Liver Pathologies

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

Cirrhosis

• It is an irreversible condition where normal liver tissue is replaced by non-functional scar tissue.
• Common causes include alcoholic hepatitis, viral hepatitis (B and 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, causing 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 can lead to hematemesis
  • Rectal varices (hemorrhoids)
  • Ascites, which is fluid in the abdominal space
  • Kidney failure
  • Hepatic encephalopathy
• Decrease in bile can lead to decreased absorption of vitamin D potentially leading to osteoporosis
• Poor vitamin K absorption can lead to a tendency for bleeding.
• Splenomegaly occurs as platelets get trapped.
• Bleeding can lead to anemia.

Cirrhosis Signs and Symptoms

• Initial stages may be asymptomatic for several years.
• Later symptoms fall into two categories: declining liver function and portal hypertension.
• Common symptoms include weakness, malaise, fatigue, weight loss, ascites, and loss of appetite.
• Declining liver function results in decreased absorption of fat and fat-soluble vitamins, leading to greasy, foul-smelling steatorrhea.
• Other signs include dark urine, generalized edema, and malabsorption.
• Portal hypertension can cause jaundice, ascites, hepatomegaly, splenomegaly, digital clubbing, caput medusae, spider telangiectasia, and small yellow nodules (xanthelasma).
• Spider telangiectasia (spider angioma) may be due to elevated vascular endothelial growth factor, fibroblast growth factor, or altered estrogen/testosterone ratio.
• Digital clubbing may also result from elevated vascular endothelial growth factor or fibroblast growth factor.
• Caput medusae are swollen veins around the umbilicus caused by portal hypertension.
• Xanthelasma are cholesterol deposits under the skin, associated with dyslipidemia, altered lipoprotein profiles, and metabolic disease.
• Other symptoms include sarcopenia, palmar erythema, gynecomastia, testicular atrophy, thinning of armpit hair, and Dupuytren's contracture.
• Diagnosis includes reviewing history, symptoms, physical exam, and blood tests.
• On palpation, the liver feels nodular and firm.
• Advanced imagine includes Ultrasound or CT, biopsy can also confirm.
• Blood tests include LFTs (liver function tests) showing elevated AST and ALT, elevated bilirubin, and decreased albumin.
• CBC may show signs of anemia.
• Blood work may reveal the underlying cause, like hepatitis B or C serology.

Cirrhosis Treatment

• Eliminate alcohol, especially in cases of alcoholic hepatitis.
• Improve diet and activity if caused by metabolic disease.
• Review medications (Rx and OTC) and supplements with a physician, as some may be hard for the liver to process.
• Diuretics and a low-sodium diet may be prescribed for blood pressure control.
• Liver transplant may be necessary if liver failure occurs after 80-90% of liver destruction.

Massage for Cirrhosis

• Massage is generally not contraindicated.
• Less pressure may be considered to avoid easy bruising.
• Focus on the patient's overall comfort.

Portal Hypertension

• Portal hypertension is an abnormally high blood pressure in the branches of the portal vein.
• Presentation includes enlarged abdomen, abdominal discomfort, confusion, and internal bleeding.
• Cirrhosis is the most common cause.
• Causes include cirrhosis, thrombosis in the portal vein, parasitic infection (schistosomiasis), and malignancy.
• Portal hypertension itself may not cause symptoms, but its consequences do.

Signs and Symptoms of Portal Hypertension

• Ascites
• Telangiectasia and caput medusae
• Esophageal varices with potential for hematemesis
• Splenomegaly
• Hepatic encephalopathy causing drowsiness, confusion, and coma
• Gastrointestinal bleeding.
• Diagnosis is based on symptoms, history, physical exam, and confirmed with ultrasound.
• Most cases are irreversible, caused by cirrhosis.
• Medications like beta blockers can reduce portal blood pressure.
• Emergency treatment is required if bleeding occurs, including surgery or a bypass shunt between the portal venous system and general circulation.

Massage for Portal Hypertension

• Massage normally has no contraindications
• Any abdominal massage should be performed with very light pressure
• Consider less pressure to avoid bruising and focus on patient comfort.

Esophageal Varices

• Esophageal varices are engorged, tortuous, and fragile varicose vessels of the lower esophagus.
• Etiology includes portal hypertension causing retrograde flow into the lower esophageal vessels.

Signs and Symptoms of Esophageal Varices

• Hematemesis (mild to fatal)
• Black, tarry, or bloody stools
• Lightheadedness due to blood loss
• Treatments include beta blockers to reduce blood pressure.
• Bleeding is a medical emergency, requiring endoscopy to confirm the source.
• Banding off or chemical injections of veins may be performed.
• Vasopressin given IV constricts bleeding veins.
• Transfusion to replace blood loss.

Massage for Esophageal Varices

• Massage may be a contraindication, depending on the severity of varices.
• Some cases may be a medical emergency.

Hepatic Encephalopathy

• Hepatic encephalopathy is the deterioration of brain function due to a buildup of toxic substances normally removed by the liver.
• Ammonia, an end product of normal protein breakdown, plays a significant role.
• Etiology includes portal hypertension (blood bypasses the liver) and liver failure.
• Can be triggered by an alcohol binge, drug intake, or other liver stressors in those with longstanding liver disorders.

Signs and Symptoms of Hepatic Encephalopathy

• Decreased brain function w/ reduces alertness, increased confusion
• Early stages: subtle changes in logical thinking, judgement, mood, personality, and behavior
• Late stages: drowsiness, confusion, disorientation, asterixis (flapping tremors), and sluggish movements and speech
• Uncommon symptoms: agitation, seizures
• Eventual loss of consciousness and coma
• Diagnosis is based on symptoms, history, physical exam, CT scan, EEG, and blood tests for liver function and ammonia levels.
• Treatment involves identifying and eliminating triggers, reducing protein intake, and dietary restrictions.
• Lactulose in diet is helpful for decreasing blood ammonia.
• Liver treatment is also administered.

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 80% of people who fall into a coma.

Jaundice

• Jaundice is caused by excess bilirubin circulating in the bloodstream, dissolving in subcutaneous fat and causing a yellowish appearance of the skin and eyes.
• Prehepatic jaundice results from conditions affecting the blood's rate of breaking down blood cells like sickle cell anemia and thalassemia.
• Intrahepatic jaundice occurs when liver tissue becomes less effective at filtering out bilirubin from the blood, as seen in hepatitis, cirrhosis, and hepatocellular carcinoma.
• Posthepatic (obstructive) jaundice happens when bilirubin filtered from the blood can't drain properly into the bile ducts or digestive tract due to cholelithiasis, pancreatitis, or pancreatic cancer.

Signs and Symptoms of Jaundice

• Yellow skin and sclera
• Yellow color inside the mouth
• Dark or brown-colored urine
• Pale or clay-colored stools
• Itching (pruritis)
• Treatment may or may not be indicated based on the cause and severity of jaundice.

Hepatitis

• Hepatitis is inflammation of the liver resulting from viral infection, heavy alcohol use, autoimmune disorders, drugs, or toxins.
• Types include viral hepatitis (A-E) and alcoholic hepatitis, both of which can lead to chronic hepatitis.

Acute Viral Hepatitis

• Inflammation is due to infection with one of the five hepatitis viruses (A-E).
• Hepatitis A virus is the most common cause of acute viral hepatitis.
• Hepatitis D and E are rare.
• Sudden, rapid onset with a short duration of a few weeks.
• Symptoms range from none to severe, including N/V, poor appetite, fever, RUQ pain, and jaundice.
• Usually no specific treatment is necessary for hep A, hep B, and hep E.
• Antiviral treatments are 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.
• Vaccines exist for hep A, B, and therefore D.
• NO VACCINE FOR HEP C
• Severity depends on the virus and host response.
• Hep A and C are often mild and sometimes unnoticed.
• Hep B and E are more severe.

Common Signs and Symptoms of acute viral hepatitis

• Symptoms have sudden onset and include prodromal symptoms such as: -Poor appetite -N/V -Fever
• RUQ pain
• Splenomegaly
• Hep B can cause joint pain
• Hep B and hep C can cause urticaria
• Progressive symptoms include dark urine and jaundice.
• Jaundice lingers for ~1 month as other symptoms disappear.
• Hep A can cause cholestasis, resulting in pale stool and itchiness. Progression to liver failure is rare, but most common with hepatitis B virus.
• Initial suspicion is based on positive symptoms.
• Palpation of RUQ reveals tenderness and hepatomegaly in 50% of acute viral hepatitis.
• LFTs (liver function tests) blood work can indicate liver function and inflammation.
• Varying ratios of blood tests can DDx viral infections from EtOH.
• Antigen/antibody blood tests reveal the specific virus causing hepatitis.
• If DDx is unclear, a biopsy is done (usually not indicated).
• Vaccines are available for hepatitis A and B viruses.
• No current vaccine for hep C, D, or E.
• Hep D cannot occur without hep B infection present; therefore, the hep B vaccine will reduce risk of hep D.

Other preventative measures for acute viral hepatitis

• Washing hands thoroughly before handling food
• Not sharing needles
• Not sharing razors, toothbrushes, or items that could contain blood
• Practicing safe sex

General Treatment and Prognosis of acute viral hepatitis

• Typically, no Tx needed Diet and activity restriction unnecessary
• Vitamin supplementation not required
• Avoid alcohol and meds metabolized in the liver
• Return alcohol and meds metabolized in the liver
• Return to most ADL after jaundice clears, even if LFT not WNL
• Severe cases may require hospitalization
• Acute viral hepatitis usually clears in 4-8 weeks
• Some cases can turn chronic

Fulminant Hepatitis

• A 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
• Hep E infections are more likely to become fulminant in pregnant women
• Signs and symptoms include encephalopathy/edema, GI bleeds, kidney failure
• High mortality rate of 40-80%

Hepatitis A

• Transmitted fecal-orally through poor hygiene, contaminated shellfish or diaper changing
• Epidemics are often linked to contamination of the water supply.
• Spread can also occur through blood.
• It's rare in Canada.
• Highest reported Hep A rates are in age groups 30-59 years.
• It can be endemic in areas with poor water sanitation.

Signs & Symptoms of Hepatitis A

• Incubation period of 2-6 weeks
• Can be asymptomatic and infection goes unrecognized
• Mild fever, N/V, loss of appetite, jaundice
• Rare symptoms: arthropathy, pancreatitis, renal failure
• Complete recovery within days to months.
• Does NOT result in chronic hepatitis.
• No carrier state or chronic hepatitis from hepatitis A infections.

Prevention of Hepatitis A

• Proper hand hygiene
• Avoiding contamination of water supplies
• Vaccination (Twinrix) recommended for all children and for adults at high risk of exposure

Hepatitis B

• Transmitted via blood and body fluids through sexual intercourse, needle sharing, blood transfusions (rare due to screening), and birth.
• Rare in Canada, but more common in some countries in Asia, Africa, South America, and the Caribbean.

Signs and Symptoms of Hepatitis B

• Incubation period of 40 – 180 days

• Generally more serious than Hep A.

• Symptoms range from mild – severe: -Illness followed by fever, jaundice and choluria (cholesterol in urine) -Joint pain and uricaria are more likely in hep B infection

• Occasionally fatal, especially in immunocompromised or with concomitant infection with hepatitis D

• Blood tests confirm presence of infection, or immunity to hepatitis B.

• Hepatitis B Surface Antigen Test (HBsAg) Tests for the presence of hepatitis B surface antigens in blood. A positive test indicates acute or chronic infection.

• Antibody Serology measures the presence/ level of specific antibodies in the blood.

Prognosis of Hepatitis B

• More cases self-resolve in 4-8 weeks
• 5-7% of adults develop chronic hepatitis B
• Inverse correlation between age and risk The 5-year survival rates were 97% for patients with chronic persistent hepatitis and 55% for those with chronic active hepatitis with cirrhosis
• Can have a carrier state.

Healthy Hepatitis B Carriers

• 10% of infected become healthy carriers Surface antigen present months, years, sometimes for life
• Otherwise healthy and unaware of status
• Must have had infection in order to be a carrier
• 70% of carriers develop chronic persistent hepatitis B
• Most do not appear to be ill

Phases of Hepatitis B Infection

• Pre-icteric: days to weeks with mild fever, N/V, anorexia, myalgia, malaise, weakness
• Icteric: one to two months with jaundice, hepatomegaly w/ tenderness, urticaria w/ prutitis. Pre-icteric symptoms abate
• Convalescent: up to six months with resolution of symptoms, viral Ag disappear and immune Ab appear

Prevention of Hepatitis B

• Vaccination is recommended for everyone < 18 but especially for those at risk of exposure. Immunocompromised, cirrhosis, and those on dialysis may need booster
• Avoid needle sharing
• Engage in safe sex practices
• If exposed, persons are given a hep B immunoglobulin and the vaccine which prevents chronic hep B in most.

Hepatitis C

• Transmitted via blood through needle sharing and transfusions (rare due to screening).
• Transmission via sex/pregnancy & birth is rare; via bodily fluids.
• For unknown reasons, 20% of persons with alcoholic liver disease develop hepatitis C.

Signs and Symptoms of hepatitis C

• Unpredictable course of symptoms
• Initial infection (acute) is usually mild and w/o symptoms
• The clinical presentation is indistinguishable from hep B but less severe
• Illness followed by fever, jaundice and choluria
• Urticaria, more likely in hep C infection
• LFTs ebb and flow for several months or years

Prognosis of Hepatitis C

• Chronic infection results in 75% of cases
• Usually mild for decades, but eventually steatosis
• Cirrhosis in 20-30% of those w/ chronic infection which can lead to liver CA
• Carrier state in small portion of healthy people

Prevention of Hepatitis C

• No vaccine is available
• Avoid high-risk behavior/needle sharing

Hepatitis D

• Can only infect people who are also infected by the hepatitis B virus (HBV)
• HBV can cause severe symptoms and serious illness that can lead to liver damage and even death

Hepatitis E

• Fecal-oral transmission
• Usually mild disease but especially dangerous to pregnant women
• At risk of complication of Fulminant Hepatitis

Massage & Viral Hepatitis

• Appropriateness of massage determined by the patient's symptoms
• Treatment is CONTRAINDICATED if a fever is present.
• Wait until 24 hour fever free without the use of antipyretics