, discomfort in the upper abdomen. Some other symptoms that have been witnessed in patients suffering from NAFLD include the development of breasts in men, swelling of the abdomen, red palms, jaundice, swelling of the blood vessels etc.

Causes: Experts have not been able to identify the exact causes of NAFLD. However, it is pretty evident that this condition only arises when the liver fails to produce bile which is responsible for digesting the fat cells. The fat in turn deposits in the liver cells resulting in NAFLD. Some of the possible causes include the following:

The resistance of insulin
Type 2 diabetes
High level of triglyceride in the blood
Obesity
Risk Factors: There is a wide array of risk factors that can pose a threat of NAFLD. Some of them include metabolic syndrome, high cholesterol, hypothyroidism, type 2 diabetes, hypopituitarism, obesity, polycystic ovary syndrome etc.

Complications: The major complications of NAFLD is liver cirrhosis. This is a condition that results in scarring of the liver cells resulting in fibrosis. Some other complications include fluid accumulation in the liver, liver cancer, swelling of the vein etc.

Diet: A mediterranean diet is a perfect diet suited for patients suffering from NAFLD. It includes nuts, fish, vegetables, grains, fruits and olive oil. Fat should be eliminated from the diet by a significant bit. It is important to add the right kind of fat in the diet. Omega-3 fatty acid available in flaxseed oil, leafy vegetables, and nuts fits the bill. Studies have shown that vitamin D and E helps a great deal in fighting liver diseases. Some other food items that should be included in the diet are green-tea, red grapes, Brazil nuts, raw garlic, wolfberry etc.

Treatment: Once the disease is diagnosed, a doctor s first endeavour is to ensure that the patient loses weight through a combination of diet and exercise. Vaccination against hepatitis A and B is the next step that a doctor would ideally suggest. For patients who are suffering from cirrhosis, a liver transplant is the only viable option to increase mortality.

What Are The Reasons Behind Non-Alcoholic Fatty Liver Disease?

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