Liver Abscess

What is Liver abscess?

A liver abscess is a pocket of pus that forms in the liver due to a bacterial infection. Pus is a fluid composed of white blood cells and dead cells that typically forms when your body fights off infection. In the case of liver abscess, instead of draining from the infection site, the pus collects in a pocket inside the liver. An abscess is usually accompanied by swelling and inflammation in the surrounding area. It can cause pain and swelling in the abdomen. A liver abscess can be fatal if it’s not treated promptly.

What are the causes of Liver Abscess?

There are many possible causes of liver abscesses, including:

  1. Abdominal infection, such as appendicitis, diverticulitis, or a perforated bowel
  2. Infection in the blood
  3. Infection of the bile draining tubes
  4. Recent endoscopy of the bile draining tubes
  5. Trauma that damages the liver

What are the symptoms of Liver Abscess?

Symptoms of liver abscess may include:

  1. Chest pain (lower right)
  2. Pain in the right upper abdomen (more common) or throughout the abdomen (less common)
  3. Clay-colored stools
  4. Dark urine
  5. Fever, chills, night sweats
  6. Loss of appetite
  7. Nausea, vomiting
  8. Unintentional weight loss
  9. Weakness
  10. Yellow skin (jaundice)
  11. Right shoulder pain (referred pain)

How is Liver Abscess diagnosed?

The following tests may be used:

  1. an abdominal ultrasound to locate an abscess
  2. a CT scan with intravenous contrast, or injected dye, to find and measure the abscess
  3. blood tests to look for signs of infectious inflammation, such as an increased serum white blood count and neutrophil level
  4. blood cultures for bacterial growth to determine which antibiotic(s) you need

What is the treatment for Liver Abscess?

Some people can be successfully treated for PLA with antibiotics alone. Most, however, need drainage of the abscess, which is considered to be the ideal therapy for Liver Abscess. This involves inserting a needle and possibly placing a drainage catheter into the abscess to remove the infection-containing pus. These invasive interventional procedures are performed with CT scan or ultrasound guidance. However, in more severe cases, surgery may be required to fully remove the abscess material. After surgery you’ll be treated with antibiotics for several weeks to help fully remove the infection.

Liver Cirrhosis

What is cirrhosis?

Cirrhosis is the severe scarring of the liver and poor liver function seen at the terminal stages of chronic liver disease. The scarring is most often caused by long-term exposure to toxins such as alcohol or viral infections.

How does Cirrhosis develop?

Each time your liver is injured — whether by disease, excessive alcohol consumption or another cause — it tries to repair itself. In the process, scar tissue forms. As cirrhosis progresses, more and more scar tissue forms, making it difficult for the liver to function (decompensated cirrhosis). Advanced cirrhosis is life-threatening.

The liver damage done by cirrhosis generally can't be undone. But if liver cirrhosis is diagnosed early and the cause is treated, further damage can be limited and, rarely, reversed.

What are the causes of Cirrhosis?

A wide range of diseases and conditions can damage the liver and lead to cirrhosis.

Some of the causes include:

  1. Chronic alcohol abuse
  2. Chronic viral hepatitis (hepatitis B, C and D)
  3. Fat accumulating in the liver (nonalcoholic fatty liver disease)
  4. Iron buildup in the body (hemochromatosis)
  5. Cystic fibrosis
  6. Copper accumulated in the liver (Wilson's disease)
  7. Poorly formed bile ducts (biliary atresia)
  8. Alpha-1 antitrypsin deficiency
  9. Inherited disorders of sugar metabolism (galactosemia or glycogen storage disease)
  10. Genetic digestive disorder (Alagille syndrome)
  11. Liver disease caused by your body's immune system (autoimmune hepatitis)
  12. Destruction of the bile ducts (primary biliary cirrhosis)
  13. Hardening and scarring of the bile ducts (primary sclerosing cholangitis
  14. Infection, such as syphilis or brucellosis
  15. Medications, including methotrexate or isoniazid

What are the symptoms of Cirrhosis?

The symptoms of cirrhosis occur because the liver is unable to purify the blood, break down toxins, produce clotting proteins, and help with absorption of fats and fat-soluble vitamins. Often, there are no symptoms until the disorder has progressed. Some of the symptoms include:

  1. decreased appetite
  2. nose bleeds
  3. jaundice (yellow discoloration)
  4. small spider-shaped veins underneath the skin
  5. weight loss
  6. anorexia
  7. itchy skin
  8. weakness

More serious symptoms include:

  1. confusion and difficulty thinking clearly
  2. abdominal swelling (ascites)
  3. swelling of the legs (edema)
  4. impotence
  5. gynecomastia (when males start to develop breast tissue)

What are the risk factors for Cirrhosis?

  1. Drinking too much alcohol. Excessive alcohol consumption is a risk factor for cirrhosis.
  2. Being overweight. Being obese increases your risk of conditions that may lead to cirrhosis, such as nonalcoholic fatty liver disease and nonalcoholic steatohepatitis.
  3. Having viral hepatitis. Not everyone with chronic hepatitis will develop cirrhosis, but it's one of the world's leading causes of liver disease.

What are the complications of Cirrhosis?

If your blood is unable to pass through the liver, it creates a backup through other veins such as those in the esophagus. This backup is called esophageal varices. These veins are not built to handle high pressures, and begin to bulge from the extra blood flow.

Other complications from cirrhosis include:

  1. bruising (due to low platelet count and/or poor clotting)
  2. bleeding (due to decreased clotting proteins)
  3. sensitivity to medications (the liver processes medications in the body)
  4. kidney failure
  5. liver cancer
  6. insulin resistance and type 2 diabetes
  7. hepatic encephalopathy (confusion due to the effects of blood toxins on the brain)
  8. gallstones (interference with bile flow can cause bile to harden and form stones)
  9. esophageal varices
  10. enlarged spleen (splenomegaly)
  11. edema and ascites

What is the treatment of Cirrhosis?

Treatment for cirrhosis varies based on what caused it and how far the disorder has progressed. Some treatments include:

  1. beta blockers or nitrates (for portal hypertension)
  2. quitting drinking (if the cirrhosis is caused by alcohol)
  3. banding procedures (used to control bleeding from esophageal varices)
  4. intravenous antibiotics (to treat peritonitis that can occur with ascites)
  5. hemodialysis (to purify the blood of those in kidney failure)
  6. lactulose and a low protein diet (to treat encephalopathy)

Liver transplantation is an option of last resort, when other treatments fail.

All patients must stop drinking alcohol. Medications, even over-the-counter ones, should not be taken without consulting your doctor.

How can I prevent cirrhosis of the liver?

  1. Do not drink alcohol if you have cirrhosis. If you have liver disease, you should avoid alcohol.
  2. Eat a healthy diet. Choose a plant-based diet that's full of fruits and vegetables. Select whole grains and lean sources of protein. Reduce the amount of fatty and fried foods you eat.
  3. Maintain a healthy weight. An excess amount of body fat can damage your liver. Talk to your doctor about a weight-loss plan if you are obese or overweight.
  4. Reduce your risk of hepatitis. Sharing needles and having unprotected sex can increase your risk of hepatitis B and C. Ask your doctor about hepatitis vaccinations.

Portal Hypertension

What is Portal Hypertension?

Portal hypertension is an increase in the pressure within the portal vein (the vein that carries blood from the digestive organs to the liver). The increase in pressure is caused by a blockage in the blood flow through the liver.

Increased pressure in the portal vein causes large veins (varices) to develop across the esophagus and stomach to get around the blockage. The varices become fragile and can bleed easily.

What causes Portal Hypertension?

The main cause of portal hypertension is cirrhosis. This is a scarring of the liver. It can result from several conditions such as hepatitis (an inflammatory disease) or alcohol abuse.

Autoimmune diseases of the liver such as autoimmune hepatitis, primary sclerosing cholangitis, and primary biliary cholangitis also are causes of cirrhosis and portal hypertension.

Whenever your liver is harmed, it attempts to heal itself. This causes scar tissue to form. Too much scarring makes it harder for your liver to do its job.

Other cirrhosis causes include:

  1. nonalcoholic fatty liver disease
  2. iron buildup in your body
  3. cystic fibrosis
  4. poorly developed bile ducts
  5. liver infections
  6. reaction to certain medications, such as methotrexate

What are the symptoms of Portal Hypertension?

The onset of portal hypertension may not always be associated with specific symptoms that identify what is happening in the liver. But if you have liver disease that leads to cirrhosis, the chance of developing portal hypertension is high.

The main symptoms and complications of portal hypertension include:

  1. Gastrointestinal bleeding: Black, tarry stools or blood in the stools; or vomiting of blood due to the spontaneous rupture and bleeding from varices.
  2. Ascites: An accumulation of fluid in the abdomen.
  3. Encephalopathy: Confusion and forgetfulness caused by poor liver function and the diversion of blood flow away from your liver.
  4. Reduced levels of platelets or decreased white blood cell count.

What are the treatment options for Portal Hypertension?

First level of treatment

When you are first diagnosed with variceal bleeding, you may be treated with endoscopic therapy or medications. Dietary and lifestyle changes are also important.

Endoscopic therapy consists of either sclerotherapy or banding. Sclerotherapy is a procedure performed by a gastroenterologist in which a solution is injected into the bleeding varices to stop or control the risk of bleeding. Banding is a procedure in which a gastroenterologist uses rubber bands to block the blood supply to each varix (enlarged vein).

Medications such as beta blockers or nitrates may be prescribed alone or in combination with endoscopic therapy to reduce the pressure in your varices and further reduce the risk of recurrent bleeding.

Medications such as propranolol and isosorbide may be prescribed to lower the pressure in the portal vein and reduce the risk of recurrent bleeding.

The drug lactulose can help treat confusion and other mental changes associated with encephalopathy. This medication has the ability to increase the amount of bowel movements you will have per day.

Dietary and lifestyle changes

Maintaining good nutritional habits and keeping a healthy lifestyle will help your liver function properly. Some of the things you can do to improve the function of your liver include the following:

  1. Do not use alcohol or street drugs.
  2. Do not take any over-the-counter or prescription drugs without first consulting with your physician or nurse. Some medications may make liver disease worse, and they may interfere with the positive effects of your other prescription medications.
  3. Follow a low-sodium (salt) diet. You will probably be required to consume no more than 2 grams of sodium per day. Reduced protein intake is required only if confusion is a symptom.

Second level of treatment

If the first level of treatment does not successfully control your variceal bleeding, you may require one of the following decompression procedures to reduce the pressure in these veins.

  1. Transjugular intrahepatic portosystemic shunt (TIPS): A radiological procedure in which a stent (a tubular device) is placed in the middle of the liver.
  2. Distal splenorenal shunt (DSRS): A surgical procedure that connects the splenic vein to the left kidney vein in order to reduce pressure in your varices and control bleeding.

What happens during the TIPS procedure?

During the TIPS procedure, a radiologist makes a tunnel through the liver with a needle, connecting the portal vein (the vein that carries blood from the digestive organs to the liver) to one of the hepatic veins (the 3 veins that carry blood from the liver). A metal stent is placed in this tunnel to keep the tunnel open.

The TIPS procedure reroutes blood flow in the liver and reduces pressure in all abnormal veins, not only in the stomach and esophagus, but also in the bowel and the liver

The TIPS procedure is not a surgical procedure. The radiologist performs the procedure within the vessels under X-ray guidance. The procedure lasts 1 to 3 hours. You should expect to stay in the hospital 1 to 2 days after the procedure.

The TIPS procedure controls bleeding immediately in over 90% of patients. However, in about 30% of patients, the shunt may narrow, causing varices to bleed again at a later time.

What happens during the DSRS procedure?

The DSRS is a surgical procedure. During the surgery, the vein from the spleen (called the splenic vein) is detached from the portal vein and attached to the left kidney (renal) vein. This surgery selectively reduces the pressure in your varices and controls the bleeding.

A general anesthetic is given to you before the surgery. The surgery lasts about 4 hours. You should expect to stay in the hospital from 7 to 10 days.

DSRS controls bleeding in over 90% of patients; the highest risk of any recurrent bleeding is in the first month. However, the DSRS procedure provides good long-term control of bleeding.

What are other treatment procedures for portal hypertension?

  1. Liver transplant is done in cases of end-stage liver disease.
  2. Devascularization is a surgical procedure that removes the bleeding varices. This procedure is done when a TIPS or a surgical shunt is not possible or is unsuccessful in controlling the bleeding.
  3. The accumulation of fluid in the abdomen (called ascites) sometimes needs to be directly removed. This procedure is called paracentesis.