- Morbidity in different countries
- Reasons for
- Ethanol metabolism in the liver
- Development mechanism of
- Symptoms of alcoholic cirrhosis of the liver
- Stages of the disease
- How to confirm the diagnosis?
- Related Videos
Alcoholic cirrhosis of the liver is a chronic lesion of hepatocyte cells due to the toxic property of alcohol. The disease causes the death of the functioning tissue of the organ and its replacement by fibrous scars. Signs of liver cirrhosis in alcoholics arise in connection with a violation of detoxification function, the formation of hepatic insufficiency, hypertension in the portal venous system, hepatorenal syndrome( connect kidney damage).
Half of all cases of liver cirrhosis is confirmed by alcoholic disease. The majority of patients are men of 40-60 years of age. The prevalence per 100 thousand population is from 7 to 15 cases. Mortality remains high.
Morbidity in different countries
The incidence of alcoholic cirrhosis of the liver does not have national characteristics, but depends on the culture of drinking. The countries of the world are divided into consumption levels per capita:
- is considered to be minimal up to 5 liters per year - this is the situation in Southeast Asia, India, China, Saudi Arabia, Turkey, the most "non-drinking" Norway - from Europe, here the prevalence of cirrhosisthe liver of alcoholic etiology is very small;
- low level is 10 liters per year - typical for Canada, South America, Sweden, Finland, Japan, Italy, Australia, USA, respectively, they have incidence of cirrhosis at the lower level;
- high levels of consumption( 15 liters / year) differ from Moldova, Denmark, France, Portugal, Greenland, here the prevalence refers to the average figures;
- has the highest level of alcohol consumption( 19 liters / year and more) per person in Russia, Belarus, Ukraine, these countries have the highest prevalence of liver cirrhosis.
The main reason for the development of alcoholic cirrhosis of the liver is a long "experience" of consumption of alcohol-containing beverages, up to 10-15 years. It does not matter the kind of drinks, but the dosage in recalculation on pure alcohol and the regularity of the intake. For men, it is 40-60 g / day, for women enough 20 g.
Drunken drunkenness leads gradually to the destruction of hepatocytes of the liver. First develops fatty degeneration, then alcoholic hepatitis, as an extreme option - cell necrosis and cirrhosis. With necrosis of more than 50-70% of liver cells with replacement for connective tissue, hepatic insufficiency of irreversible character is formed.
Exchange processes of ethanol in the liver
Biochemists identify 3 stages of interaction of cells of hepatocytes and alcohol( ethanol).They are determined by the involvement of certain liver enzymes in the process. The decisive importance of genes in the formation and activation of protein-enzymes involved in the metabolism of alcohol has been established.
- Stage I - the action of alcohol dehydrogenase begins with gastric juice. Here, up to 25% ethanol is converted to acetaldehyde. In women, the activity of this enzyme is low due to a lack of production in the stomach, so they are more sensitive even to small doses of alcohol.
- Stage II - ethanol enters the bloodstream into the liver and here it occurs with hepatic alcohol dehydrogenase activated by coenzyme nicotinamide dinucleotide( NAD +), resulting in the formation of acetaldehyde and reduced coenzyme. The work of alcohol dehydrogenase is controlled by three genes, their activity leads to more or less formation of acetaldehyde. The most intensified processes in the liver of individuals of the Mongoloid race have been identified. These people are more sensitive to alcohol.
- Stage III - is the transformation of acetaldehyde into acetic acid under the influence of the microsomal oxidative system of the cytoplasm of cells and the enzyme catalase. Microsomes are complexes of oxidative enzymes that do not require the participation and energy of ATP.They are up to 20% of cells by weight.
In the pathogenetic changes in the liver, the coenzyme ratio is important. They cause an increased synthesis of triglycerides that reduce the decomposition of fatty acids.
The disruption of the production of coenzymes leads to the deposition of fatty inclusions in hepatocytes( fatty liver disease), then to cirrhosis
The toxicity of acetaldehyde is a violation of the function of hepatocyte membranes. A complex is formed with protein tubulin( alcoholic hyaline), which destroys the structure of hepatocytes, stops intracellular transport of proteins and water molecules. The balance of biochemical reactions that support the functioning of the cell changes.
Enhancement of cytokine production facilitates transformation into fibroblasts and further synthesis of collagen in the liver. This process is helped by increased production of angiotensinogen II.Of great importance are immune disorders. A sharp increase in serum immunoglobulins causes the formation of antibodies to the nuclei of liver cells, alcoholic hyaline and their deposition in the liver structures. The anti-inflammatory cytokines produced by them lead to disturbances in other organs.
Symptoms of alcoholic cirrhosis of the liver
All manifestations of alcoholic cirrhosis can be divided into general and specific for liver disease. The onset of the disease is difficult to noticeMost often, it does not have a significant symptomatology for a long time. The first sign may be the identification of an enlarged liver, a dense edge and a tuberous surface at the doctor's office.
Common( nonspecific) manifestations are:
- an unexpected slight increase in temperature;
- complaints of weakness, increased fatigue from work;
- lack of appetite;
- poor sleep;
- moderate memory problems;
- the inability to persevere in conversation;
- volatile pain in the joints;
In 75% of patients, the clinical picture is called "small hepatic signs."These include:
- telangiectasia( vascular "sprouts") on the skin;
- redness of the palms( palmar erythema).
Teleangiectasis on the skin - the cause of a constantly red nose in alcoholics
Specific symptoms of an increase in hepatic-cellular insufficiency are:
- blunt pain and constant heaviness in the right hypochondrium;
- attacks of vomiting;
- jaundice of the skin, sclera, mucous membranes;
- enlargement of the liver with a subsequent decrease;
- increased fat in the thighs and lower abdomen;
- formation of "drumsticks" on the fingers;
- dark urine;
- discolored stool masses.
Signs of hepatic encephalopathy include:
- disorientation in time and place;
- loss of self-criticism;
- alternation of excitation and drowsiness;
- in the last stage - complete dementia.
Symptoms of liver cirrhosis in men can be:
- testicular atrophy;
- lack of sexual desire( libido);
- a rare hair growth under the armpits and pubic hair;
- enlargement of mammary glands( gynecomastia).
Signs of portal hypertension develop when there is a violation of venous outflow from the portal vein system, the network of which extends to the intestine, part of the stomach and esophagus, and the pancreas. These include:
- ascites( abdominal enlargement) due to accumulation of fluid in the abdominal cavity;
- "jellyfish head" is a divergent pattern of dilated subcutaneous veins around the navel;
- vomiting with an admixture of dark blood, called "coffee grounds" with bleeding from the veins of the stomach;
- black loose stool - if bleeding is localized in the intestine;
- fresh blood on stools with hemorrhoidal veins bleeding;
- enlarged spleen.
Symptoms of polyneuropathy appear in connection with the general intoxication of the body:
- in the arms and legs is broken pain and tactile sensitivity, the patient does not feel the difference between hot and cold objects;
- decreases the strength in the muscles of the limbs, reduces the amount of motion;
- muscle atrophy occurs;
- falls in sight and hearing.
Cardiovascular signs are accompanied by signs of circulatory failure:
- on the lower limbs, edema appears;The
- patient is worried about shortness of breath even with a slight load;
- arterial blood pressure decreases;
- increases the heart rate( tachycardia);
- possible attacks of atrial fibrillation, frequent extrasystoles;
- is sometimes disturbed by stitching pains in the heart area.
The stages of the disease
Alcohol cirrhosis is classified according to the degree of liver damage and the following stages of the disease are established:
- Compensation - symptoms do not manifest, the liver copes with its functions, it is confirmed only with biopsy.
- Subcompensations - the initial phenomena of liver failure, in laboratory studies reveal a violation of liver tests.
- Decompensation - there is a complete disruption of work with the defeat of other organs.
How to confirm the diagnosis?
In the diagnosis of the most difficult - to exclude non-alcoholic cirrhosis of the liver. For an alcoholic etiology, there is information from an anamnesis( a history of the disease) about prolonged alcoholism and negative reactions to viruses.
With the help of ultrasound it is possible to fix the transition of cirrhosis from micronodular( nodes up to 3 mm) to macronodular with the presence of fat deposits in the liver
In laboratory tests, pathological changes are found. In the clinical blood test:
- a low amount of red blood cells, platelets and hemoglobin;
- significant acceleration of ESR;
- absence of leukocytosis, but an increase in the specific gravity of reticulocytes in the formula.
In the analysis of urine:
- decrease in specific gravity;
- change reaction to neutral or alkaline;
- increased number of leukocytes, red blood cells and epithelial cells.
Biochemical blood tests are very important. They note:
- a drop in total protein, including albumin fraction;
- increase in creatinine, urea.
Electrolyte disturbances are found in all patients:
- shift of acid-base balance towards alkalosis in 33% of patients.
Specific hepatic assays indicative of impaired hepatocyte function are:
- increase in total bilirubin by "direct" 4 and more times;
- significant growth of enzymes alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, lactate dehydrogenase;
- growth of biochemical thymol assay.
As a result of instrumental research,
- is detected on the ultrasound of the liver - a change in the structure of the parenchyma, the size of the organ, the sclerosis sites, the presence of small nodules;
- for computer and magnetic resonance tomography, in addition to disturbed structure, fatty inclusions.
Biopsy of part of the hepatic tissue helps to verify the final cause of
disorders. To identify portal hypertension, additional methods are used:
- fibrogastroduodenoscopy - allows visually detecting the expansion of the veins of the stomach and esophagus, diagnose the degree of stagnation and the presence of bleeding;
- sigmoidoscopy is a method of examining the rectus and parts of the large intestine, in which the doctor evaluates the condition of the veins.
Treatment of alcoholic cirrhosis of the liver is impossible without refusing patients from any type of alcohol, correcting the diet and adhering to a strict diet. Return to alcoholism can cause significant progression, additionally inflammation( hepatitis) against the already existing cirrhosis. About this doctor warns every patient before treating the disease.
The patient is absolutely contraindicated:
- fatty meat products in fried, smoked and canned form;
- spicy seasonings, sauces, pickles;
- mushrooms of any preparation;
- use of legumes;
- coffee, strong tea, cocoa;
- candy and chocolate;
- store juices with preservatives;
- fizzy drinks.
- soups from low-fat meat of chicken, vegetables, dairy;
- porridge on water or diluted milk, especially oatmeal, buckwheat, rice, semolina;
- boiled meat, fish, they can be stewed or baked, but you can not fry;
- low-fat cottage cheese and yogurt;
- toast of white bread;
- egg white;
- fruit and berry compotes, fruit drinks, broth of wild rose.
The standard of food is determined by table number 5 according to Pevzner.
Treatment with medicines
The use of drugs in the treatment of alcoholic cirrhosis should not be accompanied by an additional burden on the liver. To remove intoxication appoint:
- intravenous drip fluid( glucose, Ringer's solution), Rheosorbilact;
- inside - enterosorbents( Enterosgel or Polysorb).
Polysorb extracts internal toxins from the intestine
Glucocorticosteroids( Dexamethasone, Methylprednisone) are used to suppress the disintegration of hepatocytes and immune mechanisms, depending on the patient's condition inside or intravenously. Preparations from the group of hepatoprotectors( Ursosan, Essentiale, Ursofalk) are indicated for the protection and restoration of a part of the cellular composition that has not yet been fibrosed.
Pancreatic enzymes( Creon, Pansinorm) contribute to the maintenance of the digestive process. To reduce pressure in the portal vein, use Anaprilin, Nitrosorbide. With significant edema and ascites, the patient needs diuretics. Use Furosemide, Veroshpiron, Trifas according to the individual scheme.
For the purpose of replacement appoint:
- B vitamins;
- drip intravenously injected with albumin solution, erythrocyte and platelet mass.
Application of surgical methods
Surgical treatment consists in combating complications:
- In the case of esophageal bleeding, a rubber tube with an inflated cuff( Blackmore probe) is inserted. It is inflated with air, as a result of which the veins are pressed against the walls. Through the middle of the patient you can feed.
- To reduce the tension of ascites, the fluid is removed by the method of paracentesis( by puncturing the abdominal wall).
- If there is bleeding from the hemorrhoidal veins, suturing is performed by a proctologist.
Treatment options do not completely cure the patient, but prolong and improve the quality of life. The only way to get rid of cirrhosis is liver transplantation, but with alcoholic form, it is not done.
Hepatologists and gastroenterologists believe that the prognosis for alcoholic liver cirrhosis is more favorable than in others, if detected in the first two stages and with complete abandonment of alcohol.
A significant improvement in the metabolic processes in the liver is observed from the termination of the intake of ethanol into the body
With a compensated condition, the patient lives for at least seven years with the right diet and treatment. But, if the pathology is revealed in the stage of decompensation, a survival barrier of only 11 to 41% of patients lasts three years. Accession of encephalopathy reduces the life of a person up to a year.
Alcoholic cirrhosis of the liver is a disease that the sick person "keeps in hands".Propensity to alcoholism and abnormal nutrition is a problem that can be solved in society. Doctors very much regret when to understand this patient begins with the big delay.