The Liver Life Project
Medical Consequences
Medical Consequences
In people who have cirrhosis, high blood pressure in the veins that carry blood from the intestines to the liver can cause many problems. One such serious complication is that of
portal hypertension. When blood pressure increases in the portal vein system, veins in the
oesophagus, stomach, and rectum enlarge to accommodate blocked blood flow through the
liver. The presence of enlarged veins (varices) usually causes no symptoms. (They may be
found during an endoscopy exam of the oesophagus.) About 50 to 60 out of 100 people who
have cirrhosis develop varices in the oesophagus.
Some people may feel that this video sequence is too graphic. For this, I make no apologies.
This condition is going to happen to you if your liver becomes too badly damaged. 50% of
those people who have cirrhosis of the liver will suffer from a varices condition.
In some people with a liver disorder, ascitic fluid leaks from the surface of the liver and
intestine and accumulates within the abdomen. A combination of factors is responsible.
They include the following:
*
Portal hypertension
*
Fluid retention by the kidneys
Alterations in various hormones and chemicals that regulate body fluids. Also, albumin
usually leaks from blood vessels into the abdomen. Normally, albumin, the main protein in
the blood, helps keep fluid from leaking out of blood vessels. When albumin leaks out of
blood vessels, fluid also leaks out.
A person with portal hypertension may also develop a build-up of fluid in their abdomen (tummy) and around the intestines. This fluid is known as Ascites. Initially, this can be
treated with water tablets (diuretics). If the problem progresses, many litres of fluid can build up, which needs to be drained. This is a procedure known as paracentesis and
involves a long, thin tube being placed into the fluid through the skin under
local anaesthetic
. One of the problems associated with the development of ascites is the risk of infection
in the fluid (spontaneous bacterial
peritonitis
). This is a potentially very serious complication and is linked to an increased risk of kidney failure and death.
The main symptom of
ascites is a swollen tummy. Other symptoms include:
pain and discomfort in the tummy
feeling sick (nausea)
reduced appetite
indigestion
feeling full
tiredness
breathlessness
Ascites can make it difficult for you to get comfortable, sit up and walk.
Hepatic encephalopathy is a brain disorder and refers to the changes in the brain that occur in patients with advanced, acute or chronic
liver disease and is one of the major complications of cirrhosis. Hepatic encephalopathy (HE), may occur suddenly in people with acute liver
failure however, the condition is more often seen in people with chronic liver disease.
An important job of the liver is to change harmful substances that are either made by the body or taken into the body (such as medicines)
and make them harmless. However, when the liver is damaged and unable to function fully, these “toxins” may build up in the bloodstream.
HE occurs when the liver cannot remove chemicals, such as ammonia. These chemicals then enter the brain and can affect both the mental and physical condition of patients.
Often certain factors can be responsible for triggering an episode of HE in liver patients. The following factors may trigger an episode of HE:
• Dehydration (loss of water from the body)
• Low oxygen levels in the body
• Eating too much protein
• Constipation
• Infections
• Intestine, stomach, or oesophagus bleeding
• Medications that affect the nervous system, such as tranquilisers or sleep
medications
• Kidney problems or Surgery
Patients with acute liver disease, who have an episode of HE, generally find that once the trigger is removed and their liver condition is treated, the HE disappears. However, some
patients with chronic liver disease find they will have recurring episodes of HE. Episodes of HE usually result in hospitalisation, as without treatment, patients remain at high risk
for recurrence. Other complications of untreated HE can be brain swelling, permanent nervous system damage, increased risk of heart failure, kidney failure, respiratory failure
and sepsis (blood poisoning) and in severe cases coma.
HE symptoms can present at a range of stages from mild to overt (severe). Mild Symptoms of HE can be observed in nearly 70% of patients with cirrhosis. Overt HE occurs in about
30-45% of patients with cirrhosis. HE symptoms can vary from person to person; they can develop rapidly or slowly over time. Patients with HE can have both physical symptoms
and reduced mental function.
I believe, that it is so important for family members and friends to understand that when a person suffers from a HE episode. It isn’t the individual being mean or nasty. It is a chemical
reaction within the brain that is causing this uncommon behaviour. It isn’t the fault of the patient, and although the words are spoken and often confusing, there is no meaning behind them
as they are being chemically driven.
For me this is a thorny subject, over the years, I’ve come across several diabetic nurses who for some reason, seem to once again put all
type-2 diabetes suffers in the same little box, and labelling everyone with the same condition and cause. “
It’s because your pancreas isn’t
producing enough insulin
”. This then blames the poor pancreas, when in truth it’s having to work flat out.
I have carried out a lot of my research into the possible cause of my diabetes, and while I tend to avoid a lot of the American websites, I must
confess that a huge amount of research has been done into Type 2 Diabetes and liver disease by our esteemed cousins. It makes perfect sense to me, that when the liver becomes
damaged through scaring, or alcohol-related liver disease. Strange things will start to happen.
This is my understanding as to what is going on:
The Liver is one of the most complicated organs in the body, and possibly the least understood. It plays a huge role in handling sugars and starches, making sure our bodies have
enough fuel to function. When there’s a lot of sugar in the system, it stores some of the excesses in a storage form of carbohydrate called glycogen. When blood sugar levels get
low, as in times of hunger or at night, it converts some of the glycogen to glucose and makes it available for the body to use.
Easy to say, but how does the liver know what to do and when to do it? Scientists have found a “molecular switch” called the “CRTC2 gene” (or “Switch Gene” as it’s sometimes
called) that controls this process.
When the CRTC2 switch is on, the liver pours sugar (glucose) into the system. When there’s enough glucose circulating, CRTC2 should be turned off. The turn-off signal is thought to
be insulin. This may be an over
simplification
, though.
In a post-transplant patient – here the medications used to prevent rejection can alter the way hepatocytes in the liver handle sugars and can drive the overproduction and release
of glucose into the blood. Also, patients with diabetic risks before transplant are more likely to experience it after transplant.
The other wonderful aspect of this CRTC2 switch gene is that during a persons REM sleep pattern, any excess sugars stored in the liver are burnt off and
exhaled
out through the
lungs.
So, the CRTC2 gene does indeed act as a switch to produce more sugar in fasting situations and is down-regulated when abundant sugar is present. Levels change in type 2
diabetes and this makes the hyperglycemia worse. What’s most interesting is that the signals that act through this molecule are linked to a protein called calcineurin which is
activated and causes the liver to make more sugar. The calcineurin levels increase in insulin-resistant states. CRCT2 is found in many cells including immune cells, heart and
placenta and some studies suggest in liver cells too. It is also down-regulated in some cancers.
However, calcineurin is also found in immune cells and is linked to growth and functional responses. So, some types of anti-rejection medications used after transplant, target
calcineurin to dampen down anti-graft immune responses. Tacrolimus and cyclosporin are calcineurin inhibitors. I can therefore, see how there might be a connection between
anti-rejection medication and function of CRCT2.
The human body is composed of billions of cells that are continually ageing, dying and being replaced. Cell death, replacement, growth
and development are normally tightly controlled. If this control breaks down, cells begin to grow and divide abnormally, clustering
together to form a lump known as a tumour. These tumours are either benign or malignant. Cancer is the name given to a malignant
tumour. There are two broad categories of liver cancer: secondary and primary.
1.
Secondary liver cancer is cancer that first develops elsewhere in the body and
then spreads (metastasises) to the liver. It is sometimes called metastatic cancer.
2.
Primary liver cancers are cancers that start in the liver. The two main types are:
Hepatoma, also called hepatocellular carcinoma (HCC) and Biliary tree cancer, which includes cholangiocarcinoma (bile duct cancer)
and gallbladder cancer.
Using heat to destroy Cancer/Tumour cells (Ablation)
Ablation uses heat to destroy cancer cells. There are three types of ablation that produce heat in different ways. These are:
• Microwave
• Radiofrequency
• Laser ablation.
Each type destroys cancer cells by heating them to a high temperature. They may be used if you have previously had surgery or if
you’re not fit enough to have surgery.
You will be given a sedative drug to make you feel drowsy and a local anaesthetic to numb the skin of your abdomen. Sometimes ablation is performed using a general anaesthetic.
The doctor puts a fine needle through the skin over your liver and into the centre of each tumour. An ultrasound or CT scan is used to guide them. The microwave, radio-frequency
or laser then produces heat which passes through the needle and into the tumour. This treatment takes about 30–60 minutes and can be used to treat tumours up to 5cm (2in) in
size. You can usually go home a few hours after you’ve had your treatment.
The side effects of ablation are usually mild and may last up to a week. They include pain in the liver area, which you can
control by taking regular painkillers. Other side effects
are a fever (high temperature) and feeling tired and generally unwell. These side effects are due to the body getting rid of the cells that have been destroyed. Try to drink plenty of
fluids and get
enough rest. Your doctor or nurse may ask you to contact the hospital if your temperature doesn’t settle within a few days or
if it goes higher than 38˚C (100.4°F).
This is to make sure you don’t have an infection.
Your specialist can give you more information about the possible benefits and risks of these procedures. There is a useful guide that may be of interest at the following web
address: https://flipbooks.leedsth.nhs.uk/LN005000.pdf
TIPSS (Transjugular Intrahepatic PortoSystemic Shunt)
I’ve been trolling the internet to find a suitable presentation of this procedure, but sadly, there appears
to be nothing available from a British perspective. I have therefore used an American
video to best
illustrate this procedure. I suspect, the procedure to be pretty much the same. This procedure does
look a little
tricky. I think the best way of describing what TIPSS is, is to explain what each of the letters
stands for:
T. Is for TRANSJUGULAR. This means that the radiologist will put a fine, hollow needle into the jugular
vein in your neck while you are asleep. Through this needle, he, or she, will pass a fine, thin wire in a
straight line until it reaches the veins from your liver. This is much easier than you would imagine. Over this wire, the radiologist will pass a fine plastic tube called a catheter, about
the size of a very long piece of spaghetti.
I. Is for INTRAHEPATIC. The catheter that the radiologist has inserted will be passed down one of your liver veins into the liver itself. The radiologist will then take the wire out and
insert a long-curved needle.
PS.
is for PORTO-SYSTEMIC. The long needle will be pushed from your liver vein, (or SYSTEMIC vein) into your PORTAL vein, which lies close to it. It is this portal vein which has
become partially blocked up by your liver disease. Because of the blockage, there is high blood pressure in this part of your circulation, and this procedure is designed to relieve this.
S.
is for SHUNT. Once the needle has been passed between your liver vein and the portal vein, a wire will be passed through the needle and the needle is withdrawn. Over the wire,
the radiologist will pass a metal spring called a stent. This stent will expand to create a channel between the two veins. Blood will then flow from the high-pressure portal vein into
the low-pressure liver (or systemic) vein. The high pressure in the portal vein which is causing your problem will consequently be reduced, back towards normal.
