Cirrhosis – the disease which is characterized by regeneration of parenchymatous tissue of liver in fibrous connecting fabric. Is followed by dull ache in the right podreberye, jaundice, increase in pressure in system of a vorotny vein with bleedings, characteristic of portal hypertensia (esophageal, gemorroidalny), ascites and so forth. The disease has chronic character. In diagnosis of cirrhosis the defining role is played by data of ultrasonography, liver KI and MRT, indicators of biochemical tests, a liver biopsy. Treatment of cirrhosis provides strict refusal of alcohol, observance of a diet, reception of gepatoprotektor; in hard cases – transplantation of a donor liver.
Cirrhosis is characterized by emergence in tissue of a liver of soyedinitelnotkanny knots, growth of connecting fabric, formation of "false" segments. Cirrhosis is distinguished by the size of the formed knots on small nodular (a set of small knots up to 3 mm in the diameter) and krupnouzlovy (knots exceed 3 mm in the diameter). Changes of structure of body unlike hepatitises are irreversible, thus, cirrhosis belongs to incurable diseases.
Among the reasons of development of cirrhosis abuse of alcohol is in the lead (from 35,5% to 40,9% of patients). Viral hepatitis C is at the second place. At men cirrhosis develops more often than at women that is connected with big distribution in the men's environment of abuse of alcohol.
Etiology and pathogenesis
In most cases abuse of alcohol and viral hepatitises B and C is the reason of development of cirrhosis. Regular alcohol intake in doses of 80-160 ml of ethanol leads to development of an alcoholic liver disease which in turn progresses with developing of cirrhosis. Among the persons abusing alcohol for 5-10 years, cirrhosis suffers from 35%.
Chronic hepatitises also often lead to fibrous regeneration of tissue of liver. On the frequency of diagnosing viral hepatitises B and C are on the first place (hepatitis C is inclined to more destructive current and progresses in cirrhosis more often). Also cirrhosis can become result of chronic autoimmune hepatitis, a skleroziruyushchy holangit, primary holestatichesky hepatitis, narrowing of bilious channels, stagnation of bile.
The cirrhoses developing owing to violations in bile circulation call biliarny. They are subdivided on primary and secondary. In most cases viruses of the chronic hepatitis B and C and abuse of alcohol are the most frequent reasons of development of cirrhosis. Exchange pathology or insufficiency of enzymes can become the reason of development of cirrhosis: , galactosemia, , hemochromatosis.
Also carry to risk factors of regeneration of hepatic fabric: a gepatolentikulyarny degeneration (Wilson's disease), reception of gepatotoksichny medicines (the methotrexate, an isoniazid, , marked-dopa), chronic heart failure, Bud-Kiari's syndrome, operational interventions on intestines, and also parasitic damages of intestines and liver. In 20-30% of cases at women the reason of development of cirrhosis does not manage to be established, such cirrhoses call cryptogene.
The major pathogenetic factor of development of cirrhosis is chronic violation traffic of hepatocytes, their destruction. Gradual formation of a small knot - the site of connecting fabric becomes result. The created knots squeeze vessels in segments and insufficiency of blood circulation progresses. At the same time the movement of blood in system of a vorotny vein is slowed down, vessels are overflowed and pererastyagivatsya. Blood begins to look for roundabout ways and mainly moves on vessels of collateral blood circulation, passing a liver. Vessels which undertake the main volume of a hepatic blood-groove – a vein of a gullet and a stomach gemorroidalny, a forward belly wall – are considerably overflowed, there is their varicosity, thinning of walls that provokes bleedings.
Expressiveness of clinical symptoms depends on the causes of cirrhosis, activity of progressing and extent of damage of a liver.
The asymptomatic current is noted at 20% of patients, quite often the disease proceeds originally with the minimum manifestations (a meteorizm, decrease in working capacity), the periodic dull ache in the right podreberye provoked by alcohol intake or violations of a diet and not stopped by reception of spazmolitik, bystry saturation (feeling of overflow of a stomach) and a skin itch can join later. Some temperature increase of a body, nasal bleedings is sometimes noted.
At further progressing jaundice, symptoms of portal hypertensia, varicose bleedings from esophageal and gemorroidalny veins, ascites is found (increase in amount of liquid in an abdominal cavity).
Characteristic symptoms at patients with cirrhosis: "drum sticks" (a specific thickening of phalanxes of fingers), "hour glasses" (characteristic change of nails), a palmar eritema (reddening of palms), teleangiektaziya ("vascular asterisks", a vystupaniye of thin hypodermic vessels on a face and a body).
At men increase in mammary glands can be noted (ginekomastiya) and testicles decrease. As a rule, the progressing cirrhosis leads to decrease in body weight, dystrophy.
One of life-threatening complications of cirrhosis is the liver failure. The acute liver failure is the terminal state demanding urgent medical actions, the chronic liver failure leads to heavy violations from nervous system as a result of the excess content in blood of ammonia and poisoning with it of a brain. In the absence of treatment the liver failure flows in a hepatic coma (mortality of patients in a hepatic coma from 80 to 100%).
Almost in most cases the progressing cirrhosis is complicated by ascites and portal hypertensia. Ascites represents a liquid congestion in an abdominal cavity, is shown as increase in a stomach, is defined at fizikalny survey, percussion method. Often is followed by hypostases of legs. Its emergence is connected with violation of a proteinaceous homeostasis.
Portal hypertensia – stagnation of blood in system of a vorotny vein, is characterized by strengthening of roundabout (collateral) venous outflow. The varicosity of a gullet, stomach, rectum is as a result formed, there are ruptures of their walls and bleeding. Visually portal hypertensia is defined by a symptom "the head of a jellyfish" - the expanded veins around a navel dispersing in different directions.
Besides the above-mentioned, cirrhosis can be complicated by accession of an infection, emergence of a malignant new growth (a gepatotsellyulyarny carcinoma) in a liver, and there is also a probability of development of a renal failure.
Diagnosis of cirrhosis
Diagnosis is carried out by the gastroenterologist or the hepatologist on the basis of a data set of the anamnesis and fizikalny survey, laboratory researches, functional tests, methods of tool diagnostics.
In the general blood test at cirrhosis anemia, a leykotsitopeniye, thrombocytopenia (usually it speaks about development of a gipersplenizm) can be noted, these koagulogramma show decrease in a protrombinovy index. Biochemical blood test reveals increase in activity of hepatic enzymes (Alt, NUCLEAR HEATING PLANT, alkaline phosphatase), increase in content in bilirubin blood (both fractions), potassium and sodium, urea and creatinine, the level of albumine is lowered. Also carry out analyses on identification of antibodies to viruses of hepatitis and definition contents alpha .
Treat the tool methods of diagnostics helping to add a clinical picture of cirrhosis ultrasonography of abdominal organs (note change of the sizes and a shape of a liver, its sound permeability, symptoms of portal hypertensia, change of a spleen are also visible). The computer tomography of an abdominal cavity allows to visualize even more in details a liver, vessels, bilious channels. If necessary MRT of a liver and a dopplerometriya of vessels of a liver is carried out.
The liver biopsy is necessary for final diagnosis and the choice of tactics of treatment (allows to estimate the nature of morphological changes and to make the assumption of the reasons of development of cirrhosis). As auxiliary methods of identification of the cause of this disease apply techniques identification of fermental nedostatochnost, investigate iron metabolism indicators, activity of proteins – markers of exchange frustration.
Treatment of cirrhosis
Therapy of patients has to solve the following problems with cirrhosis: to stop the progressing regeneration of hepatic fabric, to compensate the available functional frustration, to reduce load of veins of a collateral blood-groove, to prevent development of complications.
To all patients the special diet is appointed and the diet is recommended. At cirrhosis in a phase of compensation it is necessary to eat fully, to observe balance of content of proteins, fats and carbohydrates, to accept necessary vitamins and minerals. Patients with cirrhosis have to refuse flatly alcohol intake.
At emergence of high risk of development of encephalopathy, liver failure, patients are transferred to a diet with the lowered protein content. At ascites and hypostases the refusal of salt is recommended to patients. Recommendations about the mode: food is regular, 3-5 once a day, occupations physical exercises, avoiding of a hypodynamia (walks, swimming, LFK). Many medicines are contraindicated to the patients having cirrhosis. It is also desirable to limit the use of officinal herbs and dietary supplements to food.
Medicamentous therapy of cirrhosis consists in a correcting of the symptoms connected with exchange violation, application of gepatoprotektor (, , ursodezoksikholiyevy acid). Also apply the medicines promoting removal of ammonia and normalization of intestinal flora (laktuloz), enteroseptika.
Besides direct treatment of cirrhosis, medicamentous therapy is appointed for fight against the pathology which served as the reason for regeneration of hepatic fabric: antiviral interferonoterapiya, hormonal therapy of autoimmune states etc.
At the expressed ascites make and pumping of excess of liquid from an abdominal cavity. For formation of an alternative blood-groove do shunting of collateral vessels. But a cardinal surgical technique of treatment of cirrhosis is transplantation of a donor liver. Transplantation is shown to patients with a heavy current, bystry progressing, high extent of regeneration of hepatic fabric, a liver failure.
Prevention and forecast of cirrhosis
Prevention of cirrhosis consists in alcohol intake restriction, timely and adequate treatment of the viral hepatitises and other diseases promoting development of cirrhosis. The healthy balanced food and active lifestyle is also recommended.
Cirrhosis is an incurable disease, but at identification at early stages, successful eradication of an etiologichesky factor and following to recommendations about a diet and a way of life the forecast of survival is rather favorable. Alcoholic cirrhosis at continuation of abuse of alcohol is inclined to a fast decompensation and development of dangerous complications.
Patients with the developed ascites have the forecast of survival about 3-5 years. When developing bleeding mortality in the first episode makes about 30-50% of varicose veins of a collateral blood-groove. Development of a hepatic coma conducts by a lethal outcome in most cases (80-100%).