Curing Liver Cirrhosis Forever

Liver Disease Survivors Guide

Renowned Health Specialist experienced in working with numerous people with liver disorders share with you and: Explains how the liver works and how liver disorders develop in Simple English without Medical Jargon. Shares the facts about cirrhosis of the liver. Explains complications and treatments in simple language. Talks about Nutrition in Liver Disease. Explains Alternative Treatments available. Talks about the latest research developments in liver disease treatment. Shares resources for Liver disease forums and help-lines. Gives you the true in-depth stories from survivors and how they coped with the challenges of liver disorder. Shares touching stories of family members who had to cope with their loved ones suffering from cirrhosis of the liver, and the strategies they used to cope with them. With Liver Disease Survivors Guide, you will discover : Credible information on Liver disease obtained from detailed interviews with specialist doctors, explained in simple language. Healthy steps in dealing with liver disorders. What to do and what not to do while learning to adapt to the liver disorder. Remarkable stories in patients own words. It gives you a real emotional experience of a person with serious liver disorder and how they view the world. Latest research on liver disorders. Best resources and direct links to forums. Direct links to get professional help and identify the best experts in your area. Alternative treatments and therapies available for liver disorders. No medical jargon or difficult language, the book is written in simple and easy to understand language.

Liver Disease Survivors Guide Overview


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Clinical Presentation And Diagnosis Diagnosis of Cirrhosis

In some cases, cirrhosis is diagnosed incidentally before the patient develops symptoms or acute complications. Other patients may have decompensated cirrhosis at initial presentation they may present with variceal bleeding, ascites, SBP, or HE. At diagnosis, patients may have some, all, or none of the laboratory abnormalities and or signs and symptoms that are associated with cirrhosis. Ultrasound examination is used routinely to evaluate cirrhosis a small, nodular liver with increased echogenicity is consistent with cirrhosis. Liver biopsy is the only way to diagnose cirrhosis definitively, but this is often deferred in lieu of a presumptive diagnosis. Because it is an invasive procedure, the decision to perform a biopsy is based on the expected clinical utility of the biopsy results. If the results have the potential to change the course of treatment, it may be advisable to perform a biopsy. The modified Child-Pugh and Model for End-Stage Liver Disease (MELD) classification systems...

Treatment Of Cirrhosis Portal Hypertension And Complications

Recognizing and treating the cause of cirrhosis is paramount. Cirrhosis is irreversible treatments are directed at limiting disease progression and minimizing1 complications. The immediate treatment goals are to stabilize acute complications such as variceal bleeding and prevent SBP. Once life-threatening conditions have stabilized, the focus shifts to preventing complications and preventing further liver damage. Complication prevention involves both primary and secondary prophylaxis. To determine appropriate prophylactic therapy, a careful analysis of patient characteristics and disease history is mandatory. The sections that follow concentrate on treatment and prevention of cirrhotic complications. Lifestyle modifications can limit disease complications and slow further liver damage. Avoidance of additional hepatic insult is critical for successful cirrhosis treatment. The only proven treatment for alcoholic liver disease is the immediate cessation of alcohol consumption. Patients...


Cirrhosis is a chronic disorder characterized by liver fibrosis and nodule formation, which produce portal hypertension and hepatocellular failure. Cirrhosis is the end product of progressive liver injury resulting from diverse causes including toxins, drugs, viruses, and parasites. Clinical manifestations of cirrhosis vary with the underlying disease. In the West, cirrhosis is a cause of disability and death among middle-aged alcoholic males. Elsewhere, cirrhosis is predominantly an intermediate lesion in the evolution from chronic hepatitis B infection to primary hepatocellular carcinoma.

VIII28 Cirrhosis

Cirrhosis is a chronic hepatic disorder, anatomically characterized by diffuse liver fibrosis and nodule formation. These pathological changes produce the clinical features of portal hypertension and hepatocellular failure. Cirrhosis is the end product of progressive liver injury resulting from many diverse causes including toxins, drugs, viruses, and parasites. The clinical manifestations of cirrhosis vary according to the severity and duration of the underlying disease. In the West, cirrhosis is a major cause of disability and death among middle-aged alcoholic males. In the East and Africa, cirrhosis is predominantly an intermediate lesion in the evolution from chronic hepatitis B infection to primary hepatocellular carcinoma.

Gastrointestinal System

Hepatobiliary disease occurs due to bile duct obstruction from abnormal bile composition and flow. Hepatomegaly, splenomegaly, and cholecystitis may be present. Hepatic steatosis may also be present due to effects of malnutrition. The progression from cholestasis (impaired bile flow) to portal fibrosis and to focal and multilobar cirrhosis, esophageal varices, and portal hypertension takes several years. Many patients are compensated and asymptomatic but may be susceptible to acute decompensation in the event of extrinsic hepatic insult from viruses, medications, or other factors.7

Hepatic encephalopathy

This may result from increased concentrations of false neurotransmitters, such as octopamine and 5-HT, which replace the normal dopamine and norepinephrine. GABA is produced in the gut by bacterial action on protein and may lead to coma by passing through the blood-brain barrier in liver failure. The number of binding sites for GABA, glycine and benzodiazepines on postsynaptic neurones is increased in acute liver failure present data suggest that this mechanism is the most important contributor to hepatic encephalopathy. The benzodiazepine antagonists reverse hepatic encephalopathy temporarily. The hypersensitivity to benzodiazepines in patients with hepatic encephalopathy may be explained by an increase in the free drug concentration.

Amide Local Anesthetics

For example, drugs such as general anesthetics, norepinephrine, cimetidine, propranolol, and calcium channel blockers (e.g., diltiazem) all can decrease hepatic blood flow and increase the elimination half-life of the amide-linked local anesthetics. Similarly, decreases in hepatic function caused by a lowering of body temperature, immaturity of the hepatic enzyme system in the fetus, or liver damage (e.g., cirrhosis) lead to a decreased rate of hepatic metabolism of the amide local anesthetics.

Epidemiology And Etiology

Cirrhosis is the result of long-term insult to the liver, so damage is typically not evident clinically until the fourth decade of life. Chronic liver disease and cirrhosis combined were the 12th leading cause of death in the United States in 2002. In patients between the ages of 25 and 64 years, damage from excessive alcohol use accounted for over one-half of the deaths. Alcoholic liver disease and viral hepatitis C are the most common causes of cirrhosis in the United States, whereas hepatitis B accounts for the majority of cases worldwide. Once cirrhosis is diagnosed, the disease progression is relentless, regardless of the initial insult to the liver. Variations occur, but cirrhosis secondary to alcohol abuse typically develops after 10 or more years of daily ingestion of 80 g of ethyl alcohol this is an average of 6 to 8 drinks per day (a drink is equivalent to 1 ounce 30 mL of hard liquor, 4 ounces 120 mL of wine, or a 12-ounce 360-mL beer).4 With equivalent alcohol intake,...

Epidemiology And Etiology Hepatitis A

Hepatitis B is a bloodborne infection affecting more than 2 billion people worldwide. Approximately 400 million people have chronic infection, which may lead to cirrhosis and complications of ESLD.8 There are 500,000 to 700,000 deaths annually due to hepatitis B.9 Despite having an effective vaccine against HBV, more than 300,000 newly diagnosed infections emerge each year. Fewer than 1 of individuals in North America and western Europe are chronically infected compared with 8 to 10 in developing areas such as Southeast Asia.8

Recommended References

Black cohosh extract The roots of this herb have been used to prepare medication for menopausal symptoms since ancient times, but conflicting research results have not always supported its effectiveness. Liver failure has been reported as a result of its use. Goldenseal The Cherokees and other Native American tribes have used this herbal remedy for centuries. As a tea, it was used to treat sores of the mouth and throat, and to help calm inflammation of the digestive and urinary tracts. A tea wash with Goldenseal is a folk remedy for eye infections. The main compounds in goldenseal, berberine and hydrastine, have been studied widely. In animal studies, berberine reduced fevers, killed bacteria, fungi and protozoa, and slowed the growth of tumors. In human research, berberine treated acute diarrhea, probably because of its antibacterial properties, and improved chronic gall bladder inflammation and liver cirrhosis. Hydrastine constricted blood vessels in the arms and legs. Women who are...

Pleural Effusion Fluid in the Chest

There are many causes of pleural effusions. They could develop as a result of heart failure, liver failure, or kidney failure or be related to a tumor in the chest. Sometimes, fluid can accumulate in the chest cavity for other reasons, such as an infection. In this case, the material may be pus. Sometimes the fluid is bloody, and when related to trauma, the fluid may actually be blood.

Diseases and Disease Ecology of the Modern Period in Southeast Asia

The ecology of disease in Southeast Asia is currently in a period of rapid and significant change, the beginning of which is usually dated around 1970. For one thing, except for infants and children under 5 years, infectious diseases are no longer a significant threat to health. Tuberculosis remains a hazard for the aged population (which has grown), and malaria remains endemic in many areas, but, in general, tuberculosis, pneumonia, malaria, diarrheal diseases, and nutritional deficiencies, along with other infectious diseases, have declined. On the other hand, death rates for heart-related diseases, cancer, and accidents along with violent deaths have significantly increased (Institute for Population and Social Research 1985). Increasing attention is being given to the problem of infant mortality, for persons under 5 years have benefited least from the overall improvement in health. Diseases of pregnancy, delivery, and puerperium have also become more prominent of late. In addition,...

Laboratory Parameters

It is important to obtain a serum chemistry profile to help identify the underlying cause of SE. Abnormalities that can cause seizures include hypoglycemia, hyponatremia, hypernatremia, hypomagnesemia, hypocalcemia, and renal and liver failure. In a febrile patient with an elevated white blood cell count (WBC), an active infection should be ruled out or treated appropriately. Cultures from the blood, cerebrospinal fluid (CSF), respiratory tract, and urine should be obtained once the seizures are controlled. CT or MRI can be done to rule out CNS abscesses, bleeding, or tumors, all of which may be a source for seizure activity. A blood alcohol level and urine toxicology screen for drugs of abuse should also be conducted to determine if alcohol withdrawal, illicit drug use, or a drug overdose could be the underlying cause of SE. Also, drug levels should be obtained in a drug overdose situation to rule out

Search for causes of disease occurrence Why does disease occur

Cirrhosis (Premise A) Liver cirrhosis is due to alcohol abuse (Premise B) Liver cirrhosis course might improve if patient stops drinking (Conclusion C) Valid diagnosis liver cirrhosis and exclusion of other competing diagnoses Alcohol abuse causes liver cirrhosis (causal proof f rom etiological research) That the patient really has liver cirrhosis (from the field of diagnosis see Chapter 6) That liver cirrhosis is caused by alcohol abuse (from the field of etiological research as

Pharmacokinetic Studies Of rFVIIa In Humans

With cirrhosis, and healthy volunteers. The pharmacokinetic parameter values of rFVIIa after bolus administration were similar. The elimination half-life (r1 2) ranged from 2.45 to 2.72 h and clearance (CL) ranged from 32.8 to 34.9 ml h.kg23. Lindley and colleagues investigated the single-dose pharmacokinetics of rFVIIa, evaluated in three dose levels (17.5, 35.0, 70 lg kg) in hemophilic A B patients with inhibitors. The results of these investigations demonstrate that the mean t1 2 of recombinant factor VIIa is independent of dose level24.

Lymphedema Clinical Summary

Lymphedema occurs from obstruction of lymphatic channels and is associated with malignancy, radiation, trauma, surgery, inflammation, infection, parasitic invasion, paralysis, renal insufficiency, congestive heart failure, cirrhosis, and malnutrition. Lymphedema is characterized by painless pitting edema, fatigue, increase in limb size (particularly during the day), and presence of lymph vesicles. The skin becomes thickened and brown in the late stages. Cellulitis, deep venous thrombosis (DVT), lymphangitis, traumatic hematoma, right heart failure, tuberculosis, and lymphogranuloma venereum should be considered when the diagnosis of lymphedema is made. Imaging techniques of the lymphatic system include radionuclide imaging (lymphoscintigraphy), which is the preferred method, and lymphangiography.

Distribution and Incidence

Cirrhosis is distributed worldwide, affecting all races, nationalities, ages, and both sexes. Well over 300,000 persons die of the disease annually. This figure, based on World Health Organization statistics of the 1960s, is an underestimate because countries such as mainland China and the former Soviet Union are not included. In the United States in 1983, cirrhosis ranked as the ninth leading cause of mortality, accounting for 27,000 deaths. The worldwide incidence of cirrhosis is determined chiefly by the per capita consumption of alcohol and the prevalence of the hepatitis viruses. The rise in the number of cases of cirrhosis is attributable to an increase in one or both of these factors. Based on mortality statistics (WHO data, 1983 or 1984), the incidence of cirrhosis in various countries can be grouped as follows Occurrence rates for the different types of cirrhosis are presented in Table VIII.28.1.

Clinical Manifestations and Diagnosis

Clinically cirrhosis may be latent (5 to 10 percent of cases), well compensated, or active and decompensated. The clinical features depend on the underlying etiology and the appearance of the two cardinal manifestations, portal hypertension and hepatocellular failure. As cirrhosis usually evolves over a period of several years, the course may be intermittent with therapeutic intervention such as with corticosteroids or with temporary cessation of injury. During the early phase of disease, patients often present with nonspecific symptoms and signs including malaise, lethargy, anorexia, loss of libido, and weight gain. Incidental laboratory findings of abnormal liver function tests, positive hepatitis B serology and hypergammaglobulinemia, and incidental physical findings such as icterus, hepatomegaly, gynecomastia, and spider nevi may point to the presence of cirrhosis. With the progression of disease, portal hypertension and hepatocellular failure invariably supervene. These two...

History and Geography

The ancient Greeks recognized the clinical features of cirrhosis. In about 300 B.C., Erasistratus associated ascites with liver disease. Galen, in the third century A.D., commented on the physical diagnosis, and noted that heavy wine consumption will increase the damage to the liver when inflammation and scirrhus already existed. His contemporary, Aretaeus the Cappadocian, suggested that cirrhosis may evolve from hepatitis, and carcinoma, from cirrhosis. The clinical descriptions left by the Greeks remained unexcelled until recent times. discipline in the seventeenth century, sporadic reports of the cirrhotic liver appeared. Among the earliest illustrations of cirrhosis was that by Frederik Ruysch in his atlas of normal and abnormal anatomy (1701-16). In his massive tome on pathology, Giovanni B. Morgagni (1716) introduced the term tubercle to denote any nodule of the liver. This covered a variety of lesions, and sowed the confusion between carcinoma and cirrhosis of the liver for...

Reproductive Age Women

Abnormal bleeding in ovulatory cycles includes menorrha-gia, polymenorrhea, oligomenorrhea, and intermenstrual bleeding. Menorrhagia can be associated with structural lesions (uterine leiomyomas, endometrial polyps or hyperplasia), coagulation disorder, liver failure, or chronic renal failure. Polymenorrhea (bleeding at short intervals) can be caused by a luteal-phase disorder (not enough progesterone is produced after ovulation to stabilize the endometrium) or a short follicular phase. Oligomenorrhea (infrequent bleeding) is usually caused by a prolonged follicular phase.

Factors affecting drug distribution

Some drugs bind more strongly to plasma proteins than others - these are termed highly protein-bound. The more highly protein-bound a drug is the less free drug is available to distribute into the body tissues. This means that it is often necessary to give high doses of drugs that are highly protein-bound in order for them to have a therapeutic effect. Disease conditions that cause a decrease in blood plasma protein levels, e.g. hypoalbuminaemia due to liver failure, can mean that a higher than normal amount of free drug is available for distribution and this can result in toxicity.

Etiology and Epidemiology

The major underlying causes of dropsy are congestive heart failure, liver failure, kidney failure, and malnutrition. Because they were not clearly differentiated before the nineteenth century, a historical diagnosis of dropsy cannot be taken to indicate any one of these alone in the absence of unequivocal supporting evidence, as from an autopsy. However, heart failure was probably the most frequent of the four. 1. Liver failure capable of producing ascites most often occurs in advanced cirrhosis because the diseased liver cannot manufacture sufficient protein (albumin) to maintain the oncotic pressure of the blood. Right ventricular failure (see below) can also produce hepatic congestion and failure. Heart failure occurs more often in men than women, inasmuch as men are at greater risk for most forms of cardiovascular disease. The risk is greater for older than younger patients Three quarters of heart failure patients are over 50 years of age. Risk factors for hepatic cirrhosis...

Jaundice Clinical Summary

Jaundice presents as light yellowing of the skin, mucous membranes, and sclera it is generally detectable when bilirubin levels are about 3.0 mg dL. Many patients may not be aware of the faint yellowing of their skin and present with seemingly unrelated symptoms. Be aware that up to 50 of patients with jaundice will have pruritus. The most important diagnoses to rule out are hemolytic anemias, viral hepatitis, chronic alcohol abuse, autoimmune hepatitis, medications, primary biliary cirrhosis, primary sclerosing cholangitis, cholelithiasis, surgical strictures, and obstructive malignancies. Acetaminophen, penicillins, and oral contraceptives are some of the more common medications associated with jaundice.

Disorders of Later Infancy with Recurrent Metabolic Crises

Hyperammonemia is encountered in other disorders. Reye's syndrome can be differentiated by the elevated transaminase and high plasma lysine levels. Patients with liver failure usually have elevated plasma methionine and tyrosine levels, which are not observed in UCDs of various types. Patients with valproate toxicity have elevated valproylcarnitine levels and deficiency of free carnitine in studies with tandem mass spectrometry.

Reduced conscious level the Glasgow Coma Scale

A pathological reduced conscious level can be caused by bilateral cerebral hemisphere lesions, brainstem compression or ischaemia, reduced cerebral perfusion, metabolic disturbance or seizure activity. Most intracranial neurosurgical pathologies can give rise to a reduced conscious level by reason of pressure, direct or indirect, on the brainstem, or by causing raised ICP and reduced cerebral perfusion. Many non-CNS systemic pathologies will also produce a reduced conscious level, for example hypoglycaemia, liver failure, hypoxia (cardiac or respiratory abnormalities) and sepsis. Therefore a reduced conscious level in itself is not an indication of primary intracranial pathology.

Arthritis of Systemic Disease

Metabolic disorders can cause degenerative arthritis. Hemochromatosis (caused by iron deposition) typically affects the second and third metacarpophalangeal (MCP) joints, wrists, knees, hips, and shoulders. Wilson's disease (caused by copper deposition) can cause premature OA in wrists and knees. Sickle cell disease can be complicated by knee arthritis arthritis is also often seen in patients with hemophilia and leukemia. Arthritis is associated with inflammatory bowel disease and primary biliary cirrhosis. Reactive carcinoma synovitis can be the presenting symptom of an underlying malignancy, particularly of the breast or the prostate.

Medical Overview and Epidemiology

Hepatitis C is a common blood-borne infection that when left untreated can lead to cirrhosis, hepatic encephalopathy, and death and is a leading cause of chronic liver disease, liver transplantation, and hepatocellular carcinoma (Saunders 2008). The presentation of hepatitis C infection is variable, with most acutely infected people being asymptomatic (70 -80 ), although they may have elevated liver enzymes. The most common symptoms of acute infection include fever, malaise, loss of appetite, jaundice, fatigue, nausea and vomiting, dark urine, and joint pain (Dieperink et al. 2000). With chronic infection, the most common presentations include jaundice, encephalopathy, or ascites. In the

Androgeninduced liver disorders

A consistent adverse feature of pharmacological androgen therapy, regardless of indication, is the risk of androgen-induced liver disorders (Ishak and Zimmerman 1987). These involve biochemical effects on hepatic function, hepatotoxicity (hepatitic or cholestatic) and liver tumor development (benign or malignant) and peliosis hepatis. These risks are a class-specific adverse effect of 17a-alkylated androgens, especially when used orally but no reliable estimates of the incidence or prevalence are available. The East German national sports doping programme involving oral 17a-alkylated androgens resulted in deaths from liver failure and chronic liver disease (Franke and Berendonk 1997). Every marketed 17a-alkylated androgen is associated with hepatotoxicity, whereas other androgens (1-methyl androgens, nandrolone, testosterone, dihydrotestosterone) are not hepatotoxic. Cholestasis and functional impairment of liver function (BSP retention, antipyrine clearance) are consistently impaired...

Principles of Treatment

The first principle is that no single treatment is good for all individuals. What a counselor would do for a college student who gets stoned on marijuana a lot, and whose grades are falling is different from what a doctor would do for a sixty-year-old alcoholic who has imbibed every day for years and years and is on the verge of liver failure. Importantly, if treatment does not seem to be working, consider another type or source of treatment. A life might be at stake

Alcoholism Or Alcohol Abuse And Dependence Definition and Diagnosis

Social problems are problems that result directly from the use of alcohol. Driving or violence while intoxicated, neglect of responsibilities due to alcohol use, or failure to decrease alcohol use even in the face of physical problems caused by the exposure, such as cirrhosis, are all included in this category. This list parallels the list of consequences noted earlier and has been adapted from the studies of drinking problems. Accordingly, the same problems of attribution, labeling, and denial apply. Social consequences can be affected by a number of different drinking-related behaviors. They can result from the acute effects of intoxication, the effects of chronic drinking, or the prioritization of drinking over other roles and responsibilities.

Treatment of onychomycosis

The FDA has released warnings pertaining to itraconazole and terbinafine as there is a small but real risk of developing congestive heart failure with itraconazole therapy due to its negative inotropic effects. Itraconazole should not be administered to patients with ventricular dysfunction such as congestive heart failure. The FDA also released warnings that itraconazole and terbinafine are associated with serious hepatic toxicity, including liver failure and death. Liver failure associated with these medications has occurred in patients with no pre-existing living disease or serious underlying medical conditions. Treatment with itraconazole or terbinafine for prolonged periods requires laboratory monitoring of liver function tests before initiation of therapy and at monthly intervals thereafter.

Laparoscopy and Litigation

Laparoscopic cholecystectomy was widely adopted in 1990. Just four years later, litigation centering around bile duct injury for the laparoscopic technique surpassed similar litigation for open cholecystectomy by more than 20-fold (19). Kern suggests that this was in part due to the great deal of negative press surrounding laparoscopic injuries during cholecystectomy. In 1992, the New York Times reported, Surgeons who rushed to use a new technique to remove gallbladders without adequate training have botched many procedures, New York State health officials and surgical experts say (20). Certainly, the fact that bile duct injury may require reoperation, prolonged hospitaliza-tion, and potential long-term consequences such as biliary cirrhosis and portal hypertension must be considered a factor as well. Claims related to laparosocpic chole-cystectomy remained the most common in a recent report by the Physician Insurers Association of America (21). The Physician Insurers Association of...

Bacterial Endocarditis

A 62-year-old man is brought to the emergency room after being found roaming the hallways of his apartment building. He lives alone and was last seen well by neighbors two days before. He was unable to provide a cogent history but was recognized by staff from prior evaluations. Previous medical history was notable for hypertension, cirrhosis due to chronic alcohol use, alcohol intoxication with withdrawal seizures, tobacco use, and medication noncompliance.

Laparoscopic Radical Simple Nephrectomy Models

Planned adrenalectomy, planned lymph node dissection, gastro-esophageal reflux disease, hypertension, smoking, diabetes mellitus, hyperlipidemia, chronic obstructive pulmonary disease, coronary artery disease, hematuria (micro or gross), kidney stones, obstructive sleep apnea, congestive heart failure, cerebrovascular accident, polycystic kidney disease depression, fibromyalgia, liver cirrhosis, bleeding disorders, planned transperitoneal versus retroperitoneal approach, side of nephrectomy, tumor size, nodal involvement, renal vein involvement, body mass index, American Society of Anesthesiology grade, planned specimen extraction incision and duration of hospital stay (in days).

Laparoscopic Partial Nephrectomy Models

The following patient parameters were recorded during the retrospective chart review (334 patients) age, sex, surgeon, body mass index, American society in anesthasiology grade, hypertension, prior pancreatitis, prior abdominal surgery, prior deep venous thrombus, peripheral vascular disease, smoking, coronary astery disease, gastic erophageal refull disease, anxiety, hyperlipidemia, depression, renal stone disease, constipation, liver cirrhosis, hepatitis C, hematuria (micro or gross), chronic obstructive pulmonary disease, alcohol use, hypothyroidism, diabetes mellitus, chronic renal insufficiency, cerebrovascular accident, gout, congestive heart failure, osteoarthritis, bleeding disorder, Crohn's disease or inflammatory bowel disease, obstructive sleep apnea, polycystic kidney disease, seizures, anemia, von Hippel-Lindau disease, simple or partial nephrectomy, planned retroperitoneal versus transperitoneal approach, tumor size (by computed tomography), solitary kidney, preoperative...

Abdominal and Intestinal Disorders

Udara is the anatomical name used in the texts for the abdomen. The term also signifies generalized abdominal disease manifested by enlargement. Most of the Udara disorders are ascribed to bad eating habits or to eating spoiled or poisonous food. A few conditions, however, can be understood by modern medicine. Among them is enlargement of the left side of the abdomen because of a large spleen. The symptoms associated with this condition suggest splenomegaly resulting from malaria or filariasis. Enlargement of the right side of the abdomen was the result of involvement of the liver and at times must have indicated cirrhosis. A particularly ominous situation resulted when all three dosas were disturbed The patient turned yellow and suffered from pain, ascites, and emaciation. This could have been either advanced hepatic cirrhosis with liver failure or liver or pancreatic cancer.

Pharmacologic Treatment

Most patients with erysipelas or cellulitis are not hospitalized. Hospitalization and treatment with IV antibiotics should be considered if there are systemic signs and symptoms of infection (such as fever, chills, or hypotension), the patient has significant comorbid conditions (such as immunocompromise, diabetes, cirrhosis, cardiac failure, or renal insufficiency), or the cellulitis is spreading rapidly, involves a large area of the body, or is chronic.14

Regulation Of Srebp Isoform Expression

Plasma Fplc

Taken together, the above evidence suggests that SREBP-lc mediates insulin's lipogenic actions in liver. This observation led to the discovery that SREBP-lc contributes to the development of hepatic steatosis or fatty liver associated with diabetes, obesity, and the metabolic syndrome. Hepatic steatosis is the most commonly encountered liver abnormality in the United States, owing to its strong association with obesity and insulin-resistant diabetes mellitus (Mokdad et al. 200l). Conservative estimates indicate that 40-60 of individuals with obesity or diabetes develop fatty livers. A subset of patients with fatty liver will subsequently develop fibrosis, cirrhosis, and liver failure. Data initially obtained in mice indicate that the fatty liver associated with insulin resistance is caused, in part, by increased SREBP-lc expression. The increased SREBP-lc expression occurs in response to the high insulin levels present in insulin-resistant states. Thus, SREBP-lc levels are elevated in...

Stroke manifestations of systemic disease

Non-infective endocarditis is termed nonbacterial thrombotic endocarditis (NBTE). It is characterized by the accumulation of sterile platelet and fibrin aggregates on the heart valves to form small vegetations. About 50 of NBTE cases occur in association with cancer, especially mucin-producing adenocarcinomas (particularly pancreatic carcinoma and non-small-cell lung cancer) and hematological malignancies (lymphoma and leukemia 24 ). Although only less than 2 of patients with cancer have NBTE, up to 50 of these patients with NBTE suffer from stroke 25 . A significant proportion of patients with NBTE have other disorders, including rheumatic heart disease, rheumatological diseases such as lupus (where it is referred to as Lipman-Sacks endocarditis), AIDS, gastrointestinal diseases such as cirrhosis, and severe systemic illness, such as burns or sepsis 26 . Small and large multi-territorial infarction is a radiographic sign in NBTE 27 . Thus, encephalopathy rather than focal deficits...

Ascites In Pathophysiology In Book

Portal Vein Anatomy

Portal Hypertension and Cirrhosis Portal hypertension is a consequence of increased resistance to blood flow through the portal vein. This is usually due to restructuring of intrahepatic tissue (sinusoidal damage) but may also be caused by presinusoidal damage such as portal vein occlusion from trauma, malignancy, or thrombosis. The third (and the least common) cause of portal hypertension is outflow obstruction of the hepatic vein. This latter damage is posthepatic, and normal liver structure is maintained. This chapter will focus on portal hypertension caused by intrahepatic damage from cirrhosis. Sinusoidal damage from cirrhosis is the most common cause of portal hypertension. The sinusoids are porous vessels within the liver that surround radiating rows of hepatocytes, which are the basic functional cells of the liver (Fig. 22-2). Progressive destruction of hepatocytes and an increase in fibroblasts and connective tissue surrounding the hepatocytes culminate in cirrhosis. Fibrosis...

Fluid Management Strategies

In summary, common settings for fluid resuscitation include hypovolemic patients (e.g., sepsis or pneumonia), hypervolemic patients (e.g., congestive heart failure CHF , cirrhosis, or renal failure), euvolemic patients who are unable to take oral fluids in proportion to insensible losses (e.g., the perioperative period), and patients with electrolyte abnormalities (see below).

Pharmacologic Interventions Statins

Knee Plica Exercises

Although there is some concern about the potential toxicity of statins, their benefits significantly outweigh their risks. Liver toxicity can occur and is defined as an alanine transaminase (ALT) elevation of three times or more the upper limit of normal (ULN) on two occasions at least 1 month apart. The average risk of hepatotoxicity from statin therapy is approximately 1 , but risk increases as a function of increasing doses. Mild elevations in serum transaminase levels early during the course of therapy are relatively common and usually resolve spontaneously. If hepatotoxicity develops, statin therapy should be discontinued until transaminase levels normalize and therapy with a different statin can be initiated. There is no documented evidence that the statins increase risk for liver failure. The most important adverse event associated with statin therapy is rhabdomyolysis, myoglobinuria, and renal failure. The risk for rhabdomyolysis is less than 0.1 . Symptoms of rhabdomyolysis...

Prevention And Treatment Of Viral Hepatitis Desired Outcomes

General desired outcomes for treating hepatitis are to (a) prevent the spread of the disease (b) prevent and treat symptoms (c) suppress viral replication (d) normalize hepatic aminotransferases (e) improve histology on liver biopsy and (f) decrease morbidity and mortality by preventing cirrhosis, HCC, and ESLD. resistance. Patients with elevated ALT (more than two times the upper limit of normal) and positive HBV DNA levels require treatment to delay progression to cirrhosis and prevent the development of ESLD. Adverse effects are minimal and include fatigue, diarrhea, nausea, vomiting, and headaches. ALT levels should be monitored carefully, as two- to threefold increases may be observed. ALT should also be monitored closely when lamivudine therapy is being discontinued, as increased levels may indicate a flare in disease activity leading to liver failure. 10 mm less than 50 x 10 L ). However, caution is required in patients with cirrhosis because they may already have low platelet...

Levocarnitinein Libido

In allergic rhinitis, 1049-1050 in cirrhosis, 394 in constipation, 373 in erectile dysfunction, 885 in GERD, 317, 319, 320t in hyperlipidemia, 234, 236t, 240, 958 in hypertension, 58-59, 59t, 957-958 in ischemic heart disease, 117-118 in musculoskeletal disorders, 1027-1028 in osteoarthritis, 1000 in Parkinson's disease, 557 in urinary incontinence, 914 Lifting, in enuresis, 9231 Lifting techniques, 1028 Ligament, 1020, 1020 alcoholic. See Alcoholic liver disease Cirrhosis dosing adjustments for chemotherapy, 1471t drug-related, 1437t end-stage, 413 viral hepatitis and, 413, 418 erectile dysfunction with, 885t in inflammatory bowel disease, 344 obstructive, 2361 oral contraceptives and, 846 with parenteral nutrition, 1696 in sickle cell anemia disease, 1145t Liver failure DIC with, 1131t nausea and vomiting with, 358t protein requirement in, 1689t respiratory alkalosis in, 504t treatment of, enteral nutrition, 1702t, 1710 tuberculosis and, 1261 Liver transplantation. See also...

Toxicities and Management of Preparative Regimens

Must occur in the absence of other causes of post-transplant liver failure, including GVHD, viral hepatitis, fungal abscesses, or drug reactions. Most cases of sinusoidal obstruction syndrome occur within three weeks of HSCT and clinical diagnosis can be confirmed histologically via liver biopsy.

Factors affecting serum testosterone levels in elderly men

Smokers tend to have higher testosterone levels than non-smokers (Barrett-Connor and Khaw 1987 Dai etal. 1988 Deslypere and Vermeulen 1984 Field etal. 1994). This is observed in both young and elderly men, the difference amounting to 5-15 of the levels in non-smokers for both total and free testosterone levels (Vermeulen et al. 1996). Alcohol abuse, also in the absence of liver cirrhosis, may accentuate the age-associated decrease of testosterone levels, estradiol serum levels being increased (Cicero 1982 Ida et al. 1992 Irwin et al. 1988) moderate alcohol consumption has no adverse effect (Longcope etal. 2000 Sparrow etal. 1980). increase of SHBG, androstenedione and estrone levels (Baker et al. 1979 Elewaut et al. 1979). Hypogonadism in hemochromatosis is multifactorially determined with a major contribution of pituitary insufficiency (Duranteau etal. 1993) besides primary testicular defects, cirrhosis of the liver and diabetes mellitus (Kelly et al. 1984).

Acute Bacterial Meningitis

S. pneumoniae is the most common causative organism of community-acquired bacterial meningitis in the adult. Pneumonia and acute and chronic otitis media are important antecedent events. Chronic disease, specifically alcoholism, sickle cell anemia, diabetes, renal failure, cirrhosis, splenectomy, hypogammaglobulinemia, and organ transplantation are predisposing conditions for pneumococcal bacteremia and meningitis. The pneumococci are a common cause of recurrent meningitis in patients with head trauma and cerebrospinal fluid (CSF) rhinorrhea. In the older adult (50 years of age and older), S. pneumoniae is likely to cause meningitis in association with pneumonia or otitis media, and gram-negative bacilli are the likely organisms to cause meningitis in association with chronic lung disease, sinusitis, a neurosurgical procedure, or a

Portalcaval Anastomoses

VWhen hepatocytes are damaged (e.g., due to disease, alcohol, or drugs), the liver cells are replaced by fibrous tissue, which impedes the flow of blood through the liver (cirrhosis). When the hepatic portal system is blocked, the return of blood from the intestines and spleen through the liver is impeded, resulting in portal hypertension. Therefore, veins that usually flow into the liver are blocked. Consequently, blood pressure in the blocked veins increases, causing them to dilate and gradually reopen previously closed connections with the caval system. Veins in the distal portion of the esophagus begin to enlarge (esophageal varices) veins in the rectum begin to enlarge (internal hemorrhoids) and in chronic cases, the veins of the paraumbilical region enlarge (caput medusa).

Contraindications To Laparoscopic Radical Nephrectomy

There are general contraindications for performing surgical intervention, and specific clinical states which would prohibit a transperitoneal laparoscopic radical nephrec-tomy. General contraindications include those patients who cannot tolerate a general anesthetic, those who present with an uncorrectable bleeding diathesis, or patients with underlying severe cardiovascular or pulmonary disease, who are thus not ideal surgical candidates. Relative contraindications to transperitoneal laparoscopic surgery include abdominal wall infection or suspected carcinomatosis and malignant ascites. Other specific and relative contraindications to a transperitoneal laparoscopic nephrectomy include multiple prior intra-abdominal procedures with severe adhesions, a history of severe peritonitis, or a diaphragmatic hernia. Patients with a history of cirrhosis with portal hypertension reflect another relative contraindication to transperitoneal laparoscopic radical nephrectomy. A retroperitoneal...

Differential Diagnosis of Hypoglycemia

Glyucos e-6-phosphatas e Liver phosphorylase Pyruvate carboxylase Phosphoenoipyruvate carboxykinase Fructose 1,6-biphosphate Glycogen synthetase Substrate deficiency Ketotic hypoglycemia of infancy Severe malnutrition, muscie wasting Late pregnancy Acquired liver disease Hepatic congestion Severe hepatitis Cirrhosis Drugs Alcohol Propranolol Salicylates

Table 305 Glycogenoses

Clinical manifestations of the infantile brancher deficiency syndrome are generally seen in the first 6 months of life and are related to failure to thrive, hepatosplenomegaly, and frank liver failure with cirrhosis. Such patients have poor motor and mental development, muscular hypotonia, and weakness. Muscle atrophy appears early and is accompanied by hyporeflexia. More benign forms of this variant present later in life with only mild hepatomegaly and elevated liver enzymes. Differential Diagnosis. Most of the glycogen storage disorders must be differentiated from various myopathies and muscular dystrophies. In the former, abnormalities are seldom limited to the muscle. Liver failure problems and other systemic symptoms are often obvious. Because of the liver problems present in most of these diseases, one must always consider other storage diseases such as the mucopolysaccharidoses, mucolipidoses, sphingomyelinoses, cere- brosidoses, and gangliosidoses in the differential diagnosis.

Congenital Pulmonary Arteriovenous Fistula

Acquired pulmonary arteriovenous fistulae are occasional sequelae of cavopulmonary shunts, especially Glenn shunts.12,92 Acquired pulmonary arteriovenous fistulae occur in children with liver cirrhosis and portal hypertension, especially with biliary atresia and right isomerism10,39,101 (see Chapter 3) and regress after liver transplantation.10 Large hepatic arteriovenous fistulae sometimes occur with Rendu-

Practical Points In Clinical Assessment Of The Arterial Pulse

The pulse amplitude will also be exaggerated in conditions associated with vasodilatation and low peripheral resistance, since in these states (e.g., septic states, drugs causing vasodilatation, arterio-venous communications congenital or iatrogenic or due to pathological processes in systemic organs as in cirrhosis of the liver, chronic renal disease, chronic pulmonary disease, Paget's disease, and beriberi) the diastolic pressure in the vessel is low and therefore the change in tension is better appreciated.

Medical tests

Microscopic studies of individual cells, or of a larger sample of tissue containing a variety of cells, can give a definitive diagnosis for many disorders. Tests on cells are often used to diagnose cancer or screen for genetic disorders. Cells may be obtained from body fluids such as sputum (fluid coughed up from the lungs) or scraped from tissue surfaces such as the cervix (see Cervical smear test, p.264). Cells may also be withdrawn from the body using a needle and syringe. This process, called aspiration, is often used to take cells from the lungs, thyroid gland, or breasts (see Aspiration of a breast lump, p.256). Tissue tests are used to detect areas of abnormal tissue such as cirrhosis of the liver or tumours. Samples are taken by biopsy, in which a small piece of tissue is removed from parts of the body such as the skin (see Skin biopsy, p.183) or the liver (below).

Clinical History

A patient's description of the nature and onset of the chemosensory problem is an essential element of the clinical history, as is an historical assessment of the patient's general health, including endocrinological state, hospital admissions, surgical interventions, radiological treatments, and medications received for other conditions. The use of thyroid agents and drugs that affect cell turnover (e.g., chemotherapeutic drugs) may be of etiological significance. Retarded or delayed puberty in association with anosmia (with or without midline craniofacial abnormalities, deafness, and renal anomalies) suggests the possibility of Kallmann's syndrome. Importantly, associated events such as viral or bacterial respiratory infections, head trauma, exposure to toxic fumes, systemic diseases, and signs of early parkinsonism or central tumors are critical for arriving at an etiological diagnosis, which is possible in the majority of cases. Information related to exposure to environmental...

C4 binding Protein

C4BPA and C4BPB genes, have been identified. The P chain contains three SCRs and contains a binding site for the anticoagulant protein S in the SCR-1 region (56). Enzyme assays have been developed to measure the serum levels of C4BP and protein S-C4BP complex. Levels of both of these proteins have been shown to be increased in patients with membranous nephropathy, decreased in liver cirrhosis patients, and unchanged in patients with IgA nephropathy (57). SLE patients have not yet been studied.

Alkaline Phosphatase

Alkaline phosphatase (ALP) is found in a wide variety of tissues, including the liver, bone, intestine, and placenta. The reference value for ALP depends on age and gender, with higher levels in childhood, adolescence, and pregnancy. A typical reference range in an adult is 25 to 100 U L. In adults, the source of an elevated ALP is the liver, bone, or medication (Table 15-5). Typically, hepatic elevations of ALP are suggestive of cholestatic liver disease or biliary tract dysfunction. Mild ALP elevations (one to two times above reference range) can occur with parenchymal liver disease, such as hepatitis or cirrhosis. Marked ALP elevations occur with infiltrative liver disease or biliary obstruction, intrahepatic or extrahepatic. A persistently elevated ALP level can be an early sign of primary biliary cirrhosis. In cholestatic liver disease, bilirubin and gamma-glutamyltransferase (GGT) levels are increased as well, with less prominent elevations in aminotransferase levels. To confirm...


Nephrotic syndrome Cirrhosis Primary biliary cirrhosis Cirrhosis liver, and medications. Probably the most common cause of persistently elevated unexplained aminotransferases is fatty infiltration of the liver. Less common causes of mildly elevated aminotransferases with ALT > AST include autoimmune hepatitis, hemochromatosis, alpha-1 antitrypsin disease, Wilson's disease, metastatic disease, and cholestatic liver disease. Mild aminotransferase elevations with AST > ALT are more suggestive of alcohol-related liver disease, but can also occur with cirrhosis and fatty liver. With alcoholic hepatitis, AST levels typically are approximately twice ALT levels, but the AST levels rarely are greater than 300 U L. Marked elevations (greater than 15 times upper limit of normal) of AST and ALT suggest significant necrosis, such as seen in acute viral or drug-induced hepatitis, in ischemic hepatitis, or as can occur with acute biliary obstruction (Green and Flamm, 2002). However, the...


Conjugated hyperbilirubinemia generally occurs with defects of hepatic excretion, including extrahepatic obstruction, intrahepatic cholestasis, cirrhosis, hepatitis, and toxins. Bili-rubinuria is a fairly sensitive marker for biliary obstruction and may occasionally be found before jaundice is evident.


Congestive heart failure, nephrotic syndrome, cirrhosis Hypervolemic hyponatremia can occur with advanced congestive heart failure, cirrhosis, nephrotic syndrome, and renal failure in the presence of total-body sodium overload and edema. In these disorders, effective renal blood flow is reduced, thus stimulating the release of antidiuretic hormone

Swelling Edema

Edema can occur in the legs as a result of problems like kidney failure, liver failure, blood clots in the veins in the legs, and local infections in the legs. Sometimes mild swelling in the feet and ankles is related to nothing more than sitting in a chair for a long time, such as in an airline seat during a long flight. It can also be caused by having your legs crossed for extended periods. A severe form of swelling is called anasarca. This swelling extends throughout the body but affects the legs and abdomen more than the chest and the face. It can be caused by severe heart failure. It can also be caused by other problems such as liver failure or kidney failure, and in severe forms of anasarca, one may accumulate extra fluid inside the abdominal cavity, which is called ascites.

Sjogrens Syndrome

Mune diseases in families of patients with primary Sjogren's syndrome (Anaya et al. 2006). The suggestion is that autoimmune diseases in general may aggregate as a trait favoring a common immu-nogenetic origin for diverse autoimmune phe-notypes, such that a risk factor exists for the development of primary Sjogren's syndrome and other autoimmune diseases. Secondary Sjogren's syndrome is defined when the disease is associated with other clinically expressed autoimmune processes, specifically rheumatoid arthritis, systemic lupus erythematosus, myositis, biliary cirrhosis, systemic sclerosis, chronic hepatitis, cryoglobulinemia, thyroiditis, and vasculitis. Following rheumatoid arthritis, Sjogren's syndrome is the second most common autoimmune rheumatic disorder (Moutsopoulos 1993). Eight to 10 years are generally required for the disorder to progress from initial symptoms to the development of the syndrome. Although typically seen in middle-aged women, Sjogren's syndrome can occur in...

Treatment of RSE

Metabolic disorders, liver failure, or fever. In general, patients with RSE are managed in an ICU where hemodynamic and respiratory support are available and frequent monitoring can be performed. Continuous EEG monitoring is desirable to document cessation of seizure activity, but treatment should not be delayed if continuous EEG monitoring is not immediately available or while waiting for results. Any AEDs initiated before treatment for RSE should be continued, and their serum levels optimal


Patients with systemic diseases such as diabetes mellitus, cirrhosis, uremia, and cancer infections of the perioral regions and trimethylaminuria (fish odor syndrome) can suffer from bad breath. These conditions must be considered in the absence of oral and sinonasal disease.

Protein Metabolism

Oxidative deamination is used in the catabolism of amino acids. It is the mechanism by which excess amino acids are removed from the body and involves the removal of the amino group, leaving ammonia and a keto acid. Ammonia, a toxic product, is converted into urea by the liver and the keto acids are used as intermediates of the TCA and glycolytic cycles. Urea is an economical way of excreting ammonia, as it has a high nitrogen content and is water-soluble. It is therefore excreted in the urine, making it an efficient way to excrete excess nitrogen. In liver failure, urea synthesis is impaired and ammonia accumulates. This is thought to be a major chemical responsible for the development of hepatic encephalopathy in these situations.


Spironolactone is the logical choice of diuretic in the management of cirrhosis of the liver, ascites and secondary hyperaldos-teronism. Cardiac failure or hypertension in the presence of high mineralocorticoid levels (Conn's syndrome or prednisone therapy) is another indication. It is often combined with thiazides to maximize the diuretic effect and prevent potassium loss.

Inspect the Skin

Figure 14-13 shows multiple tuberous xanthomata of the hand of another patient. This patient had primary biliary cirrhosis and extremely elevated cholesterol levels. Primary biliary cirrhosis is a rare, progressive, and often fatal liver disease occurring mostly in women. Pruritus is a common symptom. Xanthomata develop in approximately 15 to 20 of affected patients and are typically found on the palms, soles, knees, elbows, and hands. The serum cholesterol, usually low-density lipoprotein, is often as high as 1000 to 1500 mg dL. Antimitochondrial antibody is present in nearly 90 of patients.

Clinical Summary

Digital clubbing is characterized by bulbous fusiform enlargement of the distal portion of a digit with loss of the angle between the proximal nail fold and the nail plate (Lovibond angle). Associated with the increased tissue mass is enhanced blood flow, excessive curvature of the fingernails, and hyperemic and swollen skin folds around the fingernail. Clubbing may also be seen in the toes. The mechanism underlying clubbing is not known, but it is postulated that the end result is dilatation of the distal digital blood vessels with soft tissue hypertrophy. Clubbing may be hereditary, idiopathic, or acquired and is associated with multiple medical conditions including carcinoma, intrathoracic sepsis, bacterial endocarditis, cyanotic congenital heart disease, esophageal disorders, cirrhosis, inflammatory bowel disease, pulmonary disorders, atrial myxoma, repeated pregnancies, and pachydermoperiostosis. The incidence of clubbing with each of these conditions is variable. Digital...


Cirrhosis is classified on the basis of morphology and etiology. The morphological classification recognizes three types based on the size of the nodules 1. Macronodular cirrhosis. The liver is firm, large or small in size, with bulging irregular nodules greater than 3 millimeters in diameter. 2. Micronodular cirrhosis. The liver is usually enlarged, and very firm or hard in consistency. The nodules on cut sections appear small and uniform, less than 3 millimeters wide. 3. Mixed micro macronodular cirrhosis. The liver The terms micronodular and macronodular cirrhosis replace the older terminology, Laennec's and postnecrotic cirrhosis. Table VIII.28.1. Etiology and incidence of cirrhosis Primary biliary cirrhosis Indian childhood cirrhosis Intestinal bypass lar cirrhosis, and other causes in this category include primary biliary cirrhosis, primary hemochromatosis, and chronic right heart failure. The macronodular deformation is seen in the cirrhosis due to viral, drug, and cryptogenic...

CR1 Deficiency

Patients with a wide variety of autoimmune diseases including SLE, rheumatoid arthritis, hydralazine-induced lupus, discoid lupus erythematosus, primary phospholipid syndrome, essential mixed cryoglobulinemia, primary biliary cirrhosis, ulcerative colitis, and on cells in the MRL lpr mouse SLE model. The decrease in receptor numbers has been correlated with disease activity and can be reversed on the red cells by the production of new red cells stimulated by erythropoietin in some patients.

Cystic fibrosis

Some patients with cystic fibrosis suffer from liver cirrhosis, resulting in venous congestion in the esophagus (varicosis) and splenomegaly. Trauma may result in severe hemorrhage which can sometimes be fatal. Therefore, contact sports and bungee jumping should not be recommended to patients with liver cirrhosis 79 .

Choice Of Anesthesia

The combined technique is indicated for patients with aortic aneurysms, splenorenal shunts, portocaval shunts (in patients with splenorenal or portocaval shunts, however, liver failure may be so marked that coagulation abnormalities constitute a relative contraindication to regional anesthesia), vascular tumor of the hepatic artery, or any prolonged abdominal procedure for vascular surgery.

Hepatitis B

Infection with hepatitis B can have a variety of outcomes. It may be inapparent, or it may cause a disease indistinguishable from that caused by hepatitis A. It may also, however, cause chronic active hepatitis with or without cirrhosis. Any of these forms may lead to a chronic carrier state, which may damage the kidneys or lead to cancer. Thus, although uncomplicated hepatitis B is not often fatal in the acute phase, the total mortality it causes can be great.

Cancer Outcomes

Three cases of port site metastasis have been documented after laparoscopic nephrectomy and specimen morcellation for renal carcinoma (Table 3) (33-35). In two cases, tumor (high grade, advanced stage) and patient (cirrhosis and ascites) characteristics likely contributed to the situation. In the other case, no risk factor or explanation is available and the potential etiology may have been unrecognized bag perforation during morcellation. There are no case reports of port site recurrence after laparoscopic radical nephrectomy and intact specimen retrieval, although the omission of a bag has been associated with port site recurrence after laparoscopic surgery for urothelial carcinoma and prostate cancer (36).

Liver Disease

This may be defined as acute renal failure developing in patients with pre-existing chronic liver failure, laundiced patients are at risk of developing postoperative renal failure. This may be precipitated by hypovolaemia. Prevention involves adequate preoperative hydration, with i.v. infusion for at least 12 h before surgery, and close monitoring of urine output, intra- and postoperatively. Intravenous 20 mannitol 100 ml is recommended immediately preoperatively and is indicated postoperatively if the hourly urine output decreases below 50 ml. Close cardiovascular monitoring is essential.

Abdominal Distention

Abdominal distention may be related to increased gas in the gastrointestinal tract or to the presence of ascites. Increased gas can result from malabsorption, irritable colon, or air swallowing (aerophagia). Ascites can have a variety of causes, such as cirrhosis, congestive heart failure, portal hypertension, peritonitis, or neoplasia. To try to identify the cause of abdominal distention, ask these questions Gaseous distention related to eating is intermittent and is relieved by the passage of flatus or belching. A patient with ascites has the insidious development of increased abdominal girth, noted through a progressive increase in belt size. Loss of appetite is often associated with cirrhosis and malignancy, although end-stage congestive heart failure may produce this symptom as well. Shortness of breath and ascites may be symptoms of congestive heart failure, but the shortness of breath may be the result of a decrease in pulmonary capacity owing to ascites from another cause....

Laboratory Studies

A complete cell count (CBC) with differential, urinalysis, and renal and liver function tests should be performed if asymptomatic rheumatic disease is suspected. Importantly, the frequency of abnormal laboratory results increases with increasing age in the normal population, even in the absence of disease, including common tests such as erythrocyte sedimentation rate (ESR), uric acid, antinuclear antibodies (ANAs), and rheumatoid factor (RF). Thus, arthritis panels can confuse the situation and should not be performed routinely. For example, only 80 of patients with RA have a positive RF. RF is a serum autoantibody against immunoglobulin G (IgG). Up to 4 of the healthy population has a positive RF, which is also frequently positive in patients with chronic obstructive pulmonary disease (COPD), viral hepatitis, and sarcoidosis, and can also be positive in malignancy, and primary biliary cirrhosis and other autoimmune diseases. The higher the RF titer, however, the more likely it is...

Oral administration

Et al. 1978 Johnsen et al. 1974 Nieschlag et al. 1975 1977). The testosterone-metabolizing capacity of the liver, however, is age- and sex-dependent. An oral dose of 60 mg unmodified testosterone does not affect peripheral testosterone levels in normal adult men, but produces a significant rise in prepubertal boys and women (Nieschlag etal. 1977). This demonstrates that testosterone induces liver enzymes responsible for its own metabolism (Johnsen etal. 1976). When the liver is severely damaged its metabolizing capacity decreases. Thus, in patients with liver cirrhosis a dose of 60 mg testosterone (ineffective in normal men) produces high serum levels (Nieschlag etal. 1977).

Liver Palpation

The normal liver edge has a firm, regular ridge, with a smooth surface. If the liver edge is not felt, repeat the maneuver after readjusting your right hand closer to the costal margin. Enlargement of the liver results from vascular congestion, hepatitis, neoplasm, or cirrhosis.

Infectious Hepatitis

Even the distinction between infectious and noninfectious hepatitis is a problem. Autoimmune chronic active hepatitis will not be considered here, although there is evidence of viral involvement in triggering the autoimmune reaction. Liver cancer will be included as a late consequence of infection with hepatitis B virus, because that seems to be the main cause. Other clinically similar diseases that are not covered here are cirrhosis due to toxins such

Hepatitis B Etiology

Infection with hepatitis B can have a variety of outcomes. It may be inapparent, or it may cause a disease indistinguishable from that caused by hepatitis A. It may also, however, cause chronic active hepatitis with or without cirrhosis. Any of these forms may lead to a chronic carrier state in which large quantities of surface antigen, and sometimes infectious whole virus, circulate in the blood. This may damage the kidneys or, as described above, lead to cancer. Thus, although uncomplicated hepatitis B is not often fatal in the acute phase, the total mortality that it causes can be great.

Wilsons Disease

Ihe differential diagnosis of WD depends on the phenotypical presentation. In children, evaluation usually centers around hepatic disorders, whereas in adults, diagnostic considerations center around the type of movement disorder seen (tremor, chorea, dystonia, or parkinsonism). Although Kayser-Fleischer rings are extremely helpful in confirming this diagnosis clinically, they are also seen in patients with silver intoxication, primary biliary cirrhosis, Addison's disease, carotinemia, and chalcosis as a result of unilateral trauma to the eye with copper-containing foreign bodies. y

Medical Therapy

That treatment for spinal tuberculosis in developing countries consists of ambulatory pharmacotherapy with 6- or 9-month regimens of isoniazid or rifampin. In Western countries, drug therapy for spinal tuberculosis is 6 months of isoniazid, rifampin, and pyrazinamide. Others advocate a more aggressive approach to spinal tuberculosis with 12 months of treatment, beginning with isoniazid, ethambutol, rifampin, and pyrazinamide for the first 2 months, followed by tailoring of the therapy based on sensitivities. Multimodal therapy is often necessary due to potential drug resistance, as well as the decreased accessibility of certain agents to different involved organ systems. Unfortunately, many of these agents have potential side effects, with the risk of liver failure among the more clinically significant.


Dilutional hyponatraemic states may be associated with hyper-volaemia and oedema or with normovolaemia. Again, assessment of volaemic status is important. If oedema is present, there is an excess of total body sodium with a proportionately greater excess of TBW. This is seen in congestive heart failure, cirrhosis and the nephrotic syndrome and is caused by secondary hyperaldosteron-ism. Treatment comprises salt and water restriction and spironolactone.

Hepatic Failure

A variety of substances have been implicated in the pathogenesis of HE, including ammonia, endogenous benzodiazepines, Na K ATPase inhibitors (e.g., glutamine, short-chain fatty acids, aromatic amino acids, and mercaptans), false neurotransmitters (e.g., octopamine), and gamma-aminobutyric acid. i36 The leading hypothesis relates to the effects of ammonia and states that HE results from its systemic accumulation. Findings supporting this hypothesis include (1) patients with He usually have elevated arterial ammonia levels, (2) the degree of hyperammonemia correlates with the depth of coma, (3) ammonia metabolites (alpha-ketoglutarate and glutamine) are elevated in the brains and CSF of patients with HE, (4) the BBB permeability increases for ammonia, (5) the cerebral metabolic rate increases for ammonia, (6) experimental administration of ammonium salts results in reversible HE, (7) ammonia-forming compounds in the GI tract (e.g., protein meals, blood) reproducibly precipitate coma,...

Subjective Objective

Anorexia, Jaundice, scleral icterus, Kayser-Fleischer rings (Wilson's disease, primary biliary cirrhosis'p, fetor hepaticus (musty, sweet breath odor), spider nevi, fatigue gynecomastla. caput medusa (dilation of the umbilical vessels), splenomegaly, aseites, xanthomas, palmar crythema, Dupuytren s contractures of the Differential Diagnosis and Evaluation. Any disorder resulting in liver failure may cause HE. Viral hepatitis is the most common cause of FHF in the United States, followed by drug-induced liver dysfunction (e.g., acetaminophen, isoniazid, rifampin, methyldopa Aldomet , halothane), fatty infiltration, Reye's syndrome, infiltrative diseases, and less common causes.W , 138 Management. Prevention is an important aspect of treatment among patients with chronic liver disease. Known precipitants of HE should be avoided and, if they are identified, reversed. Because the onset of PSE is slow, insidious, and often subclinical, patients with chronic liver disease should undergo...

Muscle Cramps

Muscle cramping may be totally unrelated to cancer, or it can be a symptom of a systemwide problem such as uremia (a buildup of toxic substances in the blood due to poor kidney function), cirrhosis, or other metabolic condition. In cancer patients, muscle cramps may also be caused by the tumor exerting pressure on certain nerves or by dehydration (from sweating or diarrhea), or it may be a side effect of medication (such as diuretics), radiation, chemotherapy (when vinca alkaloids or cisplatin are used), hormone therapy (such as those used for breast cancer), or surgery, which may cause nerve damage.

Fatty Liver Disease

Fatty liver disease is the most common reason for elevated serum liver enzymes and affects an estimated 20 of the U.S. population (Angelico et al., 2005). First described in obese diabetic females, fatty liver disease is widely recognized as a complication of obesity and is associated with the features of the metabolic syndrome. The spectrum of fatty liver disease ranges from nonalcoholic fatty liver disease (NAFLD) to nonalcoholic steatohepatitis (NASH). Fibrosis and cirrhosis can develop in NASH, which has been linked to insulin resistance, as with metabolic syndrome (Choudhury and Sanyal, 2004). The increased insulin level likely causes fatty acid flux from adipose tissue to be deposited in the liver. Inflammatory cytokine release triggered by hyperinsulinemia contributes to the steatohepatitis and fibrosis.


In 1941 Charles Huggins demonstrated that blocking the production of testosterone slows the growth of prostate cancer (as discussed in Chapter 5). Sixty-five years after Huggins' findings, we are not much further ahead we are still blocking testosterone to slow the growth of prostate cancer, especially in cases when the cancer has spread. Additional evidence that testosterone is involved in causing prostate cancer comes from a variety of sources. Rats given high doses of testosterone develop prostate cancer. Eunuchs and other males who are castrated prior to puberty do not produce testosterone and do not develop prostate cancer. Men with cirrhosis of the liver, a condition that increases their female sex hormone, which suppresses testosterone, have a lower incidence of prostate cancer. The cumulative evidence strongly suggests a role for testosterone.


(HBsAg), in addition to the vaccine, hepatitis B hyperimmune globulin should be administered during the first 12 hours of life. Patients with chronic infection can develop cirrhosis and end-stage liver disease. Antiviral treatments for hepatitis B are indicated for patients with moderate to severe disease activity diagnosed on liver biopsy. Current Hepatitis C affects more than 300 million people worldwide and 4 million people in the United States. At least six genotypes and 100 subtypes have been identified (Bukh, 2000). The diagnosis is established with serum testing for HCV RNA antibodies although an antibody is induced, it is not protective against disease contraction and progression. Transmission occurs via blood or body fluid contamination through IV and intranasal drug use, blood transfusions, and in health care workers (e.g., needle stick or skin disruption with contaminated instrument). Data on sexual transmission and though tattooing have been inconsistent. Co-infection with...

Hepatitis C

Blood transfusion following postpartum hemorrhage may cause other blood-borne infections, such as hepatitis C. In 1988, Anita Endean delivered vaginally in British Columbia. She had a postpartum hemorrhage, and she was given a transfusion of packed red cells supplied by the Canadian Red Cross (CRC). After she went home, she had a debilitating flu-like illness. Six years later in 1994, she offered to donate blood, but she now tested positive for hepatitis C. Although its short-term effects are transient, hepatitis C carries a long-term risk of cirrhosis (10 per annum) and in those patients a further risk of hepatocellular carcinoma (5 per annum). The CRC carried out a 'traceback' procedure, and found that one of her 1988 blood donors now tested positive for hepatitis C. (Hepatitis C virus (HCV) was first identified in 1988. An antibody test for HCV was soon developed, but British Columbia did not introduce widespread testing until 1990. Nevertheless, surrogate testing for non-A non-B...

Other Possibilities

The conclusion of one review was that ''moderate alcohol consumption up to about three drinks per day does not appear to influence prostate cancer risk.''34 Equivocal support was found for the possibility that heavy alcohol use (eight or more drinks a day) may increase the risk. On the other hand, two studies of autopsy tissue taken from men who died from cirrhosis of the liver reported fewer instances of prostate cancer than expected. Cirrhosis increases the production of estrogens, which block testosterone, and thus slows the growth of prostate cancer. Severe alcoholism may therefore decrease the chances of developing prostate cancer.

Population Estimates

The Alcohol Epidemiologic Data System monitors data from the National Hospital Discharge Survey for discharges due to alcohol diagnoses (using the ICD-9-CM diagnostic criteria), including alcoholic psychoses, alcohol dependence syndrome, nondependent alcohol abuse, and alcoholic liver cirrhosis (Owings and Lawrence, 1997). These discharge data are a random sample drawn from nonfederal, short-stay hospitals. In 1997, there were 30,914,000 discharges, 1.8 had an alcohol dependence syndrome'' diagnosis listed as the primary diagnosis, an additional 0.5 had an alcohol abuse diagnosis listed as a primary diagnosis. Rates of alcohol diagnoses were higher for men than for women, and were highest within the age group 15-44. Another means of assessing the prevalence of alcoholism uses the distribution of deaths from liver cirrhosis as a marker. Jellinek (WHO, 1951) developed a formula for estimating the rate of alcoholism based on the rate of liver cirrhosis, and the proportion of deaths from...


Multiple interacting factors account for indices of malnutrition in about 60 of patients with TBI who are transferred to a rehabilitation unit.46 Acute trauma increases energy expenditure by an average of 40 . The highest metabolic energy expenditures and urinary nitrogen excretions affect patients with the lowest GCS, especially in the first several weeks after TBI.47 Decerebration, spasms, seizures, agitation, and fever add to the hypermetabolic state. Mechanisms of hypercatabolism include acute-phase responses that also release cytokines, as well as autonomic hyperactivity and increases in blood catecholamines, glucagon, and cortisol. Renal and liver failure exacerbate protein loss. The likelihood of malnutrition increases when feedings are limited by gastric hypomotility, ileus, diarrhea, emesis, aspiration pneumonia, and a tracheal fistula. Swallowing disorders occur in the majority of patients who have a low GCS or tracheostomy.48 Aphagia accompanies coma and poor attention, jaw...


Albumin binding is decreased in many physical illnesses including cirrhosis, pneumonia, malnutrition, acute pancreatitis, renal failure, and nephrotic syndrome. In these conditions, albumin-bound drugs with a low therapeutic index may increase in concentration, causing toxicity. In contrast, in hypo-thyroidism albumin binding may be increased. a1 Glycoprotein plasma concentrations may increase in patients with Crohn's disease, renal failure, rheumatoid arthritis, surgery, burns, and trauma. If protein binding is affected by disease, it may be necessary to make adjustments to medication dosages.


Hepatic metabolism may be limited by the blood flow that delivers the drug to the hepatic metabolizing enzymes as well as the intrinsic capacity of the enzymes involved in metabolism. Hepatic blood flow may be altered in liver disease due to portosystemic shunting and may be increased in chronic respiratory illness, acute viral hepatitis, and diarrhea and in conjunction with certain medications (e.g., clonidine). In practice, however, only severe cirrhosis has clinically significant effects on hepatic blood flow. Hepatic metabolism is also affected by enzyme inhibition or induction caused by specific medications. Although hepatic diseases, such as acute viral hepatitis, may limit phase I metabolism, liver disease generally does not have clinically significant effects on glucuronide conjugation reactions due to its large reserve of enzymes.

Hepatic Disease

Binding, and changes in volume of distribution due to peritoneal ascites (Beliles 2000b). The effects are reduced medication availability for metabolism and a resultant increase in serum drug levels. In acute hepatitis, there is generally no need to modify dosing because metabolism is only minimally altered and the change is transient. In chronic hepatitis and cirrhosis, however, there is destruction of hepatocytes and the likely need to modify medication dosages. Cirrhosis may distort liver architecture and alter hepatic blood flow. In severe disease, portosystemic shunting may affect 60 or more of portal vein flow that diverts circulating drugs away from the liver, resulting in decreased drug extraction and first-pass metabolism (Bosch 2007). In contrast, hepatic blood flow may be increased in viral hepatitis and in chronic respiratory problems. Medications with high baseline rates of liver clearance (e.g., haloperi-dol, paroxetine, sertraline, nefazodone, venlafaxine, TCAs, and...

A71 Jaundice

The failure to excrete bilirubin gives rise to yellowish discolouration of the whites of the eyes, the skin and nails, and mucosal membranes, which is called jaundice. Jaundice is essentially a sign of liver failure. Several toxic compounds, such as some pesticides, solvents such as carbon tetrachloride, and dry-cleaning fluids, damage the liver cells and prevent them from functioning normally to bind the bilirubin to the glucuronide. There are many drugs used in the treatment of disease which also damage the liver cells and are termed hepatotoxic. For example, high levels of the common drug paracetamol can cause liver damage, liver failure, and jaundice. Another common and important cause of damage to liver cells which often results in liver failure is excessive alcohol (ethanol) consumption. In liver failure, jaundice occurs, the blood urea falls (as urea is no longer formed from ammonia), there is insufficient production of proteins, of which albumin is the most important, which...

Detailed Assessment

Once it has been established that the patient has problems with alcohol, more detailed assessment is in order. The history should then be focused on the known harmful consequences of alcohol abuse and dependency as related to the patient's history. (For a list of complications, see Woodard, 2009). Major disorders include Wernicke's encephalopathy, withdrawal seizures, cerebellar disease, peripheral neuropathy, cardiomyopathy, cirrhosis, pancreatitis, gastritis, bone marrow suppression, and aseptic necrosis of the hip. A careful history should include an assessment of tolerance and withdrawal symptoms, including shakes, hallucinosis, seizures, and delirium tremens (DTs). The time of the last drink and quantification of daily drinking are prerequisites. A history of stage 2 to 4 withdrawal with or without a history of serious medical complications is in itself justification for acute care hospitalization. Alcohol withdrawal often includes anxiety, nausea, vomiting, diarrhea, tremors,...


A GABA-B receptor agonist, baclofen has long been used as an antispasmodic. Only more recently has baclofen been investigated as a treatment for alcohol dependency. In a modest controlled trial of 1 month, baclofen was efficacious in achievement of total abstinent days compared with placebo (Addolorato et al., 2002). A follow-up study demonstrated efficacy in 84 patients with cirrhosis of the liver in maintaining abstinence (71 baclofen vs. 29 placebo) (Addolorato et al., 2007). There is potential for abuse of baclofen and withdrawal reactions, including delirium, which underscores the need for further research (Kanzler et al., 2009).