Liver Diseases: Hepatitis, Cirrhosis, and Complications

• Liver diseases include hepatitis, metabolic dysfunction-associated steatotic liver disease (MASLD), hepatocellular carcinoma (HCC), and liver failure.

Hepatitis

• Viral and alcoholic hepatitis can lead to chronic hepatitis

Broad Categories of Hepatic Injury

• Cirrhosis and portal hypertension are caused by liver damage.
• Esophageal varices and hepatic encephalopathy are complications from liver disease.

Cirrhosis

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

Cirrhosis Complications

• Portal hypertension leads to esophageal varices (possibly causing hematemesis), rectal varices (hemorrhoids), ascites (fluid in the abdomen), kidney failure, and hepatic encephalopathy.
• A decrease in bile can lead to poor vitamin D absorption (possibly causing osteoporosis) and poor vitamin K absorption (increasing the tendency for bleeding).
• Splenomegaly (enlarged spleen) can trap platelets, increasing the tendency for bleeding and leading to anemia.

Cirrhosis Signs and Symptoms

• Patients may be asymptomatic for years.
• Symptoms relate to declining liver function and portal hypertension.
• Common symptoms include weakness, malaise, fatigue, weight loss, ascites, and loss of appetite.

Symptoms Related to Declining Liver Function

• Reduced bile production results in decreased absorption of fat and fat-soluble vitamins, leading to greasy, foul-smelling steatorrhea.
• Other symptoms include fatigue, loss of appetite, weight loss, dark urine (bilirubin buildup), generalized edema, and malabsorption.

Symptoms Related to Portal Hypertension

• Jaundice, ascites, hepatomegaly and splenomegaly, digital clubbing, caput medusae, spider telangiectasia, and small yellow nodules (xanthelasma around the eyes) may occur.

Pathogenesis of Spider Telangiectasia and Digital Clubbing

• Possibly results from elevation in vascular endothelial growth factor and fibroblast growth factor or an altered estrogen/testosterone ratio.

Caput Medusae

• Swollen veins around the umbilicus are due to portal hypertension, resulting in varicose veins in the abdominal region.

Xanthelasma

• Benign yellow growths on or by the corners of the eyelids are cholesterol deposits that build up under the skin.
• Pathogenesis involves dyslipidemia, altered lipoprotein profiles, altered fat metabolism, and association with metabolic disease.

Other Cirrhosis Signs and Symptoms

• Sarcopenia (muscle atrophy), palmar erythema, gynecomastia, testicular atrophy, and thinning of armpit hair can occur due to hormonal changes.
• Dupuytren's contracture (fibrosis of the palmar aponeurosis) is linked to cirrhosis, though the exact mechanisms are not fully understood.

Diagnosis of Cirrhosis

• Diagnosis is based on history, symptoms, physical exam, and blood tests.
• The liver feels nodular and firm on palpation.
• Advanced imaging (US or CT) and biopsy are used to confirm.
• Liver function tests (LFTs) show elevated liver enzymes (AST and ALT), elevated bilirubin, and decreased albumin; CBC may show signs of anemia.
• Blood work may be done to find the underlying cause, such as hepatitis B and C serology.

Treatment of Cirrhosis

• Eliminating alcohol is crucial, especially in alcoholic hepatitis.
• Improving diet and activity is important if metabolic disease is the cause.
• Medications (Rx and OTC) and supplements should be reviewed with a GP due to potential liver processing issues.
• Diuretics and a low-sodium diet can help with blood pressure.
• A liver transplant is considered if liver failure occurs (80-90% liver destruction).

Massage Considerations for Cirrhosis

• Massage is generally safe, but less pressure may be needed to avoid easy bruising, and the patient's comfort should be considered.

Portal Hypertension

• Portal hypertension is 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 causes scarring, leading to decreased blood flow through the liver.
• Other causes include thrombosis in the portal vein, parasitic infection (schistosomiasis), and malignancy.

Signs and Symptoms of Portal Hypertension

• Portal hypertension itself doesn't cause symptoms, but its consequences do, including ascites, telangiectasia and caput medusae, esophageal varices with potential mass hematemesis, splenomegaly, and hepatic encephalopathy with drowsiness, confusion, and coma.
• Gastrointestinal bleeding may also occur.

Diagnosis of Portal Hypertension

• Diagnosis is based on symptoms, history, and physical exam, and confirmed with ultrasound.

Treatment of Portal Hypertension

• Most cases are irreversible due to cirrhosis.
• Medications (beta blockers) can reduce portal blood pressure.
• Complications are managed as needed with emergency treatment if bleeding occurs, including surgery or a bypass shunt between the portal venous system and general circulation.

Massage Considerations for Portal Hypertension

• There are no contraindications, but abdominal massage should be performed with very light pressure, and the patient's comfort should be considered.

Esophageal Varices

• Esophageal varices are engorged, tortuous, and fragile varicose vessels of the lower esophagus.

Etiology of Esophageal Varices

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

Signs and Symptoms of Esophageal Varices

• Hematemesis (mild to fatal), black, tarry or bloody stools, and light-headedness due to blood loss may occur.

Treatment of Esophageal Varices

• Beta blockers reduce blood pressure.
• Bleeding is a medical emergency requiring an endoscope to confirm bleeding is from varices, banding off/chemical injections of veins, IV vasopressin to constrict bleeding veins, and transfusion to replace blood loss.

Massage Considerations for Esophageal Varices

• Massage may be a contraindication depending on the severity.

Hepatic Encephalopathy

• Hepatic encephalopathy is the deterioration of brain function due to toxic substances normally removed by the liver reaching the brain, with ammonia playing a large role.

Etiology of Hepatic Encephalopathy

• Portal hypertension causes blood to bypass the liver due to increased blood pressure in the portal vein.
• Liver failure and triggers like alcohol, drugs, or other liver stressors can also be causes.

Signs and Symptoms of Hepatic Encephalopathy

• Decreased brain function with reduced alertness and increased confusion.
• Early stages present with subtle changes in logical thinking, judgement, mood, personality, and behavior.
• Late stages include drowsiness, confusion, disorientation, asterixis (flapping tremors), and sluggish movements and speech; agitation and seizures are uncommon.
• Eventual loss of consciousness and coma can occur.

Diagnosis of Hepatic Encephalopathy

• Diagnosis is based on symptoms, history, PE, CT scan, EEG, and blood tests for liver function and ammonia levels.

Treatment of Hepatic Encephalopathy

• Identify and eliminate triggers.
• Reduce protein intake and other dietary restrictions.
• Lactulose sugar in the diet helps decrease blood ammonia.
• Liver treatment is necessary.

Prognosis of Hepatic Encephalopathy

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

Jaundice

• Jaundice involves excess bilirubin circulating in the bloodstream, dissolving in subcutaneous fat and causing a yellowish appearance of the skin and whites of the eyes.

Etiology of Jaundice

• Prehepatic: Conditions affecting the blood's rate of breaking down blood cells cause bilirubin overflow (e.g., sickle cell anemia, thalassemia).
• Intrahepatic: Liver tissue becomes less effective at filtering out bilirubin (e.g., hepatitis, cirrhosis, hepatocellular carcinoma).
• Posthepatic (Obstructive): 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 sclera, yellow color inside the mouth, dark or brown-colored urine, pale or clay-colored stools, and itching (pruritus).

Massage Considerations for Jaundice

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

Hepatitis

• Hepatitis is inflammation of the liver that can result from various causes, such as viral infection, heavy alcohol use, autoimmune disorders, drugs, or toxins.
• Types: Viral (A-E), alcoholic. Both can lead to chronic hepatitis

Acute Viral Hepatitis

• Acute viral hepatitis: Inflammation of the liver d/t infection with one of the five hepatitis viruses (A-E).
• Hepatitis A virus is most common cause of acute viral hepatitis
• Followed by hepatitis B and hepatitis C.
• Hepatitis D and hepatitis E are rare.
• Sudden, rapid onset with a short duration (usually only a few weeks).
• Symptoms range from none to severe.
• N/V, poor appetite, fever, RUQ pain, and jaudice are common.

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.
• Can be a serious form of hepatitis.
• Vaccines for hep A, B and therefore D.
• NO VACCINE 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.
• Co-infection of hep B with hep D increases severity (has the highest mortality of all hepatitis infections).

Common Signs and Symptoms

• Symptoms have sudden onset and include.
• Prodromal – poor appetite, N/V, fever.
• RUQ pain.
• Splenomegaly.
• Hep B can cause joint pain.
• Hep B and hep C can cause urticaria.
• Progressive symptoms.
• Progression causes dark urine and jaundice.
• As other symptoms disappear, jaundice lingers for ~1 month .
• Hep A can cause cholestasis, resulting in pale stool and itchiness.
• Progression to liver failure is rare, but m/c w/ 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.
• LFT (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.
• Ultrasound of the liver to detect any changes.
• If DDx is unclear a biopsy is done (usually not indicated).

Prevention of Hepatitis

• Vaccines 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, hep B vaccine will reduce risk of hep D.
• Other preventative measures:
  • Washing hands thoroughly before handling food.
  • Not sharing needles.
  • Not sharing razors, toothbrushes, or items that could contain blood.
  • Practicing safe sex.

General Treatment & Prognosis of Hepatitis

• Typically, no Tx needed.
• Diet and activity restriction unnecessary.
• Vitamin supplementation not required.
• Avoid alcohol and meds metabolized in the liver.
• Return to most ADL after jaundice clears, even if LFT not with normal limits (WNL).
• Severe cases may require hospitalization.
• Acute viral hepatitis usually clears in 4-8 weeks.
• 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.
• Hep E infections are more likely to become fulminant in pregnant women.
• Signs and symptoms include: encephalopathy (including edema), GI bleeds, kidney failure.
• High mortality rate – 40-80%.

Hepatitis A

• Fecal-oral
• Poor hygiene – food handlers, child care workers.
• Shellfish from water where raw sewage drains.
• Diaper changing at childcare centers.
• Epidemics often linked to contamination of water supply.
• Can also spread through blood.

Epidemiology of Hepatitis A

• Rare in Canada.
• From 2011 to 2015, yearly average of 236 cases of hapatitis A reported.
• Highest reported hepatitis A rates are in age groups 30-59 years.
• Can be endemic in areas with poor water sanitation South Asia, Sub-Saharan and north Africa, parts of the far east (Except Japan), south and central america and the middle east.

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.

Prognosis of Hepatitis A

• 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 recommended for all children and for adults at high risk of exposure.

Hepatitis B

• Transmitted via blood and body fluids.
• Sexual intercourse.
• Through blood (highest risk), semen, vaginal fluids.
• Needle sharing w/o sterilization.
• Birth (vaginal and cesarean).
• Usually d/t mothers infected secretions or blood at the time of delivery.

Epidemiology of Hepatitis B

• Rare in Canada.
• More common in some countries in Asia, Africa, South America and the Caribbean.

Signs & 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 more likely in hep B infection.
• Occasionally fatal; especially in immunocompromised or with concomitant infection with hepatitis D.

Diagnosis of Hepatitis B

• 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.
• Testing also done to confirm the presence 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 The estimated 5-year survival rates are: 97% for patients with chronic persistent hepatitis and 55% for those with chronic active hepatitis with cirrhosis.
• Can have carrier state.

Healthy Carriers of Hepatitis B

• Become healthy carriers where surface antigen present months, years, or sometimes for life.
• 70% of carriers develop chronic persistent hepatitis B where most do not appear to be ill.

Phases of Hepatitis B 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; Pre-icteric symptoms abate.
• Convalescent: Up to six months; Resolution of symptoms; Viral Ag disappear and immune Ab appear.

Prevention of Hepatitis B

• Vaccination: Recommended for everyone < 18 (3 doses, usually given at birth), but especially for those at risk of exposure
• If exposed persons are given a hep B immunoglobulin and the vaccine.
• Combination prevents chronic hep B in most.

Hepatitis C

• Transmitted via blood.
• Transmission via profusion is rare d/t screening.
• Transmission is rare via sex and pregnancy/birth.
• Some 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.
• Illness followed by fever, jaundice and choluria, and urticaria if symptoms are present.
• Testing can ebb and flow for several months or years

Prognosis of Hepatitis C

• Chronic infection results in 75% of cases which can lead to mild steatosis.
• Cirrhosis in 20-30% of those w/ chronic infection and can lead to liver CA
• Carrier state in small portion of healthy people

Prevention of Hepatitis C

• No vaccine currently available.

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.