Cirrhosis of the liver
Cirrhosis of the liver is a pathological condition of the liver, which is a consequence of impaired blood circulation in the system of hepatic vessels and dysfunction of the bile ducts, usually arising on the background of chronic hepatitis and characterized by a complete violation of the architectonics of the hepatic parenchyma.
The risk group for this disease is representatives of the male half of the population over the age of 45. The incidence of cirrhosis among all nosological forms, according to world statistics, is 2-8%. Thanks to the introduction of effective methods of treatment and prevention of this pathology, the lethality is not more than 50 diagnosed diagnoses per 100,000 people.
The liver is one of the largest glands of internal secretion, possessing a number of important functions:
- the main function of the liver is detoxification, that is, the ability to destroy harmful substances and remove toxins from the body;
- in the liver there is a process of the formation of bile, containing bile acids, involved in the process of digestion;
- The synthetic function of the body is to participate in the formation of proteins, carbohydrates, vitamins and fats, as well as in the destruction of hormones;
- the liver produces the most important factors of blood coagulation;
- The liver participates in the formation of the protective function of the body by the method of antibody formation;
- the liver contains a large supply of useful substances, which, if necessary, delivers to all cells and organs.
The structural unit of the hepatic tissue is the hepatic lobule. Cirrhosis of the liver is characterized by a significant decrease in the functioning of the hepatic cells and the restructuring of the hepatic parenchyma with predominance of the connective tissue component. With cirrhosis, the liver develops changes that can not be corrected, and the doctor's task is to preserve the function of the liver and maintain the state of the vital organs of the patient at a compensated level.
Cirrhosis of the cause
Among all the etiological factors provoking the formation of liver cirrhosis, cirrhosis, which has arisen against a background of chronic hepatitis of any form (viral, toxic, autoimmune) accounts for more than 70% of cases.
The most dangerous viral hepatitis, which in 97% of cases provokes the development of liver cirrhosis, is hepatitis C. The insidiousness and unpredictability of this disease is that it has latent symptoms and is recognized by specific laboratory tests. Viral hepatitis is characterized by massive destruction of hepatocytes, after which the connective tissue grows and cicatricial changes in the liver are formed. This form of cirrhosis is called postnecrotic.
Autoimmune hepatitis is also complicated by the development of liver cirrhosis, but the frequency of its occurrence is rather low.
Prolonged exposure to the body of toxic substances also provokes the development of toxic hepatitis, which is further transformed into cirrhosis of the liver. Toxic medicines are: antibacterial agents, antiviral drugs provided they are used for a long time.
Recently, cirrhosis of the liver, which arose against a background of non-alcoholic steatohepatitis, became more and more frequently diagnosed. Fatty dystrophy of the liver affects people with obesity and diabetes, and in the initial stage this disease does not cause significant changes in the structure of the hepatic parenchyma. When the inflammatory component is attached, the pathogenetic mechanisms of proliferation of connective tissue are triggered, and cicatricial changes are formed in the liver structure, that is, cirrhosis is formed.
Chronic heart failure is accompanied by prolonged venous congestion of the liver, thereby creating conditions for cirrhotic degeneration of the liver.
An important factor for the onset of liver cirrhosis is the state of the vascular system of the liver, so a blood circulation disorder in the system of hepatic arteries and veins leads to fibrotic changes in the hepatic tissue. So, many patients suffering from congestive circulatory failure subsequently develop cirrhosis of the liver.
A significant factor in the development of biliary cirrhosis is the state of the bile ducts, as in violation of the outflow of bile conditions are created for toxic damage of the hepatic cells by bile acids. Thus, the final stage of such diseases as calculous cholecystitis and cholangitis, primary sclerosing cholangitis, provided there is no treatment, is the development of liver cirrhosis.
If it is not possible to establish the cause of cirrhosis reliably, it is a cryptogenic form of cirrhosis, which accounts for 20% of cases in the overall morbidity structure.
There are two main groups of cirrhosis, depending on the etiologic factor of occurrence: true (primary) and symptomatic (secondary), arising on the background of chronic heart failure or chronic calculous cholecystitis.
Symptoms of liver cirrhosis are quite diverse. The degree of clinical manifestations directly depends on the stage of the disease and the presence of other chronic pathologies in the patient. With this disease, not only pathological processes in the liver are noted, but all organs and systems of the human body are affected.
Cirrhosis is characterized by a slow progression with a gradual increase in clinical manifestations. Very often there is a latent (latent) course of the disease, which is dangerous because the patient does not have any complaints and for medical care the patient is already at the stage of complications of cirrhosis. On average, the course of the disease is 5-6 years, but with severe concomitant pathology, a fatal outcome may occur one year after the diagnosis has been established.
The main clinical types of liver cirrhosis are:
- portal cirrhosis of the liver, which is characterized by severe symptoms of portal hypertension in the absence of severe cholestatic syndrome. In the pre-acute period of the disease, pronounced meteorism, dyspeptic syndrome, asthenovegetative symptoms and frequent nasal bleeding are noted. The ascitic period is characterized by the appearance of abdominal pains of different localization, weakness, vomiting, and the appearance of the "jellyfish head" symptom. The late stage of this form of cirrhosis of the liver is cachexia. The transition from ascetic to cachectic takes an average of 6-24 months. Cachexia manifests itself in the form of a sharp decrease in weight, the skin becomes flabby, pale, the patient has a tendency to hypotension , gastric bleeding. Death occurs as a result of hepatic coma or intercurrent illness;
- hypertrophic biliary cirrhosis is characterized by a prolonged course and a slow increase in the clinical picture. Among the symptoms and complaints of the patient, the signs of cholestasis are the first - expressed yellowing of the mucous membranes of the oral cavity, sclera and skin, itching and the appearance of scratching on the skin, xanthelasm and trophic skin damage. Lethal outcome occurs as a result of massive hemorrhagic syndrome;
- mixed cirrhosis, accompanied by rapid dynamics of the clinical picture and a progressive increase in signs of portal hypertension .
All forms of cirrhosis are accompanied by asthenovegetative symptoms (unmotivated weakness, decreased efficiency, decreased appetite, a feeling of rapid heartbeat).
Pain in the projection of the right hypochondrium is aching and intensified after physical activity. The onset of pain is due to increased volumes of the liver and irritation of the nerve endings that are in the capsule.
A frequent early symptom of cirrhosis of the liver is hemorrhagic syndrome, which is manifested in bleeding gums and minor nosebleeds. Hemorrhagic syndrome is caused by inadequate production of the main factors of blood clotting in the liver.
Patients complain of swelling and pain along the bowels, nausea and heartburn. In the projection of the right hypochondrium, there is a feeling of heaviness and a bursting pain.
A frequent symptom in cirrhosis is a prolonged increase in body temperature to 37 ° C, and in the final stage of the disease, short-term fever may occur, due to the attachment of infectious complications and intestinal endotoxemia.
Cirrhosis of the liver is often associated with other disorders of the digestive function, so the symptoms of intestinal dysbacteriosis (stool discomfort, bowel tenderness), relix-esophagitis (nausea, belching stomach contents), chronic pancreatitis (shingles in the upper abdomen, loose stools, vomiting) and chronic gastroduodenitis ("hungry" epigastric pains, heartburn).
Patients with severe form of cirrhosis note the loss of all kinds of sensitivity (tactile, temperature, pain), which indicates the development of polyneuropathy.
At the final stage of cirrhosis of the liver, symptoms appear that indicate the complications of the underlying disease, as when portal hypertension is involved, not only the digestive system, but also hormonal, circulatory, nervous.
Thus, with prolonged accumulation in the intestine of metabolic products, in particular ammonia, which is toxic to the brain cells, damage to the cellular structures of the nervous tissue and the appearance of symptoms of hepatic encephalopathy occur. Signs of the development of hepatic encephalopathy are: a euphoric mood that quickly changes to deep depression , sleep disorder, speech disturbance, disorientation in place and personality, and various degrees of impaired consciousness. Hepatic coma, as an extreme degree of brain damage, is the most important cause of death in patients with cirrhosis of the liver.
With prolonged accumulation of ascitic fluid in the abdominal cavity, conditions for inflammatory changes are created, which leads to spontaneous bacterial peritonitis.
In patients with significant impairment of the functional state of the liver, the risk of gastric and esophageal bleeding increases, manifested as vomiting with thick dark brown masses or fresh venous blood of a dark red color.
Often cirrhosis of the liver is complicated by hepatorenal syndrome, which should be suspected if the patient has severe asthenia, anorexia , thirst, decreased skin turgor, swelling of the face.
Signs of cirrhosis of the liver
Diagnosis of cirrhosis of the liver is not a big deal and often already at the initial examination of the patient it is possible to identify a number of specific signs characterizing this disease.
Cirrhosis of the liver is always accompanied by an increase in the spleen and liver, which can be determined by palpation of the abdomen. The increase in size occurs due to a progressive process of proliferation of connective tissue. The surface of the liver is uneven, bumpy, and the edges are pointed.
Patients with cirrhosis of the liver have typical changes in the skin in the form of an earthy shade of the skin and mucous membranes and the appearance of telangiectasias in the upper half of the trunk.
As a result of a violation of liver function, there is a lack of protein in the blood, which is accompanied by anemic syndrome. In addition, any pathology of the gastrointestinal tract causes a deficiency of vitamin B12, resulting in anemia.
A specific sign of the transition of liver cirrhosis to the stage of decompensation is the accumulation of fluid in the abdominal cavity, confirmed by methods of objective examination of the patient. If there is a large volume of fluid in the abdomen, palpation is not available, and percussion is marked with a blunted percussion sound.
When examining the survey radiographs of the abdominal cavity, you can determine the indirect sign of ascites - a high arrangement of the diaphragm domes. The most reliable diagnostic method in this situation is ultrasound examination of the abdominal cavity with the determination of the volume of ascites fluid.
There are a number of specific and general laboratory signs of the development of liver cirrhosis, the priority of which are hematologic changes (anemia, thrombocytopenia and leukopenia). When joining infectious complications in the blood test, the leukocyte counts and ESR increase, and a shift of the leukocyte formula to the left is noted. Changes in the parameters of biochemical blood analysis can be combined into cytolytic syndrome (increase in the level of AST and ALT) and cholestatic syndrome (increase in the level of total bilirubin, alkaline phosphatase and LDH). As a result of the inadequacy of the synthetic function of the liver, a sharp decrease in the level of the albumin fraction of the protein in the blood, a lowered coagulation factor in the coagulogram analysis, and hypocholesterolemia.
Signs of cirrhosis of the liver that has arisen against the background of hepatitis of viral etiology is the determination of specific markers of a particular virus in the analysis of blood.
Among the instrumental diagnostic methods that contribute to the diagnosis, the most effective are: ultrasound, radionuclide study, EFGDS, laparoscopic liver examination and puncture biopsy with biopsy histology.
Specific changes in cirrhosis on ultrasound are: increased liver and spleen at the initial stage and sharp sclerosis of the liver at the stage of decompensation, heterogeneity of the hepatic parenchyma with the appearance of areas of increased density and echogenicity, increased lumen of the portal and splenic veins.
Radionuclide studies show a non-uniform distribution of colloid preparations in the hepatic tissue, and in areas with excessive proliferation of connective tissue, there is a complete lack of accumulation of the drug with a radioactive label.
EFGDS and contrast methods of radiation diagnosis are used to study the condition of the walls and lumen of the esophagus and stomach. With cirrhosis of the liver, varicose veins in the projection of the esophagus and cardia can often be found in patients.
To determine the morphological variant of cirrhosis, a laparoscopic examination of the liver should be performed. For micronodular cirrhosis of the liver, the following characteristics are characteristic: gray-brown color, the whole surface of the liver is represented by small uniform tubercles, disconnected connective tissue, and the liver is enlarged.
Macronodular cirrhosis of the liver is characterized by such changes: the liver surface is uneven due to the formation of large nodal deformations from the collateral interstitium of the liver located between them. Biliary liver cirrhosis is characterized by a significant increase in liver size and a fine-grained surface.
The most accurate method for diagnosing cirrhosis of the liver is a puncture biopsy. Histological examination of seized material reveals large areas of necrotic tissue and significant proliferation of connective tissue components between the collapsed stroma of the organ. Carrying out a liver biopsy allows you to reliably establish the diagnosis, as well as to find out the cause of the disease, the degree of damage to the liver tissue, determine the therapy technique and even allows you to make predictions for the life and health of the patient.
There are two main techniques for biopsy: percutaneous and transvenous. Absolute contraindication for percutaneous biopsy is the tendency to bleeding, expressed ascites and obesity .
Stages of cirrhosis of the liver
Cirrhosis of the liver of any etiology develops according to a single mechanism, which includes 3 stages of the disease:
1 stage (initial or latent), which is not accompanied by biochemical disorders;
2 stage of subcompensation, in which all clinical manifestations that testify to functional violations of the liver are observed;
3 stage of decompensation or stage of development of hepatic-cell insufficiency with progressive portal hypertension.
There is a common classification of Child-Pugh liver cirrhosis, which combines clinical and laboratory changes. According to this classification, 3 degrees of severity of the disease are distinguished.
Cirrhosis of class A liver is the sum of the scores to 5-6, Class B is 7-9 points, and Class C is considered as the terminal stage and is more than 10 points. The clinical parameters of classification are the presence and severity of ascites and hepatic encephalopathy. So, in the absence of ascitic fluid and manifestations of encephalopathy, 1 point is assigned, with a small amount of fluid and moderate malignant signs of encephalopathy, 2 points should be added, 3 points correspond to expressed ascites, confirmed by instrumental methods of investigation and hepatic coma.
Among the laboratory parameters of blood to determine the severity of the following parameters should be considered: total bilirubin, albumin content and prothrombin index. 1 point corresponds to bilirubin content less than 30 μmol / l, albumin more than 3.5 g and prothrombin index 80-100%. 2 points should be summarized if the level of bilirubin is 30-50 μmol / l, albuminemia is at the level of 2.8-3.5 g and the prothrombin index is 60-80%. Significant changes in laboratory parameters should be assessed at 3 points - bilirubin at a level of more than 50 μmol / l, albumin content in blood less than 2.8 g and prothrombin index less than 60%.
And another component of the classification is the condition of the esophagus veins: 1 point corresponds to varicose veins to 2 mm, 2 points is added in case of veins 2-4 mm and 3 points - the presence of varicose veins more than 5 mm.
Thus, when formulating a diagnosis of "liver cirrhosis" of any etiology, it is mandatory to indicate a class of disease according to the Child-Pugh international classification.
Also to determine the morphological type of cirrhosis, 4 forms are distinguished: portal cirrhosis of the liver, postnecrotic, biliary primary and secondary, and also mixed.
Cirrhosis of the liver last stage
The terminal stage of liver cirrhosis is characterized by a significant deterioration in the state of all organs and systems of the human body and practically can not be treated. At this stage, the liver is significantly reduced in size, has a stony consistency and completely loses its ability to regenerate.
Appearance of the patient has specific signs, so the diagnosis at the last stage of cirrhosis is not difficult. Skin covers of earthy color, low turgor. There is marked swelling of the limbs and face, especially the paraorbital region. The abdomen acquires huge dimensions due to accumulation in the abdominal cavity of a large amount of fluid. On the surface of the anterior abdominal wall there is a dense venous network.
Patients with cirrhosis of the liver in the decompensated stage need immediate hospitalization to provide medical correction and support the functioning of all organs and systems.
The main danger and unpredictability of the terminal stage is a sudden deterioration in the patient's condition and manifestations of complications - gastric and esophageal bleeding, encephalopathy, coma and ultimately malignancy of the process and the formation of liver cancer .
The only effective method of treatment of liver cirrhosis of the last stage is liver transplantation, and conservative treatment is exclusively of a preventive nature.
For the development of biliary cirrhosis the following sequence is typical: chronic cholangitis with a destructive component - prolonged cholestasis - cirrhosis of the liver.
The risk group consists of women with heredity that is burdened with this disease. Frequency of occurrence is 6 cases per 100 000 population.
With prolonged cholangitis, conditions are created to damage the biliary tract and disturb the metabolic transformations of bile acids with a change in their structure (the concentration of toxic acids increases). As a result of the toxic effect of bile acids, not only hepatic but systemic lesions occur. Toxic liver damage occurs due to damage to cell membranes of hepatocytes and inhibition of hepatic cell regeneration.
Systemic manifestations due to the damaging effect of bile acids include: erythrocytic hemolysis, impaired protective function of lymphocytes and alteration of blood circulation by hyperkinetic type.
With prolonged cholestasis, cell membranes are damaged not only in hepatocytes, but also in all organs and systems at the cellular level.
The initial manifestations of biliary cirrhosis is a painful itching , intensifying after taking a warm shower, and also at night. The skin acquires a yellowish shade and becomes rough. Later in the area of large joints there are areas of hyperpigmentation with maceration of the skin. A characteristic specific feature of biliary cirrhosis is the appearance of xantelasm in the region of the upper half of the trunk. At an early stage, there are no signs of hypersplenism and extrahepatic changes.
At the stage of the detailed clinical picture, the main complaints of patients are: severe weakness and weight loss, anorexia, subfebrile condition, dilated pain in epigastrium and right hypochondrium. Increased size of the liver and spleen can be palpated without the use of instrumental methods of investigation. The integuments acquire an earthy tinge with areas of hyperpigmentation.
Biliary cirrhosis is rapidly complicated by hepatic encephalopathy and gastric bleeding.
Laboratory indicators confirming the diagnosis are: the presence of antimitochondrial antibodies, a decrease in the level of T-lymphocytes, an increase in IgG and IgA. In the biochemical analysis of blood, an increase in the conjugated fraction of bilirubin, cholesterol, alkaline phosphatase and bile acids is observed. Changes in the coagulogram are a decrease in the level of albumins with a simultaneous increase in blood globulins.
Alcoholic cirrhosis of the liver
Numerous observations and randomized studies prove that the cause of alcoholic cirrhosis is to a greater extent the insufficient level of nutrition of the alcoholic, rather than the toxic effect of alcohol.
The risk group for this disease is men aged 40-45 years. At the initial stage, the patient does not have any complaints about his health, but with an objective examination, at this stage, an increase in liver size is determined.
At the stage of a detailed clinical picture, loss of appetite, vomiting, upset of the stool, paresthesia of the limbs, hypotrophy of the muscular mass of the upper half of the trunk and contracture, alopecia are determined. As a result of developing metabolic disorders, there are signs of vitamin and protein deficiency.
When alcoholic cirrhosis of the liver is typical of early development of violations in the hormonal sphere. In the male half of the population there are signs of gynecomastia, testicular atrophy, impotence, and in women with alcoholic cirrhosis, the risk of infertility and spontaneous abortion increases.
Alcoholic cirrhosis of the liver is characterized by the rapid appearance of signs of portal hypertension - nausea, aching girdle in the upper abdomen, swelling and rumbling along the bowel, ascites.
In the initial stage of alcoholic cirrhosis of the liver, there are no significant changes in the biochemical blood test, only a slight increase in the level of gamma globulins and aminotransferases.
The transition from the compensated stage of liver cirrhosis to terminal hepatic-cell insufficiency takes quite a long time, but the final stage of alcoholic cirrhosis is accompanied by a significant deterioration in the patient's condition.
Manifestations of hepatocellular insufficiency are severe jaundice, hemorrhagic syndrome, fever and refractory to conservative therapy of ascites. Lethal outcome in such patients occurs as a result of bleeding from the esophagus and hepatic coma.
The laboratory signs of the development of hepatic insufficiency is a significant decrease in the level of the total protein due to albumin, as an indication of the inadequacy of the synthetic function of the liver.
To determine the tactics and scope of therapeutic measures, it is necessary to take into account the etiology of liver cirrhosis, the degree of its progression, inflammatory necrotic activity and the presence of complications and concomitant diseases.
Patients with cirrhosis of the liver should be limited physical activity and dietary diet, and in the stage of decompensation a strict bed rest is shown to improve liver blood circulation and activate regeneration of the hepatic tissue.
All patients with cirrhosis of the liver should completely abandon the use of hepatotoxic drugs and alcohol. Do not apply physiotherapy and vaccine therapy to patients in the active period of the disease.
Etiotropic therapy is appropriate only if the cause of the disease is established reliably (drug, viral, alcoholic liver cirrhosis) and has a positive effect only in the initial stage of cirrhosis.
As an etiotropic treatment for hepatic cirrhosis that occurs against the background of viral liver damage, antiviral therapy with interferon is used (Laferon 5000000 IU IM / day 1 or 10,000,000 IU subcutaneously 3 r. Per week for 12 months). With cirrhosis of the liver in the decompensation stage, antiviral therapy is used with caution, taking into account the side reactions of the drugs (cytopenia, hepatic-cell insufficiency, cytolytic crisis). In this situation it will be appropriate to prescribe Lamivudine 100-150 mg per day orally or Famciclovir 500 mg 3 r. per day by oral route for at least 6 months.
As hepatoprotective therapy with subcompensated cirrhosis of the liver, Essentiale is prescribed 2 capsules 3 r. per day for 3-6 months, Gepabene 2 capsules 3 r. per day for 3 months, Lipamid 1 tablet 3 r. per day for 1 month. For intravenous infusions, 5% glucose is used. 200 ml intravenously drip by a course of 5 infusions and Neo-haemodesis in / in a drop of 200 ml.
When the protein level in the blood is clearly reduced due to the albumin fraction, it is advisable to use protein solutions - 10% of albumin solution in a dose of 100 ml IV infusion of 5 infusions and Retabolil IM in a dose of 50 mg 2 r. per month intramuscularly with a course of at least 5 injections. To eliminate iron deficiency anemia, iron-containing preparations are used - Tardiferron 1 tablet 2 rub. per day, intramuscular injections of Ferrum-lek 10 ml with a course of 10 injections.
To relieve the symptoms of portal hypertension, preparations of the group of B-blockers (Anaprilin 40-100 mg per day for 3 months), prolonged nitroglycerin (Nitrosorbit in a dose of 20 mg 4 times a day for at least 3 months) are used.
Mandatory is the appointment of combined vitamin complexes with long-term courses (Undevit, Supradit, Vitacap 1 tablet per day).
To improve the synthetic function of the liver is used Riboxin, improving the process of protein synthesis in hepatocytes, at a dose of 200 mg 3 r. per day for 1 month. In order to normalize the carbohydrate metabolism, they are prescribed Co-carboxylase at a dose of 100 mg per day in a 2-week course.
Pathogenetic treatment consists in the use of hormonal drugs and immunosuppressants, which have anti-inflammatory and antitoxic effects. The drug of choice for conducting adequate hormone therapy is Prednisolone. The maximum dose of Prednisolon is 30 mg and this amount of hormone must be taken before the normalization of biochemical blood parameters (decrease in the level of aminotransferases and bilirubin). It should be borne in mind that with a sharp discontinuation of Prednisolone, there is a "withdrawal syndrome", so the dose should be reduced gradually (2.5 mg 1 rub in 2 weeks). Some patients need long-term hormonal treatment, so in this situation, you should use Prednisolone in a maintenance dose of 10 mg. Patients who have manifestations of hypersplenism show a short course of hormone therapy within 1 month.
Absolute contraindication to the use of glucocorticoids is cirrhosis in the stage of decompensation, as the risk of complications of an infectious nature, a septic condition and osteoporosis increases.
Separate attention deserves patients with cirrhosis of the liver with ascites. Such patients should adhere to a special salt-free diet and strict bed rest. The initial treatment measures aimed at elimination of ascites are the restriction of the fluid used by the patient and the appointment of an individual scheme for the use of diuretic drugs - Veroshpiron in a daily dose of 300 mg, Furosemide up to 80 mg per day, Hypothiazide at a dose of 25 mg per day. With the development of resistance to diuretics, resort to the appointment of ACE inhibitors (Captopril orally 25 mg per day in the morning).
If a patient has a large amount of ascites fluid according to ultrasound, and if there is no positive result from the use of diuretics in the maximum dose, a diagnostic paracentesis with ascitosorption should be used. This method involves the extraction of ascitic fluid, its purification with the help of carbon sorbent from toxic metabolites and the reverse administration to the patient intravenously in order to prevent a sharp loss of electrolytes and protein.
The relief of gastric and esophageal bleeding in a patient with cirrhosis of the liver is a combined use of conservative and surgical methods of treatment.
Drug therapy for bleeding involves the use of Vasopressin 0.1-0.6 units per minute in combination with nitroglycerin at a dose of 40-400 μg per minute, intravenous infusion of 200 ml of 5% glucose with 20 units of Pituitrin, somatostatin at a dose of 500 μg by the method in / in the drip infusion.
For the implementation of hemostasis, it is advisable to carry out intravenous injection of 5% of Aminocaproic acid in a dose of 100 ml every 6 hours, IM injection of 12.5% of Etamzilat in a dose of 4 ml, IM injection of 1% p -a Vikasola in a dose of 1 ml, and in the absence of effect - fresh frozen plasma 500 ml, antihemophilic plasma in a volume of 100 ml.
Minimally invasive methods of surgical treatment include endoscopic sclerotherapy and laser therapy. Endoscopic sclerotherapy refers to the introduction into the bleeding varicose veins of the esophagus Sclerosent in a single dose of 2 ml. The course of sclerotherapy is 8 injections.
Recently, the method of introducing hemostatic drugs directly into the varicose-expanded node using an endoscope has been widely used.
Indications for the use of surgical intervention is the lack of the effect of drug treatment, the absence of severe concomitant pathology in the patient, the young age of the patient and the pronounced cholestatic and cytolytic syndromes. The most common and effective surgical operations in this situation are: gastrectomy with esophageal veins stitching, percutaneous endovascular embolization of the gastric veins, electrocoagulation of the esophageal veins.
For treatment of patients with hepatic encephalopathy Glutamic acid is used in a daily dose of 2 mg, Ornitsetil IM in a dose of 4 mg per day, prolonged use of Glutargin orally in a dose of 750 mg 3 r. per day, oral Citrarginine at the rate of 1 ampoule per 100 ml of water 2 p. per day. As agents of detoxification therapy, the use of broad-spectrum antibiotics is recommended.
In the terminal stage, with the development of the hepatic coma, the patient is given a massive infusion therapy - 5% of Glucose ration to 2 liters per day at a rate of 20 drops per minute, 300 mg of cocarboxylase at a daily dose of 300 mg, prednisolone at 90 mg every 4 hours, 10% of glutamic acid, 150 ml every 8 hours. In a situation where there is metabolic acidosis , it is advisable to use IV droplet injection of 4% sodium hydrogencarbonate in a dose of 200-600 ml.
For patients with biliary cirrhosis, drugs that affect the pathogenetic mechanisms of cholestasis are used, among which the most effective are Heptral, Antral and Ursodeoxycholic acid.
Scheme of application of Heptral: for two weeks intravenously for 5-10 ml, after which they switch to oral administration of 400 mg of 2 r. per day for 1 month. Ursodeoxycholic acid (Ursofalk) is prescribed by a long course in a dose of 1 capsule of 3 r. per day. Antral is applied for 6 weeks in a daily dose of 0.75 g.
To eliminate severe itching, the patient is prescribed Rifampicin at a daily dose of 300 mg or Phenobarbital at a dose of 150 mg per day.
To improve the normalization of the functional capacity of the liver with biliary cirrhosis, Methotrexate is administered at 15 mg per week, and in the absence of positive results, the inhibitor of cellular immunity Ciclosporin-A is 3 mg per kg of body weight for 4-6 months. Indications for the use of glucocorticoids in biliary cirrhosis are absent, therefore Prednisolone is used only as a short course as a means to eliminate itching at a dosage of 10 mg per day.
With the established syndrome of hypersplenism, there are grounds for the use of leukopoiesis stimulants (Pentoxyl at a dose of 200 mg 4 r / day, Leucogen in a daily dose of 0.06 g, Sodium nucleate at a dose of 0.2 g 4 r./day), course 1-3 month. Indication for hemotransfusion of erythrocyte or platelet mass is the level of hemoglobin less than 50 g / l and expressed thrombocytopenia.
In liver cirrhosis complicated by hepatorenal syndrome, it is necessary to increase the volume of blood plasma, for which the patient is injected dextrans (Reopoliglyukin or Polyglukin 400 ml). At the expressed reduced daily diuresis it is applied iv introduction of 20% of rn-Mannitol in a dose of 150 ml every 2 hours. To improve blood circulation in the renal arteries and to eliminate ischemia of the renal cortex, iv administration of 2.4% of Eufillin in a dose of 10 ml is recommended and the appointment of Dopegit in a dosage of 0.25 g of 3 r. per day. In order to prevent protein catabolism, it is advisable to use Retabolil in a dose of 50 mg intramuscularly 1 p. in 2 weeks.
The most radical method of treatment of liver cirrhosis is organ transplantation. This surgical intervention has a narrow spectrum of application and is performed according to strict indications: terminal stage of hepatic-cell insufficiency, critical pancytopenia, combination of hypersplenism syndrome with esophageal bleeding, primary autoimmune biliary cirrhosis and the final stage of the disease.
Diet for cirrhosis of the liver
Therapeutic dietary nutrition plays an enormous role in improving the health of patients with cirrhosis of the liver, along with the intake of medications.
When compiling a menu for a patient with cirrhosis of the liver, it is necessary to take into account the stage of the disease and the degree of disruption of the synthetic function of the liver. With compensated cirrhosis, which retains the ability to neutralize ammonia, it is inappropriate to restrict products containing protein. Portal cirrhosis of the liver is not accompanied by a significant disruption of the ability to neutralize ammonia, so this type of cirrhosis needs to increase the intake of protein with food. The only indication for the restriction of foods containing protein is the terminal stage of cirrhosis.
In addition to protein products should limit the consumption of fats of animal origin, and in the presence of vomiting and nausea should completely eliminate the intake of fat in the body.
Carbohydrates can be consumed in any amount, but with concomitant obesity, sweets and sugar should be excluded.
Patients with cirrhosis of the liver with concomitant ascites should monitor the drinking regimen and take into account daily diuresis. The amount of liquid used should be limited to 1-1.5 liters. Due to the fact that massive diuretic therapy is prescribed for ascites, there is a risk of a sharp drop in the level of potassium in the body, so patients should drink enough dried fruits and vegetables.
Special attention should be given to the method of preparing dishes: all foods should be prepared in the form of puree, as thick and solid food is difficult to digest. Products must be heat treated by the method of boiling and baking.
The organs of the digestive tract with cirrhosis of the liver can not cope with a large volume of food, so the patient should eat food fractional. The last meal should be no later than 19.00.
Of meat products should be preferred to products from minced meat, steamed, from low-fat varieties of meat. The first dishes are prepared on vegetable broth in the form of soups-mashed potatoes. Porridges should have a liquid consistency. It is undesirable to eat raw vegetables and fruits. Absolutely prohibited products for cirrhosis of the liver are coffee and alcohol.
In folk medicine, there are many recipes for broths that positively influence the regenerative properties of the liver and possess detoxifying properties. The most effective means is oatmeal, which is used instead of tea. For cooking, stir 3 tablespoons. washed oats, 3 tbsp. birch buds, 2 tbsp. crushed red bilberry leaves and pour this dry mixture 4 liters of purified water. Separately prepare a broth of dogrose. Both broths must be insisted for 1 day in a cool dry place. Then you need to combine both infusions, add 2 tablespoons to them. corn stigmas and 3 tablespoons. knotweed. Boil the infusion for 15 minutes, strain through gauze and store in the refrigerator. To use infusion it is necessary to preheat 4 times a day instead of tea.
Approximate daily food intake:
For breakfast: 1 boiled egg, 200 g of buckwheat porridge with baked apple, 100 g of salt-free bread, 100 ml of oat broth with 1 tsp. Sahara.
For lunch: 250 g of baked potatoes with greens and tomatoes, 100 g of boiled fish of low-fat varieties, fruit jelly 100 ml.
For a snack: green tea with milk, salt-free bread with jam.
For dinner: 200 g of vegetable soup puree with 1 tbsp. low-fat sour cream, 90 g of chicken fillet, steamed, 100 g of fruit jelly.
How many live with liver cirrhosis
In order to predict the patient, it is necessary to be sure of the patient's desire and desire to be healthy. Subject to the implementation of all the recommendations of the attending physician, patients with cirrhosis of the liver who is in the compensation stage can live quite a long time. Of course, this pathology is characterized by inevitable changes in the liver, but with adequate treatment for the quality of life of the patient the disease will not be practically reflected.
To return to normal normal life, it is sometimes sufficient only to eliminate the cause that caused cirrhosis and dietary intake. If the disease has reached the terminal stage, then to achieve positive results from treatment is difficult, even with modern methods of therapy.
According to world statistics, the life expectancy of patients with compensated cirrhosis of the liver exceeds 10 years. With decompensated cirrhosis, 40% of patients die in the first three years from the date of diagnosis. Patients with hepatic encephalopathy are able to live no more than 1 year.
The most effective method of prolonging life with cirrhosis is the modification of the patient's lifestyle: avoiding bad habits, normalizing eating behavior, eating large amounts of vegetables and fruits, maintaining skin health, undergoing regular medical examination, and observing the medical recommendations of the treating doctor.
Cirrhosis of the liver prognosis
A favorable outcome of the disease is observed only in case of latent clinical and morphological manifestations of liver cirrhosis, as well as with the complete exclusion of hepatotoxic substances (alcohol, narcotics, hepatotoxic drugs and viruses).
Cirrhosis of the liver in the stage of an expanded clinical and biochemical picture is incurable and favorable is the maintenance of the patient's condition in the compensation stage. According to world statistics, lethal outcomes in liver cirrhosis occur as a result of the development of hepatic-cellular insufficiency and gastric bleeding. 3% of patients with cirrhosis of the liver in the stage of decompensation become ill with hepatocellular carcinoma .