Liver Cirrhosis and Complications

• Liver diseases include hepatitis, metabolic dysfunction-associated steatotic liver disease (MASLD), hepatocellular carcinoma (HCC), and liver failure.
• Complications from liver diseases can lead to cirrhosis, portal hypertension, esophageal varices, and hepatic encephalopathy.

Cirrhosis

• Cirrhosis is the irreversible replacement of normal liver tissue with non-functional scar tissue.
• The most common cause is alcoholic hepatitis, followed by viral hepatitis (Hep B and Hep C) and metabolic dysfunction-associated steatotic liver disease (MASLD).
• Cirrhosis is twice as common in males.
• In the US, autopsy reveals that 5% of the population has cirrhosis, with 25,000 deaths per year.
• Without a transplant, patients usually die within 5-15 years due to complications.

Complications of Cirrhosis

• Portal hypertension
• Esophageal varices that may lead to mass hematemesis
• Rectal varices (hemorrhoids)
• Ascites (fluid in the abdominal space)
• Kidney failure
• Hepatic encephalopathy
• Decreased bile production, leading to poor vitamin D and K absorption
• Splenomegaly, which can lead to thrombocytopenia
• Bleeding, which leads to anemia

Signs and Symptoms of Cirrhosis

• May have no symptoms for several years
• Symptoms are related to declining liver function and portal hypertension
• Common symptoms include weakness, malaise, fatigue, weight loss, ascites, and loss of appetite

Declining Liver Function

• Reduction in bile production leads to decreased absorption of fat and fat-soluble vitamins
• Steatorrhea (greasy, foul-smelling stool)
• Fatigue, loss of appetite, and weight loss
• Dark urine due to bilirubin buildup
• Generalized edema
• Malabsorption

Portal Hypertension Signs and Symptoms

• Jaundice
• Ascites
• Hepatomegaly and splenomegaly
• Digital clubbing
• Caput medusae and spider telangiectasia
• Xanthelasma (small yellow nodules, especially around eyes)

Other Signs and Symptoms

• Sarcopenia (muscle atrophy)
• Palmar erythema
• Gynecomastia, testicular atrophy, and thinning of armpit hair (less testosterone, more estrogen)
• Dupuytren's contracture (fibrosis of the palmar aponeurosis)

Diagnosis of Cirrhosis

• Based on history, signs and symptoms, physical exam, and blood tests
• Palpation reveals a nodular and firm liver
• Advanced imaging (US or CT) and biopsy confirm the diagnosis
• Blood tests show elevated liver enzymes (AST and ALT), elevated bilirubin, and decreased albumin
• CBC may show signs of anemia
• Blood work may identify the underlying cause, such as Hep B and Hep C serology

Treatment of Cirrhosis

• Eliminating alcohol is crucial, especially in alcoholic hepatitis
• Improving diet and activity if caused by metabolic disease
• Reviewing medications (Rx and OTC) and supplements with a doctor because some may be hard for the liver to process, e.g., Tylenol
• The patient may need diuretics and a low-sodium diet.
• Liver transplant may be necessary if liver failure occurs after 80-90% of liver destruction by cirrhosis

Massage Considerations

• Massage has no specific contraindications, but practitioners may consider less pressure to avoid easy bruising and ensure patient comfort.

Portal Hypertension

• Abnormally high blood pressure in the branches of the portal vein
• Presentation includes an enlarged abdomen, abdominal discomfort, confusion, and internal bleeding
• The most common cause is cirrhosis

Etiology of Portal Hypertension

• Cirrhosis leads to decreased blood flow through the liver due to scarring.
• Other causes include thrombosis in the portal vein, parasitic infection (schistosomiasis), and malignancy

Signs and Symptoms of Portal Hypertension

• Portal hypertension itself does not cause symptoms, but creates consequences such as ascites, telangiectasia, caput medusae, esophageal varices with potential mass hematemesis, splenomegaly, and hepatic encephalopathy

Diagnosis of Portal Hypertension

• Based on symptoms, history, and physical exam
• Confirmed with ultrasound

Treatment of Portal Hypertension

• Most cases are irreversible due to cirrhosis
• Medications to reduce portal blood pressure, e.g., beta blockers
• Management of complications, with emergency treatment required if bleeding occurs
• Surgery or bypass shunt between the portal venous system and general circulation may be necessary

Massage Considerations

• No specific contraindications exist, but any abdominal massage should be performed with very light pressure, and practitioners should consider the patient's overall comfort.

Esophageal Varices

• Engorged, tortuous, and fragile varicose vessels of the lower esophagus

Etiology of Esophageal Varices

• Portal hypertension, causing retrograde flow into the lower esophageal vessels, leading to distention and varices

Signs and Symptoms of Esophageal Varices

• Hematemesis
• Black, tarry or bloody stools
• Lightheadedness due to blood loss

Treatment of Esophageal Varices

• Betablockers to reduce blood pressure
• Bleeding is a medical emergency requiring an endoscope to confirm bleeding is from varices
• Banding off/chemical injections of veins
• Vasopressin given IV to constrict bleeding veins
• Transfusion to replace blood loss

Massage Considerations

• Esophageal varices may be a contraindication depending on the severity, with some cases being a medical emergency.

Hepatic Encephalopathy

• Deterioration of brain function due to the buildup of toxic substances normally removed by the liver, reaching the brain
• Ammonia plays a large role

Etiology of Hepatic Encephalopathy

• Portal hypertension causes blood to bypass the liver
• Liver failure
• Can be triggered by alcohol, drugs, or other liver stressors

Signs and Symptoms of Hepatic Encephalopathy

• Decreased brain function, including reduced alertness and increased confusion
• Early stages involve subtle changes in logical thinking, judgement, mood, personality, and behavior
• Late stages involve drowsiness, confusion, disorientation, asterixis (flapping tremors), and sluggish movements and speech
• Eventual loss of consciousness and coma

Diagnosis of Hepatic Encephalopathy

• Based on symptoms, history, and physical exam
• CT scan and EEG (electroencephalogram)
• Blood tests for liver function and presence of ammonia

Treatment of Hepatic Encephalopathy

• Identify and eliminate triggers
• Reduce protein intake and other dietary restrictions
• Lactulose sugar in diet helpful for decreasing blood ammonia
• Liver treatment

Prognosis of Hepatic Encephalopathy

• Reversible, with complete recovery possible
• Chronic liver failure predisposes to future episodes, requiring ongoing therapy
• Acute hepatic encephalopathy is fatal in > 50% of cases and in 80% of people who fall into a coma

Jaundice

• Excess amounts of bilirubin circulating in the bloodstream, dissolving in the subcutaneous fat
• Presents as a yellowish appearance of the skin and whites of the eyes

Etiology of Jaundice

• Prehepatic conditions that affect the blood's rate of breaking down blood cells cause bilirubin to overflow into bodily tissues
• Intrahepatic conditions involving liver tissue become less effective at filtering out bilirubin from blood, e.g., hepatitis, cirrhosis, hepatocellular carcinoma
• Posthepatic (obstructive) conditions where bilirubin filtered from the blood cannot drain properly into the bile ducts or digestive tract, e.g., cholelithiasis, pancreatitis, pancreatic cancer

Signs and Symptoms of Jaundice

• Yellow skin and the white part of the eyes (sclera)
• Yellow color inside the mouth
• Dark or brown-colored urine
• Pale or clay-colored stools
• Itching (pruritis) usually occurs with jaundice

Massage Considerations

• Treatment may or may not be indicated based on the cause and severity of jaundice.

Hepatitis

• Inflammation of the liver that can result from a variety of causes, such as viral infection, heavy alcohol use, autoimmune disorders, drugs, or toxins

Types of Hepatitis

• Viral hepatitis (hepatitis viruses A-E) with varying severity and longevity
• Alcoholic hepatitis due to overconsumption of EtOH
• Both can lead to chronic hepatitis

Acute Viral Hepatitis

• Inflammation of the liver due to infection with one of the five hepatitis viruses (A-E)
• Hepatitis A virus is the most common cause
• Sudden, rapid onset with a short duration (usually only a few weeks)
• Symptoms range from none to severe, and may include N/V, poor appetite, fever, RUQ pain, and jaundice

Comparing Hepatitis Virus Types

• Usually no specific Tx necessary for Hep A, Hep B, and Hep E
• Antiviral treatments available for Hep C and Hep D
• Hep C is the most likely to become chronic
• Hep D can only be acquired if you have hep B and can be a serious form of hepatitis
• There are vaccines for Hep A, B, and therefore D
• No vaccine available for Hep C
• Severity depends on instigating virus and the host response (Hep A and C are often mild, sometimes unnoticed, Hep B and E are more severe)

Common Signs and Symptoms of Hepatitis

• Symptoms have sudden onset and include prodromal symptoms such as poor appetite, N/V, and fever
• RUQ pain
• Splenomegaly
• Hep B can cause joint pain and urticaria
• Hep B and hep C can cause urticaria

Progressive Symptoms of Hepatitis

• Progression causes dark urine and jaundice
• Progression to liver failure is rare, but more common with hepatitis B virus

Diagnosis of Hepatitis

• Initial suspicion is based on positive symptoms
• Palpation of RUQ reveals tenderness and hepatomegaly in 50% of acute viral hepatitis cases
• LFT (liver function tests) blood work can indicate liver function and inflammation
• Antigen/antibody blood tests reveal the specific virus causing hepatitis
• Ultrasound of the liver to detect any changes
• Biopsy is done if DDx is unclear (usually not indicated)

Prevention of Hepatitis

• Vaccines are available for hepatitis A and B viruses
• No current vaccine for Hep C, D, or E
• Other preventative measures include washing hands thoroughly, not sharing needles, not sharing razors, practicing safe sex

General Treatment and Prognosis of Hepatitis

• Typically, no treatment is needed
• Avoid alcohol and medications metabolized in the liver
• Acute viral hepatitis usually clears in 4-8 weeks, but some cases can turn chronic

Fulminant Hepatitis

• Rare, life-threatening complication of acute hepatitis
• Marked by the presence of massive liver necrosis
• Viral hepatitis can progress to fulminant hepatitis if it's not the B, D, or E strain
• Signs and symptoms include encephalopathy (including edema), GI bleeds, and kidney failure
• Has a high mortality rate of 40-80%

Hepatitis A

• Transmitted via the fecal-oral route
• Epidemics often linked to contamination of the water supply
• Highest reported rates are in age groups 30-59 years
• Incubation period of 2-6 weeks
• Symptoms may range from mild fever, N/V, and loss of appetite to jaundice
• Complete recovery occurs within days to months
• Does NOT result in chronic hepatitis
• Prevention includes proper hand hygiene, avoiding contamination of water supplies, and vaccination

Hepatitis B

• Transmitted via blood and body fluids (sexual intercourse, needle sharing, birth)
• In 2019, there were 178 reported acute hepatitis B cases in Canada
• Generally, more serious than Hep A, and symptoms can range from mild to severe
• Diagnosis is confirmed by blood tests
• 5-7% of adults develop chronic hepatitis B
• Prevention includes vaccination, avoiding needle sharing, and engaging in safe sex practices

Hepatitis B Phases of Infection

• Pre-icteric: Days to weeks – Mild fever, N/V, anorexia, myalgia, malaise, weakness
• Icteric: One to two months – Jaundice, hepatomegaly w/ tenderness, urticaria w/ prutitis, abate pre-icteric symptoms
• Convalescent: Up to six months – Resolution of symptoms, viral Ag disappear and immune Ab appear

Healthy Hepatitis B Carriers

• 10% of infected become healthy carriers
• Surface antigen present months, years, or sometimes for life but otherwise healthy and unaware of status
• 70% of carriers develop chronic persistent hepatitis B and most do not appear to be ill

Hepatitis C

• Transmitted via blood
• M/C route of transmission is needle sharing w/o sterilization
• Initial infection (acute) is usually mild and without symptoms
• Clinical presentation indistinguishable from Hep B, but often less severe
• Chronic infection results in 75% of cases
• Cirrhosis in 20-30% of those w/ chronic infection
• No vaccine currently available
• Avoid high risk behaviour, eg, needle sharing.

Hepatitis D and E

• Hepatitis D can only infect people who are also infected by the hepatitis B virus (HBV)
• Hepatitis E is transmitted via the fecal-oral route and is especially dangerous to pregnant women

Massage and Viral Hepatitis

• Appropriateness of massage is determined by patient's symptoms
• Treatment is contraindicated if a fever is present until 24 hours fever free without the use of antipyretics