Chronic liver failure

Any of a number of long term liver diseases such as hepatitis, cirrhosis, cancer etc leads to chronic liver failure. Chronic liver conditions tend to progressively destroy liver tissue. Serious chronic liver disease can ultimately lead to a transplant being required.

What is Hepatitis?

Hepatitis is an inflammation of the liver. The condition can be self-limiting or can progress to fibrosis (scarring), cirrhosis or liver cancer. Hepatitis viruses are the most common cause of hepatitis in the world but other infections, toxic substances (e.g. alcohol, certain drugs), and autoimmune diseases can also cause hepatitis.

There are 5 main hepatitis viruses, referred to as types A, B, C, D and E. These 5 types are of greatest concern because of the burden of illness and death they cause and the potential for outbreaks and epidemic spread. In particular, types B and C lead to chronic disease in hundreds of millions of people and, together, are the most common cause of liver cirrhosis and cancer.

Hepatitis A and E are typically caused by ingestion of contaminated food or water. Hepatitis B, C and D usually occur as a result of parenteral contact with infected body fluids. Common modes of transmission for these viruses include receipt of contaminated blood or blood products, invasive medical procedures using contaminated equipment and for hepatitis B transmission from mother to baby at birth and also by sexual contact.

Acute infection may occur with limited or no symptoms, or may include symptoms such as jaundice (yellowing of the skin and eyes), dark urine, extreme fatigue, nausea, vomiting and abdominal pain.

What are the Different Hepatitis Viruses?

Scientists have identified 5 unique hepatitis viruses, identified by the letters A, B, C, D, and E. While all cause liver disease, they vary in important ways.

Hepatitis A virus (HAV) is present in the faeces of infected persons and is most often transmitted through consumption of contaminated water or food. Certain sex practices can also spread HAV. Infections are in many cases mild, with most people making a full recovery and remaining immune from further HAV infections. However, HAV infections can also be severe and life threatening. Most people in areas of the world with poor sanitation have been infected with this virus. Safe and effective vaccines are available to prevent HAV.

Hepatitis B virus (HBV) is transmitted through exposure to infective blood, semen, and other body fluids. HBV can be transmitted from infected mothers to infants at the time of birth. Transmission may also occur through transfusions of HBV-contaminated blood and blood products, contaminated injections during medical procedures, and through injection drug use. HBV also poses a risk to healthcare workers who sustain accidental needle stick injuries while caring for infected-HBV patients. Safe and effective vaccines are available to prevent HBV.

Hepatitis C virus (HCV) is mostly transmitted through exposure to infective blood. This may happen through transfusions of HCV-contaminated blood and blood products, contaminated injections during medical procedures, and through injection drug use. Sexual transmission is also possible, but is much less common. There is no vaccine for HCV.

Hepatitis D virus (HDV) infections occur only in those who are infected with HBV. The dual infection of HDV and HBV can result in a more serious disease and worse outcome. Hepatitis B vaccines provide protection from HDV infection.

Hepatitis E virus (HEV) is mostly transmitted through consumption of contaminated water or food. HEV is a common cause of hepatitis outbreaks in developing parts of the world and is increasingly recognized as an important cause of disease in developed countries. Safe and effective vaccines to prevent HEV infection have been developed but are not widely available.

Hepatitis A Symptoms

The incubation period of hepatitis A is usually 14-28 days.

Symptoms of hepatitis A range from mild to severe, and can include fever, malaise, loss of appetite, diarrhoea, nausea, abdominal discomfort, dark-coloured urine and jaundice (a yellowing of the skin and whites of the eyes). Not everyone who is infected will have all of the symptoms.

Adults have signs and symptoms of illness more often than children, and the severity of disease and mortality increases in older age groups. Infected children under 6 years of age do not usually experience noticeable symptoms, and only 10% develop jaundice. Among older children and adults, infection usually causes more severe symptoms, with jaundice occurring in more than 70% of cases.

Who is at Risk?

Anyone who has not been vaccinated. In areas where the virus is widespread (high endemicity), most hepatitis A infections occur during early childhood. Risk factors include:

Poor sanitation
Lack of safe water
Living in a household with an infected person
Travelling to areas of high endemicity without being immunized

Prevention

Improved sanitation, food safety and immunization are the most effective ways to combat hepatitis A.

The spread of hepatitis A can be reduced by:

Adequate supplies of safe drinking water
Proper disposal of sewage within communities
Personal hygiene practices such as regular hand-washing with safe water

Several hepatitis A vaccines are available internationally. All are similar in terms of how well they protect people from the virus and their side-effects. No vaccine is licensed for children younger than 1 year of age.

Nearly 100% of people develop protective levels of antibodies to the virus within 1 month after a single dose of the vaccine. Even after exposure to the virus, a single dose of the vaccine within 2 weeks of contact with the virus has protective effects. Still, manufacturers recommend two vaccine doses to ensure a longer-term protection of about 5 to 8 years after vaccination.

Millions of people have been immunized worldwide with no serious adverse events. The vaccine can be given as part of regular childhood immunizations programmes and also with other vaccines for travellers.

Hepatitis B Symptoms

Most people do not experience any symptoms during the acute infection phase. However, some people have acute illness with symptoms that last several weeks, including yellowing of the skin and eyes (jaundice), dark urine, extreme fatigue, nausea, vomiting and abdominal pain. A small subset of persons with acute hepatitis can develop acute liver failure which can lead to death.

In some people, the hepatitis B virus can also cause a chronic liver infection that can later develop into cirrhosis of the liver or liver cancer.

More than 90% of healthy adults who are infected with the hepatitis B virus will recover naturally from the virus within the first year.

Who is at Risk for Chronic Disease?

The likelihood that infection with the virus becomes chronic depends upon the age at which a person becomes infected. Children less than 6 years of age who become infected with the hepatitis B virus are the most likely to develop chronic infections.

In infants and children:

80–90% of infants infected during the first year of life develop chronic infections
30–50% of children infected before the age of 6 years develop chronic infections

In adults:

5% of otherwise healthy persons who are infected as adults will develop chronic infection
20–30% of adults who are chronically infected will develop cirrhosis and/or liver cancer

Prevention

The hepatitis B vaccine is the mainstay of hepatitis B prevention. WHO recommends that all infants receive the hepatitis B vaccine as soon as possible after birth, preferably within 24 hours. The birth dose should be followed by 2 or 3 doses to complete the primary series. In most cases, one of the following two options is considered appropriate:

A 3-dose schedule of hepatitis B vaccine, with the first dose (monovalent) being given at birth and the second and third (monovalent or combined vaccine) given at the same time as the first and third doses of diphtheria, pertussis (whooping cough), and tetanus – (DTP) vaccine; or
4 doses, where a monovalent birth dose is followed by three monovalent or combined vaccine doses, usually given with other routine infant vaccines.

Hepatitis C Symptoms

The incubation period for hepatitis C is 2 weeks to 6 months. Following initial infection, approximately 80% of people do not exhibit any symptoms. Those who are acutely symptomatic may exhibit fever, fatigue, decreased appetite, nausea, vomiting, abdominal pain, dark urine, grey-coloured faeces, joint pain and jaundice (yellowing of skin and the whites of the eyes).

Prevention

There is no vaccine for hepatitis C, therefore prevention of HCV infection depends upon reducing the risk of exposure to the virus in health-care settings, in higher risk populations, for example, people who inject drugs, and through sexual contact.

The following list provides a limited example of primary prevention interventions recommended by WHO:

Hand hygiene: including surgical hand preparation, hand washing and use of gloves
Safe handling and disposal of sharps and waste
Provision of comprehensive harm-reduction services to people who inject drugs including sterile injecting equipment
Testing of donated blood for hepatitis B and C (as well as HIV and syphilis)
Training of health personnel
Promotion of correct and consistent use of condoms

Hepatitis E Symptoms

The incubation period following exposure to the hepatitis E virus ranges from 3 to 8 weeks, with a mean of 40 days. The period of communicability is unknown.

The hepatitis E virus causes acute sporadic and epidemic viral hepatitis. Symptomatic infection is most common in young adults aged 15–40 years. Although infection is frequent in children, the disease is mostly asymptomatic or causes a very mild illness without jaundice (anicteric) that goes undiagnosed.

Typical signs and symptoms of hepatitis include:

Jaundice (yellow discolouration of the skin and sclera of the eyes, dark urine and pale stools)
Anorexia (loss of appetite)
An enlarged, tender liver (hepatomegaly)
Abdominal pain and tenderness
Nausea and vomiting
Fever

Prevention

The risk of infection and transmission can be reduced by:

Maintaining quality standards for public water supplies
Establishing proper disposal systems to eliminate sanitary waste

On an individual level, infection risk can be reduced by:

Maintaining hygienic practices such as hand washing with safe water, particularly before handling food
Avoiding drinking water and/or ice of unknown purity
Adhering to WHO safe food practices

Liver Cancer

The liver is one of the vital organs, whose main job is to filter the blood coming from the digestive tract, before passing it to the rest of the body. The liver also detoxifies chemicals and metabolizes drugs. The liver also makes proteins important for blood clotting and other functions.

As all the blood in the body passes through it, the liver is unusually accessible to cancer cells traveling in the bloodstream.

The liver can be affected by primary liver cancer, which arises in the liver, or secondary or metastatic cancer, meaning it started elsewhere in the body.

Primary liver cancer (hepatocellular carcinoma) tends to occur in livers damaged in the form of 'Cirrhosis' (a scarring condition of the liver)secondary to certain birth defects, alcohol abuse, or chronic infection with diseases such as hepatitis B and C, hemochromatosis, obesity and fatty liver disease, etc. Liver cancer may also be linked to obesity and fatty liver disease.

Some common symptoms of liver cancer could include:

A hard lump on the right side just below the rib cage
Discomfort in the upper abdomen on the right side
A swollen abdomen
Pain near the right shoulderblade or in the back
Jaundice
Easy bruising or bleeding
Unusual tiredness
Nausea and vomiting
Loss of appetite
Weight loss for no known reason

The following tests may be used to diagnose liver cancer

Physical exam and history
Serum tumor marker test: An increased level of alpha-fetoprotein (AFP) in the blood may be a sign of liver cancer
Liver function tests: A higher than normal amount of a substance can be a sign of liver cancer
CT scan
MRI
- Ultrasound exam
Biopsy (Generally not advisable except where the diagnosis is in doubt)
- Fine-needle aspiration biopsy
- Core needle biopsy
Laparoscopy: A surgical procedure to look at the organs inside the abdomen to check for signs of disease.

There are several staging systems for liver cancer. The Barcelona Clinic Liver Cancer (BCLC) Staging System is widely used:

Stage 0: Very early
Stage A: Early
Stage B: Intermediate
Stage C: Advanced
Stage D: End-stage

Treatment of stages 0, A, and B adult primary liver cancer may include:

Partial hepatectomy
Total hepatectomy and liver transplant
Ablation of the tumor using one of the following methods:
- Radiofrequency ablation
- Microwave therapy
- Percutaneous ethanol injection
- Cryoablation

Treatment of stages C and D adult primary liver cancer may include :

Embolization therapy using one of the following methods:

Transarterial embolization (TAE)
Transarterial chemoembolization (TACE)
Radio-Frequency Ablation Targeted therapy(RFA)
Transarterieal Radio-Embolization
External Beam Radiotherapy with high dose focused conformal technology (eg: Cyberknife)

Liver Cancer is completely curable if detected early. The diagnosis of liver cirrhosis and viral hepatitis can have a preventive role in treatment of liver cancers. Please undertake screening tests for viral hepatitis and adopt a healthy ways of life that promote liver health.

Fibrosis

Liver diseases such as chronic viral hepatitis, alcohol abuse and fatty liver disease can cause scarring of the liver (fibrosis), over a period of many years.

Fibrosis is stiffening and scarring of the liver that leads to loss of function. Detecting fibrosis early provides an opportunity to undergo treatment, and prevent the fibrosis from becoming more widespread, and thereby avoiding further liver damage and liver failure.

Fibroscan is a relatively new test that can detect fibrosis in the liver. It is non-invasive, quick and simple, and gives an immediate result. Since the test is noninvasive, repeat examinations can also be done periodically to assess improvement. Also for the first time, assessment of the amount of fat in the liver can also be done.

Fibroscan assessment is very useful to:

Diagnose liver fibrosis at an early stage where effective treatment can be given
Assess the amount of fat in the liver accurately (quantification)
Plan treatment and monitor patients with hepatitis B and C
Assess extent of liver damage in those who drink excessive alcohol
Perform repeated examinations to monitor progress and improvement