Liver Diseases & Transplantation

Liver Diseases

What is Liver Disease?

Liver disease is any disorder of the liver that impairs its normal function and can range from minor infection or scarring to serious conditions such as liver cancer. More than 100 types of liver disease have been identified.

The liver is one of the largest organs of the human body and is situated in the upper right portion of your abdomen.

It performs some of the body’s vital functions including:

• Production of bile juice
• Storing sugars in the form of glycogen
• Purifying blood from harmful substances
• Making proteins that help in blood clotting

Risk Factors of Liver Disease

The common risk factors that can cause liver disease include:

• Diabetes
• Obesity
• Autoimmune diseases
• Excessive alcohol consumption
• Exposure to chemicals or toxins
• Exposure to infected blood (hepatitis infected person) by the sharing of contaminated needles, razors or blood transfusions
• Genetic diseases such as Wilson’s disease, Hemochromatosis and Alpha-1 antitrypsin deficiency

Common Liver Diseases

Some of the common liver diseases include:

Jaundice

Jaundice is a condition that occurs when bilirubin, a yellow pigment produced by the breakdown of red blood cells in the liver, accumulates in the liver. It is characterised by yellowing of the skin and the white regions of the eyes and is caused by a viral infection, blocked bile ducts, liver diseases or certain medications.

Hepatitis

Hepatitis is an inflammation of the liver tissue. Exposure to alcohol, toxins or drugs over a long period of time may result in hepatitis. It may also occur due to an autoimmune response in which antibodies (proteins) produced by your immune system damage your liver tissue, but most often, it is caused by a viral infection.

Autoimmune Liver Disease

The immune system protects the body by attacking and destroying foreign and harmful substances. However, in autoimmune liver diseases, the body’s immune system attacks its own liver (liver cells and bile duct cells), causing inflammation and liver damage. Example, autoimmune hepatitis.

Untreated autoimmune liver disease can progress into cirrhosis, liver failure and cancer.

Fatty Liver Disease

Fatty liver disease is a condition caused by excess fat buildup in the liver cells. It is most common in middle-aged people. Fatty liver disease is also called hepatic steatosis. Fatty liver is of two types:

Non-alcoholic Fatty Liver: Build-up of fat in the liver is not associated with the consumption of alcohol.

Alcoholic Fatty Liver: Build-up of fat in the liver is associated with excess alcohol consumption.

Simple fatty liver is an early stage of fatty liver disease and often not serious. Non-alcoholic Steatohepatitis (NASH) is an advanced stage that causes inflammation of the liver and damage to liver cells causing liver cirrhosis, liver cancer, ascites, and ultimately, liver failure.

Liver Cirrhosis

Cirrhosis is severe scarring of the liver and poor liver function due to excessive exposure to alcohol or due to a viral infection. According to the National Institute of Health (NIH), people who regularly consume alcohol for more than 10 years can develop cirrhosis. Excess scar tissue is formed when your liver is exposed to the damaging factors for a long period of time, making it difficult to repair itself. A cirrhotic liver appears hard and shrunken.

Wilson’s Disease

Wilson’s disease is a rare genetic disorder that causes copper poisoning in your body.

Copper is an essential micronutrient present in your food and is required for healthy nerves and bones. Normally, the liver eliminates excess copper in bile juice, but, in people with Wilson’s disease, copper elimination is impaired causing its accumulation in the liver, brain and eyes.

Untreated Wilson’s disease causes secondary complications such as kidney disorders, neurological problems, liver cirrhosis and liver failure.

Alpha-1 Antitrypsin Deficiency (A1AD)

A1AD is a genetic disorder that causes lung disease due to insufficient production of the enzyme Alpha-1 antitrypsin (AAT). Normally, AAT is produced by your liver and protects your lungs from infections and harmful chemicals. People with A1AD can develop diseases such as asthma, wheezing and Chronic obstructive pulmonary disease (COPD).

Hemochromatosis

Hemochromatosis or ‘Iron-overload’ is a genetic disorder that causes more than normal iron absorption by your body. Excess iron is stored in the pancreas, heart and liver. Untreated hemochromatosis may cause liver cirrhosis, arthritis or certain heart diseases.

Liver Cancer

Cancer is the uncontrolled division of abnormal cells. Liver cancer may begin as a mass of abnormal cells called a tumour. Benign tumours remain localised and do not spread to neighbouring tissues. Malignant tumours begin to spread into nearby tissues, lymph nodes or organs, disrupting their function. Most liver cancers are malignant and may lead to liver failure.

Liver Failure

Liver failure occurs when a significant portion of your liver is non-functional and cannot be repaired. Various untreated liver diseases may lead to liver failure and cause secondary complications such as cerebral oedema, problems related to blood clotting and kidney failure. Most often, a liver transplant is the only option and is usually successful.

Symptoms of Liver Diseases

The symptoms vary depending on the type of liver disease. Common symptoms include:

• Yellow skin and eyes
• Dark urine
• Abdominal pain
• Nausea and vomiting
• Loss of appetite
• Swelling of abdomen and legs
• Fatigue
• Itchy skin
• Blood clotting problems

Diagnosis of Liver Disease

Your doctor will assess your symptoms and may order:

• Liver function tests
• Certain blood tests
• Imaging tests such as X-ray, MRI or CT-Scan
• Liver Biopsy

Treatment for Liver Disease

Treatment depends on the underlying cause. The treatment may include:

• Quitting alcohol consumption
• Diet modification usually involves a decrease in salt intake
• Weight loss program (obese people)
• Medications to treat viral infection and other symptoms
• Medications to control autoimmunity
• Management of diabetes
• Liver transplant in severe cases

Prevention of Liver Disease

Liver disease can be prevented by:

• Vaccination
• Controlling diabetes
• Eating healthy
• Drinking alcohol in moderation
• Maintaining a healthy weight
• Avoiding contact with an infected person
• Preventing exposure to toxic chemicals

Liver Transplantation

What is Liver Transplantation?

Liver transplantation is a surgical procedure to replace a damaged or diseased liver with a healthy one. The liver is situated in the upper right portion of your abdomen and performs some of the body’s vital functions such as:

• Production of bile juice
• Storing sugars in the form of glycogen
• Purifying blood from harmful substances
• Making proteins that help in blood clotting
• Fighting infections by removing microorganisms from the blood

A whole liver or part of the liver may be transplanted from another person (donor). Usually, a family member or a close relative is the donor and your surgery will be planned well in advance. The liver can also be transplanted from a deceased donor if you enrol your name as a liver transplant candidate. On acceptance, you will be notified about the availability of a donor liver depending on the severity of your current health condition. Certain tests will be performed to confirm matching your liver with the donor.

A team of healthcare providers including a Psychologist, Anaesthesiologist, Nutritionist and Liver transplant surgeons work together to prepare you for the surgery.

Indications for Liver Transplantation

Liver transplantation is indicated for liver failure that usually develops slowly over time. Each time your liver is injured, it repairs itself and produces a small amount of scar tissue. Excess scar tissue (cirrhotic liver) is formed when your liver is exposed to the damaging factors over a long period of time, making it difficult to repair itself. A cirrhotic liver can become cancerous or no longer function (liver failure). Sudden failure may also occur due to toxins or hepatitis.

Preparing for the Procedure

Both living donor and recipient follow a similar protocol of surgery preparation and procedure.

Your healthcare provider will assess your symptoms and explain the procedure of liver transplantation. You will have to sign a consent form to confirm your permission for the surgery. The donor will have to take a psychological test to confirm that he/she is comfortable with their decision to donate.

You will be advised to stop eating 8 to 10 hours prior to the surgery. Certain imaging tests and blood tests may be ordered. Special tests such as Doppler ultrasound and echocardiogram may be ordered. Any special instructions will be provided by your surgeon.

Liver Transplantation Procedure

The surgery is performed under general anaesthesia and involves the following steps:

• You will wear a hospital gown and lie on your back.
• An IV line is started in your arm to make you sleep during the procedure.
• A catheter is placed in your bladder to drain urine.
• A tube will be placed into your lungs (through the mouth) to help you breathe.
• Your heartbeat and blood pressure are closely monitored.
• A nasogastric tube will be placed to drain secretions from your stomach.
• The skin at the surgical site is shaved and cleaned with an antiseptic solution.
• An incision will be made below your ribs and the diseased liver is carefully exposed.
• Blood supply to the diseased liver is cut off.
• Special surgical procedures are performed to separate the diseased liver
• If a living donor is used, a part of their healthy liver is separated.
• The healthy liver is then transplanted into the recipient’s body.
• The blood vessels and bile duct are re-attached to the donor’s liver.
• The incision is closed with surgical sutures and a bandage is applied.

After the Surgery

Initial recovery takes place in an intensive care unit (ICU). Your breathing tube will be retained for a few days to help you breath. You will receive intravenous pain medications and antibiotics. A liquid diet is initiated once your feeding tube is removed. After a few days, you will be moved to a private room where you will recover for about 2 to 3 weeks.

Recovery at Home

You will be advised to avoid driving and any strenuous activities for a few weeks. A nutritionist may help you plan your diet. Walking multiple times a day is beneficial for recovery. Liver regeneration begins almost immediately after surgery and a full liver may be formed within a few months (Both donor and recipient). Recipients are instructed to take prescribed anti-rejection medications for life to prevent rejection of the liver by their immune cells.

Complications of Liver Transplantation

Both donor and recipient may experience surgical complications such as pain, discomfort, allergic reactions, nausea, scar tissue formation, infection and bleeding. Long term use of anti-rejection medications in recipients may cause diabetes, bone-thinning and high cholesterol.

Contraindications of Liver Transplantation

Your healthcare team may not recommend liver transplantation if you have:

• Cancer
• Severe illness
• High blood pressure
• Active substance abuse
• Uncontrolled infection
• Uncontrolled psychiatric disease