Chronic Liver Disease

The liver is one of the most important organs of the body that plays a crucial role in digestion, detoxification, metabolism, and growth. It is located in the right upper quadrant of the abdomen and can be influenced by many different diseases that can be of shorter or longer duration. When the duration of the disease is more than six months, it is called chronic disease. So the chronic disease of the liver includes any disease which affects the liver for more than six months and results in the gradual destruction of the functional liver tissue, which is then replaced by fibrous non-functional tissue over the prolonged period of continuous injury. The liver loses its ability to execute its functions, resulting in loss of appetite,  tiredness, weakness, nausea, vomiting, unexplained weight loss. With the progression of the disease, symptoms may include jaundice, itchiness, easy bruising, swelling in the lower legs, and building of fluid in the abdomen. 
The agents and events leading to chronic liver disease may include viruses, parasites, chemicals, drugs, metabolic products, toxins, autoimmune diseases, and malformations.
Chronic liver disease is managed by correcting the underlying disorder, halting further damage, providing symptomatic relief, and offering palliative care and support.

The liver can be affected by many agents and conditions resulting in chronic disease that can be categorized as follows;
Infectious agents;

• Viruses: Hepatitis B, Hepatitis C
• Parasites: Liver flukes, Schistosoma japonicum

Toxins and drugs;

• Alcohol causing Alcoholic liver disease
• Drugs; amiodarone, methotrexate, nitrofurantoin.

Metabolic disorders;

• Non-alcoholic fatty liver disease
• Wilson's disease
• Hemochromatosis

Autoimmune disorders;

• Autoimmune Hepatitis
• Primary biliary cholangitis

Others

• Alpha-1 antitrypsin deficiency
• Chronic right-sided heart failure
• Type IV glycogen storage disease
• Granulomatous disease - Eg, sarcoidosis
• Cystic fibrosis
• Liver cancer
• Primary sclerosing cholangitis

Chronic liver disease is prevalent worldwide, resulting in serious morbidity and mortality. Around 4.5 million people in the USA are diagnosed with liver disease every year. Alcoholic liver disease is more common in the USA, and according to CDC, the percentage of adults aged 18 and over who had at least one heavy drinking day in 2018 is 25.1%. One heavy drinking day is defined as five or more drinks for men and four or more drinks for women per day. However, recent data has shown an increase in the number of viral liver diseases, among which Hepatitis B and C are the most common. According to CDC, the prevalence of any past or present HBV infection was 4.3% among adults aged 18 and over during 2015–2018. It was higher among men than women. Liver cancer is also a common disease. But it's more common in sub-Saharan Africa and Southeast Asia than in the USA. However, the death rate due to liver cancer has sown a rise of 4.3% in the USA from the year 2000 to the year 2016.

Following are the risk factors that may increase the chances of chronic liver disease.

• Excessive alcohol consumption.
• Being overweight or obese.
• IV drug abusers who share infected needles and syringes
• Unprotected sex with multiple sexual partners
• Health care professionals who are in contact with infected body fluids and blood
• Infection with viral hepatitis C and B
• Family history of having autoimmune diseases
• Using certain medicines like methotrexate, amiodarone, alpha methyldopa.

The signs and symptoms are developed slowly over several days or even years. The initial symptoms are due to hepatic insufficiency; however, later, the symptoms result from complications of the disease process, which involves the fibrosis of the liver structure. Signs and symptoms are as follows;

• Tiredness and weakness
• Loss of appetite
• Anemia
• Nausea
• Weight loss
• Jaundice
• Itchy skin
• Easy bleeding or bruising
• Swelling in your lower legs and feet, called edema
• Breasts enlargement in males (Gynecomastia)
• Changing pattern of hair distribution
• Atrophy of testicles
• Redness in the palms of the hands
• Fluid accumulation in your abdomen (ascites)

It takes several years for chronic liver disease to show evidence of fibrosis and the resulting signs and symptoms. Sometimes the disease is diagnosed accidentally by routine liver function tests or ultrasound. People suffering from inherited diseases must be under regular follow-up to check for the severity and progress of liver fibrosis. The diagnosis is made by a detailed history and a thorough physical examination. You may be advised to undergo a few investigations like;

• Blood tests: complete blood picture to assess for anemia, number of blood cells, liver function tests to determine the inflammation of the liver, coagulation profile, electrolytes and renal profile, tests for hepatitis C and B viruses, genetic testing for hereditary diseases, etc.
• Imaging: ultrasound, CT, and MRI scans can be used to assess the degree of fibrosis. The latest imaging test to determine the elasticity of the liver has been used lately called Magnetic resonance elastography (MRE).
• Biopsy: a sample of your liver tissue is taken out through a needle under local anesthesia and sent to the laboratory to check for the extent and severity of the fibrosis. It is not usually done unless needed.

Some other diseases may mimic the presentation of chronic liver diseases.

• Glycogen storage diseases
• Syphilis of the liver
• Cystic diseases of the liver
• Tuberculosis of the liver
• Trematode or other parasitic diseases.
• Tropical liver
• Bacterial liver abscess
• Amoebic liver abscess

Chronic liver disease is a progressive disease. It cannot be reversed once the liver is in the fibrosis stage. The goal of treatment is to slow down or halt further damage to the liver. Treatment depends upon the specific cause of cirrhosis, the extent of the damage, patient’s age, overall health, co-morbid diseases, preference, and tolerance for specific therapies and procedures. Abstinence from alcohol is the first and most important intervention for alcoholic liver disease. Some common medicines given for the respective causes are;

• Steroids like prednisone and azathioprine for autoimmune hepatitis,
• Phlebotomy for hemochromatosis,
• Interferon, and other antiviral agents for hepatitis B and C,
• Trientine and zinc for Wilson disease.
• Zinc sulfate is given For appetite improvement. It can also improve muscle cramps.
• Antihistamines can help mild itching
• Cholestyramine is used for specific itching due to liver disease

Liver transplant: In this procedure, your diseased liver is replaced by a new one. The liver tissue is taken from the deceased person or a living donor. Extensive investigations and medicines are ordered before the transplant to exclude the possibility of tissue rejection.

The course of chronic liver disease progression toto end-stage liver disease is variable in every individual. Some people with significant fibrosis may not show symptoms, but ultimately after a period of compensated liver disease, all will progress to decompensated liver disease with severe risks to health and life.

Once the diagnosis is made, it takes up to 10 years to develop the complications of chronic liver disease, which are:

• Portal hypertension: increased pressure in the liver’s blood supply, which causes back pooling of blood in the digestive tract and formation of an anastomosis between inside and outside of the body at multiple sites.
• Lower oesophageal and rectal varices.
• Ascites: the building up of fluid in your abdomen due to leakage from the blood vessels because of portal hypertension and decreased production of some proteins by the diseased liver called hypoalbuminemia.
• Coagulopathy: Problems with the bleeding and clotting mechanisms.
• Hepatopulmonary syndrome: lung disease due to liver disease.
• Hepatorenal syndrome: life-threatening kidney disease due to liver disease.
• Encephalopathy- brain damage
• Hepatocellular carcinoma

Chronic liver disease can be prevented by adopting the following precautions;

• Avoid drinking alcohol
• Consuming a healthy diet rich in vitamins, minerals, omega 3 fatty acids, antioxidants and avoiding fatty and fried food
• Body weight should be maintained according to BMI by taking a balanced diet and regular exercise.
• Avoid unprotected sex and sharing needles to prevent the risk of getting hepatitis B and C.
• Get vaccinated for hepatitis B and hepatitis C.
• Health care professionals should use protective equipment when exposed to infected fluids.
• Employ regular exercises to improve inactivity, muscle cramps, and muscle wasting.