Alcoholic Hepatitis: Causes, Symptoms, Pathology

Alcoholic Hepatitis

• Liver inflammation results from excessive alcohol consumption over an extended time.
• Alcohol is toxic to hepatocytes, causing liver damage and inflammation.
• Mild alcohol-related liver damage can heal.
• Excessive/prolonged alcohol consumption inhibits liver regeneration.
• Females are more susceptible to alcoholic hepatitis than males when consuming high alcohol amounts.
• One drink contains 14g of pure alcohol.
• Heavy drinkers may show early symptoms in their 30s and severe problems by their 40s.
• Onset is typically between 30-50 years old, mostly in patients under 60.
• A history of daily heavy alcohol use (>100g daily) for >20 years

Pathologic Findings

• Histological examination shows fatty liver (steatosis) that can be reversed with alcohol cessation.
• Fatty appearance of hepatocytes is due to focal necrosis of cells.

Signs & Symptoms

• Anorexia
• Jaundice
• Right Upper Quadrant/epigastric abdominal pain
• Ascites
• Tender hepatomegaly

Treatment

• Only effective treatment is alcohol cessation, with consideration of formal recovery programs.
• Liver transplant considerations.

Prognosis

• Alcohol cessation leads to semi-reversible damage without further damage (steatosis/steatohepatitis).
• Continued alcohol use results in progression to cirrhosis, liver failure, and possible liver cancer, impacting the nervous, cardiovascular, and urinary systems.

Massage Considerations

• Massage appropriateness depends on patient symptoms.
• There are no general contraindications.

Chronic Hepatitis

• Inflammation of the liver lasting longer than 6 months.
• Hepatitis C is responsible for 60-70% of chronic hepatitis cases with ~75% of hep C cases becoming chronic, while ~5-7% of hep B become chronic.
• Hepatitis A and E do not become chronic.
• Use/overuse of certain drugs, such as Tylenol, is a cause.
• Alcoholic hepatitis

Signs and Symptoms

• Mild symptoms or no significant liver damage for years.
• Some experience low-grade fever and RUQ discomfort.
• Jaundice is rare and typically appears much later.
• Continued inflammation can cause cirrhosis, liver failure, and/or liver cancer in some individuals.

Complications

• Cirrhosis leads to portal hypertension.
• Splenomegaly is due to increased venous pressure from portal HTN.
• Ascites (fluid accumulation in the abdominal cavity) is due to portal HTN.
• Spider angioma, caput medusae, palmar erythema.
• Deterioration of the peripheral nervous system and brain function is due to demyelination and increased serum toxins.
• More common with cirrhosis caused by hep C.

Prognosis

• For most, chronic hepatitis does not progress for years.
• Chronic hep C can lead to cirrhosis in 15-25% of those infected, increasing the risk of liver cancer if cirrhosis is present.
• Chronic hep B tends to worsen and is linked to an increased risk of liver cancer.
• Chronic co-infection with hep B and D causes cirrhosis in 70% of cases.
• Chronic hepatitis caused by drugs may completely resolve if the drug is stopped.

Diagnosis

• Suspect hepatitis in people presenting with typical symptoms or abnormal liver function tests (LFT).
• Definitive diagnosis with biopsy.
• Lab work helps determine severity and identify the cause, but biopsy is essential for a definitive diagnosis.
• Those with chronic hep B require annual ultrasound and blood work to screen for liver cancer.
• Hep C patients are only screened if cirrhosis has developed.

Treatment

• Eliminate noxious substances and/or treat the cause.
• Antiviral drugs
  • PO or SQ medications are given to those with chronic, progressive hep B and C.
  • SQ injections are most effective for hep C and stopping inflammation
  • after 6-12 months, 45-75% of cases improve with no further issue.
• Chronic hep B tends to recur once drug therapy ends.
  • Antiviral treatment may be indefinite.
• Family members and close contacts of those with hep B should receive a vaccine and immunoglobulin.
• Corticosteroids
• Advanced disease may require a liver transplant.

Massage Considerations

• Massage appropriateness depends on patient's symptoms.
• There are no general contraindications.

Metabolic Dysfunction – Associated Steatotic Liver Disease (MASLD)

• Previously non-alcoholic fatty liver disease (NAFLD).
• Steatosis occurs in the absence of significant alcohol consumption.
• It is the most common cause of liver disease in the US.
• Estimated to affect 25% of adults worldwide.
• Caused by "too many calories".
  • Simple hepatic steatosis (NAFLD) has little clinical significance.
  • MASH – Metabolic dysfunction-associated steatohepatitis was formerly known as non-alcoholic steatohepatitis (NASH) .
  • Progresses to cirrhosis in 10–20% of cases.

Pathologic Findings

• Initially hepatocyte ballooning, lobular inflammation, and steatosis.
• Progressive disease leads to steadily more fibrosis, eventually leading to cirrhosis.
• Strongly associated with obesity and the metabolic syndrome.

Pathophysiology

• "Two-hit" model involves hepatic fat accumulation and increased oxidative stress.
• Free radicals cause lipid peroxidation of the accumulated intracellular fat

Signs & Symptoms

• Usually asymptomatic.
• Clinical findings are usually due to atherosclerotic disease/diabetes that accompany NASH.
• Fatigue and right-sided abdominal pain can occur.
• Cardiovascular disease is a frequent cause of death in those with NASH.
• Increased risk of hepatocellular carcinoma.

Treatment

• Weight loss.
• Medication to reduce cholesterol or triglycerides.
• Medication to reduce blood pressure.
• Medication to control diabetes.
• Limiting OTC drugs.
• Avoiding alcohol.

Massage Considerations

• Massage appropriateness depends on patient's symptoms.
• There are no general contraindications.

Hepatocellular Carcinoma (HCC)

• AKA hepatoma.
• Most common primary liver tumour, most commonly caused by cirrhosis.
• Presents with vague signs of abdominal pain, fatigue, loss of weight and appetite.
• Results in late-stage diagnosis and, therefore, poor prognosis.

Signs and Symptoms

• Early signs: abdominal pain, fever, weight loss, and palpable mass in the RUQ.
• Persons with cirrhosis may have an unexpected increase in illness.
• Rupture of tumour can cause sudden abdominal pain and shock.

Diagnosis

• Blood tests.
• PE looks for a palpable liver mass.
• Advanced imaging (US, CT, MRI).
• Biopsy to confirm unclear cases.

Prevention

• Hepatitis B vaccine.
• Treatment of chronic hepatitis C.
• Alcoholism treatment and cessation programs.
• Screening for earlier diagnosis.

Treatment

• Chemotherapy, radiation, and tumour embolization.
• Surgical resection.
• High rate of recurrence.
• If no metastasis, a transplant can be performed.

Prognosis

• Vague symptoms cause late-stage diagnosis with poor prognosis.
• The 5-year survival rate is ~18%.

Other Primary Liver Cancers

• Other primary tumours are rare and have a poor prognosis.

Metastatic Disease

• Far more common than primary liver cancer.
• Commonly from breast, colon, kidney, lung, stomach, pancreas, ovaries/uterus.

Massage Considerations

• Massage appropriateness depends on patient's symptoms.
• There are no general contraindications.

Diseases of the Biliary Tract

• Cholelithiasis
• Cholecystitis

Cholelithiasis (GALLSTONES)

• "chole" = bile or gall
• "lithiasis" = stones
• Collections of solid material in the gallbladder.
• Gallstones can be dislodged and get stuck in the cystic duct, common bile duct, hepatopancreatic ampulla.

Epidemiology

• More common in Indigenous and Hispanic populations.
• In Canada, 70-80% of the First Nations population is affected by this disease.
• More common in females than males.
• Gallstones occur in up to 20% of Canadian women and 10% of men by the age of 60.

Risk Factors

• Used formerly to describe patient: Four F's: female, forty, fat, and fertile.
• Standard American Diet, family history.

Etiology

• Two main types of stones:
  • Cholesterol stones
  • Pigment stones
• More common stones – cholesterol stones.
• Cholesterol is a lipid that is created in the liver and dissolves in bile.
• If the liver secretes excess, bile becomes oversaturated and crystals can form.
• Excess hemolysis can form pigment stones made of bilirubin.

Signs & Symptoms

• 80% have no symptoms, and the gallstones remain in the gallbladder.
• As a stone passes from the gallbladder into the cystic duct, common bile duct, and/or hepatopancreatic ampulla, the GB swells and causes colicky RUQ pain.
• Pain is diffuse and hard to localize – usually RUQ or epigastric.
• Can radiate to the right shoulder or between scapulae.
• Increases over 15 minutes then plateaus at about 30 – 60 mins.
• Most episodes last < 6 hrs but can last up to 12 hrs.
• Usually severe enough to go to ER.

Complications

• Cholecystitis (inflammation of the gallbladder).

Diagnosis

• Abdominal ultrasound.

Treatment

• No treatment is required, if there are no symptoms.
• Even early episodes with symptoms will watch and wait.
• Disruptive, recurring episodes usually result in laparoscopic cholecystectomy.
• Usually, little to no effect on digestion.
• May increase the transit time of the bowel.
• Low-fat diet to reduce the strain on the gallbladder.
• Some evidence suggests extremely low-fat diets may increase gallstone formation.

Massage Considerations

• No absolute contraindications for patients that currently have or have had cholelithiasis.
• If symptoms of obstruction are present (N/V, colicky RUQ pain), then massage is CONTRAINDICATED.

Cholecystitis

• Inflammation of the gallbladder, typically occurs in those with a history of symptomatic gallstones.
• Blockage of the cystic duct by gallstones causes inflammation of the gallbladder.
• Can be acute or chronic.

Etiology

• Secondary to gallstones is most common.
• Other causes include tumours, certain viral infections.

Types of Cholecystitis

Acute Cholecystitis

• Sudden, severe, steady pain in the RUQ.
• Hurts all the time – NO COLIKY PAIN.
• More common cause – gallstones (95%).
• Acalculous cholecystitis is rare but more serious and is related to major surgery, severe burns, sepsis, prolonged parenteral nutrition, prolonged fasting.
• The Gallbladder fills with fluid, and the walls thicken.
• Can occur in children and adults.

Chronic Cholecystitis

• Chronic inflammation of the gallbladder with repeated attacks of biliary colic.
• More common cause – gallstones.
• The Gallbladder becomes thick-walled, scarred, and small.
• The Gallbladder contains sludge and/or stones that block the opening to the cystic duct or the duct itself.
• RUQ colicky pain that lasts 6 – 12 hours or more and is quite severe.
• Pain peaks at 15 – 60 minutes and remains constant.
• Can spread to the right shoulder or between scapulae.
• Increased pain with deep breaths.

Signs & Symptoms

• Nausea and vomiting are common.
• Positive Murphy's sign.
• May have abdominal rigidity and guarding.
• In acute cases, ~1/3 have a fever over 38 degrees and chills.

Diagnosis

• Ultrasound is the best way to detect gallstones, fluid around the gallbladder, and thickening of GB walls.

Treatment

• Hospitalization is likely.
• Intravenous (IV) fluids while the digestive system rests.
• IV antibiotics to treat or prevent infections.
• IV analgesics.
• Definitive treatment for both acute and chronic cholecystitis is colecystectomy.

Massage Considerations

• ABSOLUTE CONTRAINDICATION for acute cholecystitis and severe chronic cholecystitis.

Primary Biliary Cholangitis

• Previously known as primary biliary cirrhosis.
• Autoimmune disease causing inflammation and destruction of the bile ducts in the liver.

Epidemiology

• Women are predominantly affected with a sex ratio of 9:1.
• Onset is generally in the 40 to 60 years old.

Etiology

• Autoimmune disease.
• Thought to be a combination of genetic and environmental factors that triggers the disease.

Signs & Symptoms

• More than ½ of people diagnosed with PBC are asymptomatic at the time.
• Incidental findings on blood tests.
• Symptoms eventually develop over the next 5 – 20 years and include:
  • Fatigue.
  • Itchy skin.
  • Jaundice.
  • RUQ pain.
  • Edema.
• Complications include cirrhosis.

Diagnosis

• LFTs.
• Antibody serology.
• Blood tests may be done to check for anti-mitochondrial antibodies (AMA), which are very common in PBC.
• Imaging: Ultrasound, special type of MRI to view the structure of bile ducts.
• Liver biopsy may be needed to confirm.

Treatment

• No cure for primary biliary cholangitis.
• Medications are available to help slow the progression of the disease.
  • Ursodeoxycholic acid (UDCA or ursodiol).
  • Helps move bile through your liver.
  • Improves liver function and reduces liver scarring.
• Symptomatic treatment of itching and fatigue (antihistamines).
• A liver transplant may be necessary.

Prognosis

• Once symptoms develop, the average life expectancy is about 10 years.
• Successful liver transplants offer a 10-year survival rate of 65%.

Primary Sclerosing Cholangitis

• Inflammatory disease of the bile ducts, both intrahepatic and extrahepatic.
• Scarring of the ducts causes narrowing, which gradually causes serious liver damage.

Etiology

• The cause is unclear.
• An immune system reaction to infection or toxin may be a trigger in people who are genetically predisposed to it.
• Large proportion also have IBD.

Epidemiology

• Fairly rare disease.
• Estimated incidence of 1 per 100,000 per year (Europe and NA).
• Can occur at any age, with a median diagnosis age of 41.
• More common in males than females.
• More common in people of Northern European descent.

Signs and Symptoms

• Usually asymptomatic at diagnosis.
• Early signs and symptoms include:
  • Fatigue.
  • Itching.
  • Jaundice.
  • RUQ pain.
• Complications include cirrhosis and liver failure.

Diagnosis

• LFT's.
• Imaging: Ultrasound, a special type of MRI to view the structure of the bile ducts.
• Liver biopsy may be needed to confirm.

Treatment

• No cure for primary sclerosing cholangitis.
• Medications are available to help slow the progression of the disease.
  • Ursodeoxycholic acid (UDCA or ursodiol).
  • Helps move bile through your liver.
  • Improves liver function and reduces liver scarring.
• Symptomatic treatment of itching and fatigue (antihistamines).
• A liver transplant may be necessary.

Prognosis

• Once symptoms develop, the average life expectancy is between 10 and 20 years.
• Successful liver transplants can lengthen life expectancy.
• PSC returns in 15/20

Disorders of the Pancreas

• Pancreatitis
• Carcinoma of the Pancreas

Pancreatitis

• Inflammation of the pancreas that can be mild or life-threatening.
• Causes the activation and possible release of enzymes.
• Begins digesting and attacking the pancreas.
• Possibly other tissues if they enter the bloodstream.
• May be acute or chronic.

Etiology

• The most common causes of pancreatitis are:
  • Alcoholism (chronic pancreatitis).
  • Gallstones (acute pancreatitis).
• Alcohol is linked to 80% of pancreatitis cases.
• Smoking has also been linked to chronic pancreatitis.

Types of pancreatitis

Acute Pancreatitis

• More common cause is gallstones.
• Acute attacks are often precipitated by an alcoholic binge, smoking, or an excessively large meal.
• More common in females than males.

Chronic Pancreatitis

• More common cause is alcohol.
• More common in males than females.

Signs & Symptoms

• Severe epigastric and LUQ pain that often radiates to the back.
• Pain starts suddenly and reaches max intensity in 10 – 20 minutes.
• Acute onset of persistent, severe LUQ pain.
• Alcohol (chronic) causes pain onset that is less abrupt.
• Aggravating factors: coughing, deep breathing, and vigorous movement.
• Partial relief: sitting up or bending forward.
• 90% have nausea/vomiting which may persist for several hours.
• Tenderness of the epigastrium (severity of pain depends on the severity of pancreatitis).
• Abdominal distention.
• Hypoactive bowel sounds due to inflammation.
• Scleral icterus IF obstructive jaundice is present.
• In 3% of patients with acute pancreatitis, bruising along the flank may be exhibited (Grey Turner sign).

Diagnosis of Acute Pancreatitis

• Characteristic pain leads to pancreatitis suspicion.
• Acute onset of persistent, severe, epigastric pain with tenderness on palpation on PE.
• Blood tests support dx: Blood test are important.
• Increased serum lipase and amylase.
• Leukocytosis.
• US: pancreas may appear diffusely enlarged, gallstones may be visualized.

Treatment

• Whether mild or severe, usually requires hospitalization.

For chronic pancreatitis:

• Analgesics and antioxidants (E, C, selenium, methionine) for pain control.
• Pancreatic enzyme supplementation.

For acute pancreatitis:

• Fasting, IV fluids, analgesics, and antiemetics.
• Can resume normal eating within 2-3 days without further treatment.
• Must treat the underlying cause (alcohol, gallstones, etc.).

Prognosis

• In most patients with acute pancreatitis, the disease is mild in severity, and patients recover in 3-5 days without complications or organ failure.
• Recurring attacks of acute pancreatitis = chronic pancreatitis.

Massage Considerations

• Acute pancreatitis – ABSOLUTE CONTRAINDICATION.
  • Medical emergency that requires treatment.
• Chronic pancreatitis may be a possible LOCAL CONTRAINDICATION.
  • Avoid abdominal massage if pressure produces pain or discomfort.

Carcinoma of the Pancreas

• Malignant tumours of the pancreas.
• 95% of malignant tumours of the pancreas are adenocarcinomas.
• Most commonly near the pancreatic head.

Epidemiology

• 4th leading cause of cancer-related death.
• More common > 45 years old.
• Slightly more common in males than females.

Etiology

• Environmental Risk Factors:
  • Smoking
  • Chronic pancreatitis
  • DMII
  • Obesity
• Hereditary Risk Factors:
  • Cystic fibrosis
  • Family history of pancreatic cancer

Signs & Symptoms

• Abdominal pain in the epigastric region.
• Frequently is worse at night, worse after eating, and worse laying supine.
• Blocked duct resulting in jaundice and pruritus (itching).
• Early symptom.
• Weight loss.
• Pressure on the pylorus of the stomach results in vomiting.
• Obstruction of the small intestine.

Diagnosis

• Early diagnosis is difficult due to a lack of symptoms, and PE/blood work is often within normal limits (WNL).
• Bloodwork is done to evaluate for cholestasis and/or acute pancreatitis.
• A CT scan is the preferred initial imaging test, but US and MRI are sometimes used.
• If a pancreatitis mass is seen on abdominal US, a CT scan is the next step.
• A biopsy can be done for conformation.

Prognosis

• Late-stage diagnosis is common, and metastasis is present in 90% of cases.
• Five-year survival rate of 7%.

Treatment

• Pancreaticoduodenectomy (Whipple procedure) is performed on those without metastasis.
  • Remove the head of the pancreas, the duodenum, gallbladder, and bile duct.
• Chemotherapy and radiation are mostly palliative.

Massage Considerations

• No contraindications.