Liver Pathologies

Alcoholic Hepatitis

• Liver inflammation results from excessive alcohol consumption over time.
• Alcohol is toxic to hepatocytes, damaging the liver and causing 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 amounts of alcohol.
• One standard drink contains 14g of pure alcohol.
• Less than three standard drinks a week is considered moderate consumption.
• Heavy drinkers may develop early symptoms in their 30s and severe problems by their 40s.
• Typically affects individuals aged 30–50, with most patients under 60.
• Characterized by a history of daily heavy alcohol use (>100g daily) for over 20 years.
• Histological examination reveals fatty liver (steatosis) due to focal necrosis of hepatocytes.
• Fatty liver can be reversed if alcohol consumption ceases.
• Common signs and symptoms include anorexia, jaundice, RUQ/epigastric abdominal pain, ascites, and tender hepatomegaly.
• The primary treatment is alcohol cessation; formal recovery programs should be considered.
• Liver transplant is an option in severe cases.
• Alcohol cessation allows semi-reversible damage without further harm.
• Continued alcohol use can lead to cirrhosis, liver failure, and liver cancer, as well as nervous system, cardiovascular, and urinary system complications.
• Massage appropriateness depends on the patient's symptoms; there are no general contraindications.

Chronic Hepatitis

• Liver inflammation lasting longer than six months.
• Most commonly caused by hepatitis B and C viruses, as well as certain medications.
• Hepatitis C accounts for 60-70% of chronic hepatitis cases, with approximately 75% of cases becoming chronic.
• About 5-7% of hepatitis B cases become chronic; hepatitis A and E do not.
• Overuse of drugs like Tylenol and alcoholic hepatitis can also cause it.
• Associated Steatotic Liver Disease (MASLD) can cause it.
• Symptoms are usually mild for years, with possible low-grade fever and RUQ discomfort.
• Jaundice is rare and typically appears later in the disease.
• Continued inflammation can lead to cirrhosis, liver failure, or liver cancer.
• Complications include cirrhosis leading to portal hypertension, splenomegaly, ascites, spider angioma, caput medusae, palmar erythema, and deterioration of nervous system/brain function.
• Certain hepatitis viral strains cause gradually worsening symptoms.
• Chronic hepatitis C leads to cirrhosis in 15-25% of infected individuals and increases the risk of liver cancer if cirrhosis is present.
• Chronic hepatitis B tends to worsen and increases the risk of liver cancer; co-infection with hepatitis B and D causes cirrhosis in 70% of cases.
• Chronic hepatitis caused by drugs may resolve completely if the drug is discontinued.
• Suspect hepatitis with typical symptoms, abnormal liver function tests, or a history of hepatitis.
• Diagnosis confirmed with biopsy; lab work determines severity and identifies the cause.
• Chronic hepatitis B patients require annual ultrasound and blood work to screen for liver cancer; hepatitis C patients are screened only if cirrhosis develops.
• Treatment involves eliminating the noxious substance or treating the underlying cause.
• Antiviral drugs (PO or SQ) are used for chronic, progressive hepatitis B and C and SQ injections are most effective for hep C and stopping inflammation.
• Hepatitis B tends to recur after drug therapy ends, potentially requiring indefinite antiviral treatment.
• Family members and close contacts of those with hepatitis B should receive a vaccine and immunoglobulin.
• Corticosteroids may be used in treatment.
• Advanced disease may require a liver transplant.
• Massage appropriateness depends on patient symptoms; there are no general contraindications.

Metabolic Dysfunction – Associated Steatotic Liver Disease (MASLD)

• Formerly known as non-alcoholic fatty liver disease (NAFLD).
• Steatosis occurs in the absence of significant alcohol consumption.
• The most common cause of liver disease in the US, affecting an estimated 25% of adults worldwide: "too many calories."
• Forms include simple hepatic steatosis (NAFLD) with little clinical significance, and Metabolic dysfunction-associated steatohepatitis (MASH), formerly known as non-alcoholic steatohepatitis (NASH).
• MASH can progress to cirrhosis in 10–20% of cases.
• Initially, there is hepatocyte ballooning, lobular inflammation, and steatosis.
• Progressive disease leads to increased fibrosis, eventually resulting in cirrhosis.
• Strongly associated with obesity and metabolic syndrome.
• Pathophysiology involves a "two-hit" model, with hepatic fat accumulation and increased oxidative stress.
• Free radicals cause lipid peroxidation of accumulated intracellular fat.
• Usually asymptomatic; clinical findings are typically related to atherosclerotic disease/diabetes.
• Fatigue and right-sided abdominal pain can occur.
• Cardiovascular disease is a frequent cause of death.
• There is an increased risk of hepatocellular carcinoma.
• Treatment includes losing weight, medication to reduce cholesterol/triglycerides and blood pressure, controlling diabetes, limiting OTC drugs, and avoiding alcohol.
• Massage appropriateness is determined by patient symptoms; there are no general contraindications.

Hepatocellular Carcinoma (HCC)

• Also known as hepatoma.
• The most common primary liver tumor is most commonly caused by cirrhosis.
• Presents with vague signs of abdominal pain, fatigue, loss of weight, and appetite, leading to late-stage diagnosis and poor prognosis.
• Early signs include abdominal pain, fever, weight loss, and a palpable mass in the RUQ; those with cirrhosis may have an unexpected increase in illness.
• Rupture of the tumor can cause sudden abdominal pain and shock.
• Blood tests, PE for palpable liver mass, advanced imaging (US, CT, MRI) are used for diagnosis.
• Biopsy confirms unclear cases.
• Prevention includes hepatitis B vaccine, treatment of chronic hepatitis C, alcoholism treatment and cessation programs, and cancer screening for earlier diagnosis.
• Treatment involves chemotherapy, radiation, tumor embolization, and surgical resection, but recurrence rates are high.
• Transplant is possible if there is no metastasis.
• Vague symptoms lead to late-stage diagnosis and a poor prognosis; the 5-year survival rate is approximately 18%.
• Other primary liver tumors are rare and have a poor prognosis.
• Metastatic disease is more common than primary liver cancer, originating from breast, colon, kidney, lung, stomach, pancreas, and ovaries/uterus.
• Massage appropriateness depends on patient symptoms; there are no general contraindications.

Diseases of the Biliary Tract: Cholelithiasis

• "chole" = bile or gall "lithiasis" = stones
• Gallstones are collections of solid material in the gallbladder and can become lodged in the cystic duct, common bile duct, or hepatopancreatic ampulla.
• More common in Indigenous and Hispanic populations, with 70-80% of the First Nations population in Canada affected.
• Gallstones occur in up to 20% of Canadian women and 10% of men by age 60.
• Risk factors include being female, forty, fat, and fertile, as well as following the Standard American Diet and having a family history.
• Two main types of stones: cholesterol (most common) and pigment stones.
• Cholesterol stones form when the liver secretes excess cholesterol, oversaturating the bile.
• Pigment stones are made of bilirubin and form due to excess hemolysis.
• 80% of individuals with gallstones are asymptomatic.
• As a stone passes from the gallbladder into the cystic duct, common bile duct, or hepatopancreatic ampulla, the GB swells and causes colicky RUQ pain.
• Pain is diffuse and hard to localize, typically in the RUQ or epigastric region, and may radiate to the right shoulder or between the scapulae.
• Pain increases over 15 minutes, plateaus at 30-60 minutes, and usually lasts less than 6 hours but can last up to 12 hours and may be severe enough for ER.
• Complications include cholecystitis (inflammation of the gallbladder).
• Diagnosis is made with abdominal ultrasound.
• Treatment is not required if asymptomatic; disruptive, recurring episodes may require laparoscopic cholecystectomy.
• Post cholecystectomy, there is usually little to no effect on digestion, transit time of bowel may be increased.
• Consume a low-fat diet to reduce strain on the gallbladder, some evidence suggests extremely low-fat diets may increase gallstone formation.
• The massage is not absolutely contraindicated for patients who have or have had cholelithiasis; however, massage is contraindicated if symptoms of obstruction are present (N/V, colicky RUQ pain).

Cholecystitis

• Inflammation of the gallbladder, typically occurring in those with a history of symptomatic gallstones.
• Blockage of the cystic duct by gallstones causes inflammation and can be acute or chronic.
• Secondary to gallstones is the most common cause; other causes include tumors and certain viral infections.
• Acute Cholecystitis: presents as sudden, severe, steady RUQ pain, hurts all the time, no colicky pain.
• M/C cause is gallstones (95%); acalculous cholecystitis is rare but more serious (r/t 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: is chronic inflammation of the gallbladder with repeated attacks of biliary colic; m/c cause is gallstones.
• The gallbladder becomes thick-walled, scarred, and small and contains sludge/stones that block the opening to the cystic duct or the duct itself.
• • Signs and symptoms: RUQ colicky pain that lasts 6-12 hours or more and is quite severe.
• Pain peaks at 15-60 minutes and remains constant and spreads to the right shoulder or between the scapulae.
• increased pain with deep breaths.
• Nausea and vomiting are common; may have abdominal rigidity and guarding.
• In acute cases, about 1/3 of patients have a fever over 38 degrees and chills.
• Diagnosis is made with ultrasound to detect gallstones, fluid around the gallbladder, and thickening of the GB walls.
• Treatment includes hospitalization, IV fluids, IV antibiotics, IV analgesics, and colecystectomy.
• Acute cholecystitis and severe chronic cholecystitis are absolutely contraindicated for massage.

Primary Biliary Cholangitis

• Previously known as primary biliary cirrhosis.
• Autoimmune disease causing inflammation and destruction of bile ducts within the liver (intrahepatic ducts only).
• Onset is generally in the 40 to 60 years old with women predominately affected with a sex ratio of ~ 9:1.
• Thought to be a combination of genetic and environmental factors that triggers the disease.
• More than half of those diagnosed are asymptomatic at the time (incidental findings on blood tests); symptoms eventually develop over the next 5-20 years.
• Symptoms include fatigue, itchy skin, jaundice, RUQ pain, and edema; complications include cirrhosis.
• LFTs, antibody serology (anti-mitochondrial antibodies or AMA are very common), imaging (ultrasound; MRI), and liver biopsy may be needed to confirm.
• There is no cure, but medications can help slow progression.
• Ursodeoxycholic acid (UDCA) helps move bile through the liver, improves liver function, and reduces liver scarring.
• Symptomatic treatment of itching and fatigue (antihistamines) may be indicated.
• Liver transplant may be necessary.
• The average life expectancy is about 10 years once symptoms develop.
• 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.
• The cause is unclear but an immune system reaction to infection or toxin may be a trigger in people who are genetically predisposed to it and a large proportion also have IBD.
• It is a fairly rare disease with an estimated incidence of 1 per 100,000 per year (Europe and NA); it can occur at any age, median age of diagnosis of 41, more common in males than females, and in people of Northern European descent.
• Usually asymptomatic at diagnosis, early signs and symptoms include fatigue, itching, jaundice, and RUQ pain.
• Complications include cirrhosis and liver failure.
• LFT's, imaging (ultrasound; MRI), and liver biopsy may be needed to confirm.
• There is no cure, but medications can help slow progression.
• Ursodeoxycholic acid (UDCA) helps move bile through the liver, improves liver function, reduces liver scarring, and symptomatic treatment of itching and fatigue (antihistamines).
• Liver transplant may be necessary.
• The average life expectancy is between 10 and 20 years once symptoms develop and successful liver transplants can lengthen life expectancy; PSC can return in 15/20.

Disorders of the Pancreas: Pancreatitis

• Inflammation of the pancreas that can be mild or life-threatening, causing the activation and possible release of enzymes that digest and attack the pancreas and possibly other tissues if they enter the bloodstream and may be acute or chronic.
• The most common causes are alcoholism (chronic pancreatitis) and gallstones (acute pancreatitis); alcohol is linked to 80% of pancreatitis cases and smoking has also been linked to chronic pancreatitis.
• Acute Pancreatitis: m/c cause is gallstones.
• Think of acute pancreatitis as an event.
• Acute attacks often precipitated by alcoholic binge, smoking, or excessively large meal and is more common in females than males.
• Chronic Pancreatitis: m/c cause is alcohol.
• Think of chronic pancreatitis as an ongoing process of pathologic response to pancreatic injury and is more common in males than females.
• Signs & Symptoms include severe epigastric and LUQ pain that often radiates to the back.
• With gallstones (acute) pain starts suddenly and reaches max intensity in 10 – 20 minutes; acute onset of persistent, severe LUQ pain; with alcohol (chronic) pain onset is less abrupt and poorly localized.
• 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 and tenderness of epigastrium (severity of pain depends on severity of pancreatitis) with abdominal distention.
• Hypoactive bowel sounds due to inflammation and scleral icterus IF obstructive jaundice present.
• In 3% of patients with acute pancreatitis, bruising along the flank may be exhibited (grey turner sign) due to retroperitoneal bleeding.
• Diagnosis is based on characteristic pain, blood tests, US, and CT.
• Blood tests show Increased serum lipase and amylase and leukocytosis.
• The pancreas may appear diffusely enlarged on US and gallstones may be visualized.
• Whether mild or severe, pancreatitis usually requires hospitalization.
• For chronic pancreatitis: analgesics and antioxidants (E, C, selenium, methionine) for pain control and 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.).
• 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.
• Acute pancreatitis is an absolute contraindication to massage (medical emergency).
• Chronic pancreatitis may be a possible local contraindication: avoid abdominal massage if pressure produces pain or discomfort.

Carcinoma of the Pancreas

• Malignant tumors of the pancreas.
• 95% of malignant tumors of the pancreas are adenocarcinomas, most commonly near the pancreatic head.
• Not super common, but super deadly – 4th leading cause of cancer-related deaths, more common over 45 years old with a slight male predominance.
• Environmental risk factors include smoking, chronic pancreatitis, DMII, and obesity; hereditary risk factors include cystic fibrosis and family history.
• Abdominal pain that is insidious in onset, gnawing in quality, and generally epigastric, frequently worse at night, after eating, and while laying supine.
• Blocked duct resulting in jaundice and pruritits (one of few early symptoms) and weight loss with pressure on phylorus of stomach resulting in vomiting.
• Late stage diagnosis is common with metastasis present in 90% of cases resulting in a five-year survival rate of 7%.
• Early diagnosis is difficult due to a lack of symptoms and PE/blood work often WNL.
• Bloodwork done to evaluate for cholestasis and/or acute pancreatitis.
• CT is preferred initial imaging test, but US and MRI sometimes used and if pancreatitis mass is seen on abdominal US, CT is next step.
• Biopsy can be done for conformation.
• Pancreaticoduodenectomy (Whipple procedure) performed on those without metastasis.
• Chemotherapy and radiation are mostly palliative.
• There are no contraindications for massage.