Alcoholic Hepatitis

Alcoholic Hepatitis

• Alcoholic hepatitis is liver inflammation from excessive alcohol consumption over a long duration.
• Alcohol damages the liver cells (hepatocytes), which causes inflammation.
• Mild liver damage from alcohol can often heal.
• Excessive or prolonged alcohol consumption hinders liver regeneration.
• Females are at a higher risk of developing alcoholic hepatitis compared to males who consume the same amount alcohol.
• One drink is equivalent to 14g of pure alcohol.
• Current recommendations are <3 standard drinks per week.
• Heavy drinkers can develop early symptoms in their 30s and severe problems by their 40s.
• Canada recently changed the recommendation for alcohol consumption to 2 drinks per week.
• Common age of presentation is between 30-50 years old, with most patients presenting under 60 years old.
• There is often a history of daily heavy alcohol use (>100g daily) for over 20 years.
• Pathologic findings include the presence of a fatty liver (steatosis) on a histological examination.
• Hepatocytes have a fatty appearance due to focal necrosis of cells.
• Fatty liver changes can be reversed if alcohol consumption ceases.
• Signs and symptoms of alcoholic hepatitis include anorexia, jaundice, right upper quadrant (RUQ) or epigastric abdominal pain, ascites, and tender hepatomegaly.
• The only effective treatment for alcoholic hepatitis is alcohol cessation.
• Formal recovery programs should be considered for patients.
• A liver transplant may be considered if necessary.
• With alcohol cessation, damage may be semi-reversible without further damage (steatosis/steatohepatitis).
• Continued alcohol use can lead to cirrhosis, liver failure, and possibly liver cancer.
• If continued use combines with systemic damage (to the nervous, cardiovascular, or urinary systems), it is fatal.
• The appropriateness of massage is determined by the patient's symptoms for individuals with alcoholic hepatitis.
• There are no general contraindications for massage for alcoholic hepatitis, it depends on patient's symptoms.

Chronic Hepatitis

• Chronic hepatitis is liver inflammation lasting longer than 6 months.
• Common causes include hepatitis B and C viruses, and medications.
• Hepatitis C is responsible for 60-70% of chronic hepatitis cases.
• Approximately 75% of hepatitis C cases become chronic, while 5-7% of hepatitis B cases do, hepatitis A and E do not become chronic.
• Use or overuse of certain drugs such as Tylenol can be a cause.
• Alcoholic hepatitis can progress to chronic hepatitis.
• Metabolic dysfunction-associated steatotic liver disease (MASLD) can also be a cause.
• Symptoms are usually mild with no significant liver damage for years.
• Some patients may experience low-grade fever and right upper quadrant (RUQ) discomfort.
• Jaundice is rare and typically only appears much later in the disease.
• Continued inflammation can result in cirrhosis, liver failure, and/or liver cancer.
• Cirrhosis can lead to portal hypertension.
• Complications of chronic hepatitis include splenomegaly, ascites (fluid accumulation in the abdominal cavity), spider angioma, caput medusae, palmar erythema.
• Deterioration of the peripheral nervous system and brain function results from demyelination and increased serum toxins.
• The most common cause of cirrhosis is hepatitis C.
• Most patients with chronic hepatitis do not experience progression of the disease for years.
• Viral strains of hepatitis will cause gradually worsening symptoms, the outlook depends on the cause.
• Chronic hepatitis C leads to cirrhosis in 15-25% of those infected.
• Hepatitis C is related to an increased risk of liver cancer if cirrhosis is present.
• Chronic hepatitis B tends to worsen rapidly and is related to an increased risk of liver cancer as well.
• Coinfection of chronic hepatitis B and D cause cirrhosis in approximately 70% of patients.
• Chronic hepatitis caused by drugs may completely resolve if the drug is stopped.
• Hepatitis may be suspected based on typical symptoms, abnormal liver function tests (LFT), or a history of hepatitis.
• Diagnosis relies on definitive biopsy.
• Lab work helps determine severity and identify the cause; biopsy is essential for definitive diagnosis.
• Biopsy also confirms the severity of disease process and the cause.
• Patients with chronic hepatitis B require annual ultrasound and blood work to screen for liver cancer.
• Patients with hepatitis C are only screened if it has progressed to cirrhosis.
• Treatment involves eliminating noxious substances and/or treating the cause.
• Antiviral drugs are given through PO or SQ for chronic, progressive hepatitis B and C.
• SQ injections are the most effective for hepatitis C and in stopping inflammation.
• After 6-12 months of treatment, 45-75% of patients will improve with no further issues.
• Chronic hepatitis B (~5% of cases) tends to recur once drug therapy ends.
• Antiviral treatment may be indefinite.
• Family members and close contacts of those with hepatitis B should receive a vaccine and immunoglobulin.
• Corticosteroids and liver transplantation may be required in some cases.
• Appropriateness of massage and chronic hepatitis determined by patient symptoms.
• There are no general contraindications for massage in someone who has chronic hepatitis, it depends on the patient's symptoms.

Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD)

• MASLD was previously known as nonalcoholic fatty liver disease (NAFLD).
• It is defined as steatosis in the absence of significant alcohol consumption.
• MASLD is the most common cause of liver disease in the United States.
• An estimated 25% of adults worldwide suffer from NAFLD.
• Forms of MASLD include simple hepatic steatosis which has little clinical relevance.
• MASH or metabolic dysfunction-associated steatohepatitis was formally known as non-alcoholic steatohepatitis (NASH).
• MASH/NASH can progress to cirrhosis in 10-20% of cases.
• Pathologic findings are initially hepatocyte ballooning, lobular inflammation, and steatosis.
• The disease is strongly associated with obesity and the metabolic syndrome.
• It is caused by a "two-hit" model, involving hepatic fat accumulation and increased oxidative stress.
• Free radicals will cause lipid peroxidation of the accumulated intracellular fat.
• Signs and symptoms are usually asymptomatic until overt hepatic failure.
• Clinical findings are due to atherosclerotic disease/diabetes.
• Fatigue and RUQ abdominal pain may occur in some patients.
• Cardiovascular disease is a common cause of death.
• There is an increased risk of hepatocellular carcinoma (HCC) with MASLD/NASH.
• Treatment of MASLD often involves losing weight, medication to reduce cholesterol or triglycerides, medication to reduce blood pressure, Medication to control diabetes and limiting over the counter medications.
• Avoiding alcohol is a key aspect of treatment.
• Appropriateness of massage is determined by the patient's symptoms for those with MASLD.
• There are no general contraindications for MASLD, it depends on the patient's symptoms.

Hepatocellular Carcinoma (HCC)

• Hepatocellular carcinoma is also known as hepatoma.
• This is the most common primary liver tumor, commonly caused by cirrhosis.
• Hepatocellular carcinoma usually presents with vague symptoms of abdominal pain, fatigue, loss of weight, and appetite.
• Results in late stage diagnosis and poor prognosis.
• Early signs include pain in the abdomen, fever, and weight loss. There may be a palpable mass in the RUQ.
• Persons with cirrhosis may have an unexpected increase in illness.
• Rupture of the tumor can cause sudden abdominal pain and shock.
• Blood tests, physical exam, and advanced imaging (US, CT, MRI) are used for diagnosis.
• A biopsy is often required to confirm unclear findings.
• Prevention includes hepatitis B vaccine, treatment of chronic hepatitis C, alcoholism treatment/ programs, and screening.
• Treatment options include chemotherapy, radiation, tumor embolization, and surgical resection.
• Surgical resection comes with a high rate of recurrence.
• If there is no metastasis, a transplant can be performed.
• Prognosis is poor because vague symptoms cause late stage diagnosis.
• The 5-year survival rate is ~18%.
• Other primary tumors are rare and have poor prognosis.
• Metastatic disease is far more common than primary liver cancer.
• It commonly originates from cancers in the breast, colon, kidney, lung, stomach, pancreas, ovaries, or uterus.
• Appropriateness of massage & HCC is determined by a patient's symptoms.
• There are no contraindications.

Cholelithiasis

• Cholelithiasis refers to the presence of stones in the gallbladder; "chole" means bile, "lithiasis" means stones.
• It involves collections of solid material in the gallbladder.
• Stones can dislodge and get stuck in the cystic duct, common bile duct, or hepatopancreatic ampulla.
• It is more common in Indigenous and Hispanic populations: 70-80% of First Nations peoples in Canada being affected.
• Gallstones are more common in females than males.
• Up to 20% of Canadian women and 10% of men develop gallstones by age 60.
• "Four Fs" of gallstones used to describe patient: female, forty, overweight, & fertile.
• Risk factors: SAD diet; family history of gallstones.
• There are two main types of stones: cholesterol stones and pigment stones.
• The most common stones are cholesterol stones.
• Excess hemolysis can form pigment stones made of bilirubin.
• 80% are asymptomatic, gallstones remain in gallbladder.
• As a stone passes into a duct, the GB swells, causing colicky RUQ pain.
• Pain is diffuse and hard to describe, usually RUQ or epigastric.
• Pain may radiate to the right shoulder or between the scapulae.
• Pain increases over 15 minutes then plateaus at 30-60 min.
• Most episodes last <6 hours, up to 12 hours.
• Pain usually drives the patient to the ER.
• Complications include cholecystitis.
• Diagnosis is via abdominal ultrasound.
• No treatment is required if there are no symptoms.
• For even early episodes with symptoms, the patient is monitored, and the doctor will watch and wait.
• Disruptive, recurring sx usually result in laparoscopic cholecystectomy.
• There is usually little to no effect on digestion.
• There may be an increase in bowel time.
• Low fat diet to reduce strain on gallbladder.
• Certain evidence shows that "extremely" low diets may increase gallstone formulation.
• There are no absolute contraindications for those who have or have had cholelithiasis.
• If symptoms of obstruction are present, then massage is contraindicated.

Cholecystitis

• Cholecystitis is inflammation of the gallbladder, typically in those with a hisotry of symptomatic gallstones.
• It is defined by blockage of the cystic duct by gallstones leads to inflammation of gallbladder.
• Cholecystitis can be acute or chronic.
• The secondary cause is gallstones.
• Other causes include tumors and viral infections.
• Acute Cholecystitis is defined as sudden, severe, steady pain in the RUQ.
• The most common cause is gallstones (95%).
• Acalculous cholecystitis is rare, but more serious and related to to major surgery, burns, and prolonged parenteral nutrition.
• Gallbladder fills with fluid, which causes the walls to thicken.
• It can occur in children and adults.
• Chronic Cholecystitis is defined as chronic inflammation of the gallbladder with repeated attacks of biliary colic.
• The most common cause is gallstones.
• The gallbladder becomes thick-walled, scarred, and small, causing or it contains sludge and/or stones that block the opening to the cystic duct or the duct itself.
• RUQ colicky pain lasts 6-12 hours and is quite severe.
• Pain peaks at 15-60 minutes and remains constant.
• It can radiate to the right shoulder or between the scapulae.
• Pain is increased with breaths.
• Nausea and vomiting are usual.
• Positive Murphy's sign.
• Murphy's sign is when during firm palpation below the subcostal margin, the gall bladder is touched while patient takes a breath, causing sudden cessation of breath due to the pain.
• There may be abdominal rigidity and guarding.
• For acute cholecystitis, those with the condition have a fever of over 38 degrees celcius.
• The US is best way to detect gallstones, fluid around GB, and thickening of GB walls.
• Treatment involves hospitalization.
• Treatment also involves IV fluids while your digestive system rests, antibiotics to treat/prevent infections, and analgesics.
• Definitive treatment of both acute and chronic cholecystitis is colecystectomy.
• To test for the Murphy's sign firmly palpate the RUQ subcostal region, pushing under the ribs and ask the patient to take a deep breath.
• The most diagnostic aspect of a positive murphy's sign is when significant pain that is elicited by this maneuver that has the patient stopping mid-breath.
• Absolute contraindication for acute and severe chronic cholecystitis.

Primary Biliary Cholangitis

• Primary Biliary Cholangitis or PBC was previously known as primary biliary cirrhosis.
• Defined as a autoimmune disease causing inflammation and destruction of the bile ducts of the liver.
• Incidence rates range from 0.33 to 5.8 per 100,000 inhabitants/year.
• Women are predominantly affected with a sex ratio of 9:1.
• The onset is generally in the 4th to 6th decades of life.
• Etiology stems from an autoimmune disease.
• Thought to be a combination of genetic and environmental factors that triggers the disease.
• Signs and symptoms include that more than half of people diagnosed with PBC are asymptomatic at the time due to Incidental findings on blood tests.
• Symptoms eventually develop over the next 5 to 20 years and include: Fatigue, Itchy skin, and Jaundice along with pain in RUQ, and Edema.
• Complications include cirrhosis.
• Diagnosis through LFTS and antibody serology
• Antibody blood tests checked for anti-mitochondrial antibodies (AMA) which are very commonly found in PBC pt.
• The use of Ultrasound in imaging and special type of MRI to view structure of bile ducts.
• Liver biopsy may be needed to confirm.
• No cure for primary biliary cholangitis
• Medications available to help slow the progression of the disease.
• Treatment through Ursodeoxycholic acid (UDCA or ursodiol)
• helps move bile through your liver and improves liver function so it may reduce liver scarring.
• Symptomatic treatment of itching and fatigue (antihistamines)
• Liver transplant may be necessary.
• Once Symptoms Develop the average life expectancy is about 10 years but successful liver transplants offer a 10-year survival rate of 65%.

Primary Sclerosing Cholangitis

• Definition: Inflammatory disease of the bile ducts, both intrahepatic and extrahepatic
• Scarring of the bile ducts causes narrowing and leads to serious liver damage.
• Etiology: Cause is unclear but an immune system reaction to infection or toxin may be a trigger.
• There may be a trigger in people who are genetically predisposed to the above stimulus.
• A high proportion include comorbidity from inflammatory bowel disease.
• PSC has a fairly rare incidence Estimated at about 1 per 100,000 per year (Europe and NA).
• PSC Can occur at any age, median age of diagnosis of 41.
• PSC is More common in males than females.
• It is Much More common in people of Northern European descent.
• Signs and Symptoms are Usually asymptomatic at diagnosis by the time diagnosis comes about.
• Early signs and symptoms include (list symptoms); Fatigue, Itching, Jaundice, RUQ pain.
• Long-term issues can Complications from include risk of cirrhosis and liver failure.
• Diagnosis for PBC includes through LFTS, Imaging.
• Imaging used for this includes through US or even and Special type of MRI to view structure of bile duct
• Confirmation includes doing a Liver biopsy may be needed to confirm.
• Treatment has No cure for primary sclerosing cholangitis
• Medicating with medications is the best option available to help progress the disease
• Ursodeoxycholic acid (UDCA or ursodiol) will help in helping move or increasing bile in the liver.
• UDCA Improve liver function and can reduce liver scarring.
• Can treat of itching and even fatigue through use of antihistamines
• liver transplant the may be necessary for treatment at some point.
• Once SSx develop the average life expectancy is between 10 and 20 years
• successful liver transplants can lengthen life expectancy
• After a the Liver transfer PSC returns in 15/20% of patients post transplant.

Pancreatitis

• Pancreatitis is Inflammation of the pancreas that can be mild or life threatening.
• Causes the activation and possible release of enzymes
• Enzymes begin digesting and attacking the pancreas
• This may be present possibly other tissues if they enter the blood stream.
• May be acute or chronic.
• MC causes of pancreatitis are alcoholism and gallstones.
• Alcoholism is linked to chronic pancreatitis.
• Gallstones are linked to acute pancreatitis.
• Alcohol is linked to 80% of pancreatitis cases.
• Smoking has also been linked to chronic pancreatitis.
• Acute Pancreatitis MC cause is gallstones.
• Always Think of acute pancreatitis as an event
• Attacks are often precipitated by alcoholic binge, smoking or excessively large meal.
• It is More common in females than males
• Chronic Pancreatitis MC cause is alcohol.
• Consider the fact of chronic pancreatitis as an ongoing process of pathologic response to pancreatic injury.
• More common in males than females.
• Symptoms include Severe epigastric and LUQ pain that often radiates to the back.
• With acute gallstones, pain starts suddenly and reaches max intensity in 10-20 minutes and the Acute onset of persistent, severe LUQ is often present.
• Alcohol with chronic issues presents with Pain onset with is less abrupt.
• Often times the pain will be localized when dealing with it do to alcohol.
• Aggrvating factors includes coughing, deep breathing, and vigorous movement.
• Partial relief: sitting up or bending forward
• Typically 90% have nausea/vomiting which may persist for several hours.
• Signs and Symptoms include Tenderness of epigastrium (severity of pain depends on severity of pancreatitis)
• Abdominal distention
• Hypoactive bowel sounds due to inflammation
• Scleral icterus IF obstructive jaundice present
• In 3% of patients with acute pancreatitis, bruising along the flank may be exhibited (Grey Turner Sign) or d/t retroperitoneal bleeding or back pain.
• Diagnosis of Acute Pancreatitis which includes.
• Always consider Characteristic pain leads pancreatitis suspicion (acute onset of persistent, severe, epigastric pain with tenderness on palpation on PE.
• Also Blood tests support diagnosis which include: increased serum lipase and amylase (3x) and leukocytosis.
• Use US as imaging and the pancreas may appear diffusely enlarged, gallstones may be visualized.
• Whether mild or severe, usually requires hospitalization
• For chronic pancreatitis, analgesics and antioxidants (E, C, selenium, methionine) for pain control used along with Pancreatic enzyme supplementation
• For acute pancreatitis.
• Treat with Fasting, IV fluids, analgesics, and antiemetics
• Also can resume normal eating within 2-3 days without further Tx along with treatment or tending to the underlying cause of things such as alcohol or the gallstones in the area.
• In many patients with acute pancreatitis, the disease is mild and those patients recover in 3-5 days with no complications or organ failure.
• Recurring attacks are equivalent with chronic pancreatitis
• Acute pancreatitis is an ABSOLUTE CONTRAINDICATION due to the fact that there is a medical emergency that requires prompt treatment
• Chronic pancreatitis may be a possible Local contraindication.
• Ensure that one avoid abdominal massage is pressure produces pain or discomfort