How to recognize cirrhosis of the liver: stages and diagnostic methods. Diagnosis of liver cirrhosis: laboratory and instrumental methods Examination of patients with liver cirrhosis

The early stages of cirrhosis are reversible if the underlying cause of the disease is eliminated, while the later stages of cirrhosis are usually irreversible and the only treatment is liver transplantation. Left untreated, cirrhosis will lead to liver failure and/or cancer. Knowing the symptoms of liver cirrhosis, you can recognize the disease at its early, reversible stage.

Steps

Part 1

Risk factors

Think about how much alcohol you drink. Alcohol causes liver damage by blocking the metabolism of carbohydrates, fats and proteins. When these substances accumulate in damaged areas of the liver, the body can respond to such damage with inflammation, leading to hepatitis, fibrosis, and cirrhosis of the liver. However, excessive alcohol consumption is not enough to develop alcoholic liver disease. Only one in five alcoholics develops alcoholic hepatitis, and one in four develops cirrhosis of the liver.

Get tested for hepatitis B and C. Chronic inflammation and viral damage to the liver can lead to cirrhosis of the liver after several decades.

Risk factors include unprotected sex, blood transfusion, and injecting drug use with contaminated needles. In developing countries, hepatitis B is less common due to vaccination.
Major risk factors for hepatitis C include injecting drug use, blood transfusions, piercings, and tattoos.
Cirrhosis due to hepatitis C is the most common cause liver transplants.

Be aware of the relationship between cirrhosis and diabetes . In 15-30% of people with cirrhosis, diabetes is a risk factor for developing non-alcoholic steatohepatitis (NASH). Diabetes is often present in chronic infection hepatitis C, which is a common cause of cirrhosis. This is probably due to insufficient secretion of the pancreas.
- Another cause of cirrhosis often associated with diabetes is hemochromatosis.
- This disease is characterized by the accumulation of iron in the skin, heart, joints and pancreas. The accumulation of iron in the pancreas leads to diabetes.
Consider your current weight. Obesity leads to a range of health problems, from type 2 diabetes and heart disease to arthritis and stroke. But excessive accumulation of fat in the liver causes it to become inflamed and damaged, leading to the development of non-alcoholic steatohepatitis.

Know the risks associated with autoimmune and cardiovascular disease. Be careful with autoimmune diseases such as inflammatory disease intestines, rheumatoid arthritis and. Although they do not directly cause cirrhosis, they increase the risk of complications in other disorders leading to cirrhosis. Heart disease is a risk factor for the development of non-alcoholic steatohepatitis leading to cirrhosis. In addition, heart disease associated with right ventricular heart failure can lead to liver congestion ("nutmeg liver") and cardiac cirrhosis.

Family history. Some types of liver disease that lead to cirrhosis are hereditary. Browse medical history(history) of his family for the presence of diseases that increase the risk of cirrhosis:

Part 2
Recognizing symptoms and signs
1. Know the symptoms of cirrhosis of the liver. If you have these symptoms, you should seek medical attention as soon as possible. He or she will be able to provide you with a professional diagnosis and prompt treatment. If you want to know if someone other than you has cirrhosis, be sure to include that person in your assessment, as there are symptoms that don't show up outwardly. Symptoms of cirrhosis of the liver include:
  - Fatigue or feeling tired
  - Easy bruising and bruising
  - Edema lower extremities
  - Yellowness of the skin and eyes (jaundice)
  - Fever
  - Loss of appetite or weight
  - Nausea
  - Diarrhea
  - severe itching
  - Abdominal enlargement
  - Confusion
  - Sleep disturbance
2. Watch for the appearance of cobwebs from the veins. A more accurate term for this condition is "angioma", spider web or spider veins. A cobweb of vessels is an abnormal accumulation of veins, consisting of a central arteriole with a lesion. Usually angiomas occur on the trunk, face and upper limbs.
  
  Examine your palm for redness. Erythema of the palm is similar to red spotting on the surface of the palm, and it is caused by a change in the metabolism of sex hormones. Palmar erythema predominantly affects outside palms along thumb and little finger, without affecting the central part of the palm.
  
  Pay attention to the change in nails. Liver disease in general often affects the skin, but nails can also provide useful information. Muerke's nails are pale horizontal lines or streaks that extend along the nail bed. This is due to insufficient production of albumin (hypoalbuminemia), which is produced exclusively in the liver. If you press on your nails, the lines will fade and disappear, after which they will reappear.
  - With Terry's nails, two-thirds of the nail plate at the base of the nail has White color. The rest, which is closer to the tip of the nail, will have a reddish color. It is also associated with hypoalbuminemia.
  - In clubbing, the nail bed and fingertip become rounded and/or enlarged. In a severe form of this pathology, the nails become similar to drumsticks, hence the name. This symptom is more often observed in biliary cirrhosis.
3. Examine the joints long bones for edema. If you notice the presence of recurring swelling of the knee or ankles, this may be a sign of hypertrophic osteoarthropathy. Arthritis is also possible in the joints of the fingers and shoulders. This is the result chronic inflammation in the connective tissues that surround the bone, and it is very painful.
  - Note that the most common cause of hypertrophic osteoarthropathy is lung cancer, which should be ruled out if cirrhosis is detected.
4. Twisted fingers. With "Dupuytren's contracture" there is a thickening and shortening of the palmar fascia - the tissue that connects the various parts of the palm. This leads to a restriction in the mobility of the fingers, due to which they twist. This condition mainly occurs in the ring finger and little finger and is often accompanied by pain and itching. With this disease, it will be difficult for a person to hold any object, as it affects the grip strength.
  
  Examine the man's chest for a hard mass. Gynecomastia is an overgrowth of glandular tissue mammary glands in men, coming from the nipples. This is due to an increase in estradiol levels and is present in 60% of cases. Gynecomastia can be similar to pseudogynecomastia, in which breast enlargement is due to fatty deposits rather than glandular proliferation.
  
  Watch for symptoms of hyponogadism in men. In men with chronic diseases liver, for example, with cirrhosis, there is a decrease in testosterone production. Symptoms of hyponogadism include impotence, infertility, loss of sexual desire, and testicular atrophy. This may be caused by damage to the testicles or suppression of the function of the hypothalamus or pituitary gland.
  
  Pay attention to abdominal pain and bloating. These may be signs of ascites, accumulation of fluid in the peritoneal (abdominal) cavity. With a significant accumulation of fluid, you may also experience shortness of breath.
  
  Examine the abdomen for prominent veins. Medusa head is a condition in which the umbilical veins dilate, allowing blood to flow back into the venous system. This blood is then shunted into the umbilical veins and then into the superficial veins of the abdominal cavity. Because of this, the veins are clearly visible on the surface of the abdomen. These bulges are called the head of the Medusa because they resemble the head of the Gorgon Medusa from Greek mythology.
  
  Check your breath for musty smells. This points to "fetor hepaticus" (hepatic respiration), which is caused by the same severe case of hypertension that causes the jellyfish head and murmurs of Cruveilhe-Baumgarten syndrome. The smell comes from an increase in the amount of dimethyl sulfide in severe portal hypertension.
  - The noise will become quieter if the doctor realigns the blood vessels by applying pressure to the area of skin above the navel.
5. pay attention to yellow eyes and skin. Jaundice is a condition that results in an icteric discoloration due to advanced level bilirubin when the liver is unable to process it efficiently. The mucous membranes may also turn yellow and the urine darken.
  - Be aware that yellow skin can also be the result of excessive consumption of carotene (carrots). However, from eating carrots, the sclera of the eyes will not turn yellow, as with jaundice.
6. Examine your hands for asterixis. Ask the person with suspected cirrhosis to fully extend their arms in front of them, palms down. The patient's hands at the wrists will begin to move and flap like the wings of birds.
  - Asterixis is also seen in uremia and severe heart failure.
Part 3
Professional medical checkup
1. Ask your doctor to check for changes in the size of your liver and spleen. On palpation, the liver with cirrhosis will be bumpy and compacted. Splenomegaly (enlargement of the spleen) is caused by portal hypertension, which leads to the accumulation of blood in the spleen. Both of these conditions are signs of cirrhosis of the liver.
  
  Have your doctor check you for blood flow noise. Most therapists do not perform this test. This is a murmur in the veins that can be heard through a stethoscope in the epigastric (upper central) region of the abdomen. Like the "head of a jellyfish", it is the result of a problem in connecting different venous networks to each other in portal hypertension.
  - The doctor will perform a Valsalva maneuver - a test in which intra-abdominal pressure increases. This will allow him or her to hear the noise more clearly, if any.
2. Let the doctor take a blood test. Your doctor will take your blood and do lab tests to check for cirrhosis. Such tests may include:
  
  Have the doctor perform imaging studies. Imaging tests will help recognize cirrhosis, but they are more useful for detecting complications of cirrhosis, such as ascites.
  
  Do a liver biopsy for a definitive diagnosis. Checking for symptoms and blood tests are good methods confirmation of cirrhosis. However, to know for sure, it is necessary to allow the doctor to perform a liver biopsy. After examining a sample of the liver under a microscope, the doctor will be able to tell for sure if the patient has cirrhosis of the liver.
Part 4
Treatment of cirrhosis of the liver
- Do not take any medications unless your doctor tells you to. Support your immunity by taking vitamins, juices and fruits.
- Early stages of liver cirrhosis can potentially be reversible by treating the underlying cause of the disease, such as controlling diabetes, abstinence from alcohol, treating hepatitis, and weight loss.
Warnings
- Late stages of cirrhosis are usually irreversible, and the disease and subsequent complications are ultimately fatal. A liver transplant is the only option to stay alive and save your life.
Sources
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3. http://www.liverfoundation.org/education/info/alcohol/
4. Grant BF, Dufour MC, Harford TC: Epidemiology of alcoholic liver disease. Semin Liver Dis 1988;8(1):12-25.
5. http://www.cdc.gov/alcohol/faqs.htm#excessivealcohol
6. http://www.hopkinsmedicine.org/gastroenterology_hepatology/_pdfs/liver/alcoholic_liver_disease.pdf
7. Petrides AS, Vogt C, Schulze-Berge D, et al. Prognostic significance of diabetes in patients with cirrhosis. Hepatology 1994; 20:119.
8. http://www.webmd.com/diet/obesity/obesity-overview
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Cirrhosis of the liver is a disease that provokes diffuse damage to the liver cells, which as a result are replaced by connective or adipose tissue. It happens under the influence of alcohol, medicines, hepatotoxic substances, viral agents. The disease is manifested by icteric syndrome, petechial formations on the skin, erythema on the tenor and hypotenor (hills) of the palms, heaviness in the right hypochondrium, changes in laboratory blood counts.

Cirrhosis is often complicated by hepatic encephalopathy, ascites, bleeding from the veins of the esophagus and stomach, hepatorenal syndrome, low level blood sodium. The largest percentage of patients with cirrhosis of the liver is in patients with viral hepatitis C (HCV) (26%). A slightly smaller number of all cases of cirrhosis is occupied by the alcoholic etiology of the disease (20%). Combinations of alcoholic and viral (HCV) nature of the disease are also detected (15%). Fatty degeneration of the liver is 18%, hepatitis B, D - 15%, other causes - 5%.

Liver cirrhosis is ubiquitous, there are no clear global statistics, since some patients are not examined at all. Diagnosis of pathology requires an integrated approach. Let's consider what methods are used in this case, how they are carried out and how to decipher the results of the research.

Cirrhosis is not always detected on time. Often the disease does not give symptoms for a long time. Pain patients are not particularly worried, so patients do not seek help. Patients come to the doctor either with discomfort in the right hypochondrium, changes in blood tests, or when complications of the disease occur. Therefore, it is quite difficult to diagnose the disease in time.

Methods

To make a diagnosis of cirrhosis, the doctor needs the patient's history, physical examination, laboratory tests, additional methods research. Based on the results of all these data, a diagnosis of cirrhosis of the liver is made.

If a clinic of cirrhosis is detected, the patient must urgently contact a doctor who will carry out the following actions:

The first stage of the examination is the collection of anamnestic data of the patient. The doctor asks the patient about the presence of blood transfusions, place of work, past infections, the presence of viral hepatitis, chronic autoimmune diseases requiring the use of hepatotoxic drugs. The physician must verify that the patient has bad habits: alcohol, drugs, smoking (long experience).
In addition to the history, the doctor needs to conduct a physical examination. It includes examination of the skin (yellow color in cirrhosis, yellowness of the sclera), palpation and percussion to assess the size and density of the liver.

Palpation and percussion

During physical examination, palpation (palpation) of the lower edge of the liver is actively used. Normally, the edge of the organ is dense, smooth. This method allows you to assess how badly the liver is damaged. In severe lesions of the liver tissue, the organ is very large. The upper edge sometimes rises above the norm, squeezing the lung.

The liver normally should not protrude from under the costal margin. In children under 5 years of age, a decrease in the lower border of the organ by 1 cm is permissible. In newborns, this indicator is also the norm.

On palpation, smoothness, consistency, and the presence of tuberosity of the lower edge of the liver are assessed. If irregularities are detected, the doctor suspects liver cancer, cirrhosis.

Percussion must be carried out before palpation, since simply palpation does not give a reliable assessment of the size of the organ. When percussion, three sizes are evaluated:

on midline(height);
to the costal arch (right lobe);
oblique size of the left lobe.

Normal sizes are:

height (11 cm);
oblique size (right lobe) (9 cm);
oblique size (left lobe) (7 cm).

visual inspection

Percussion and palpation are objective methods of examination. Even on the basis of these data, cirrhosis can be suspected. However, first of all, the doctor still evaluates the visual signs of the disease.

During the examination, the doctor registers dry skin, petechial (pinpoint) hemorrhages, erythematous rashes on the palms. The doctor must evaluate the color of the skin. Jaundice can be detected in patients with cirrhosis. Skin and sclera in patients yellow color. By the intensity of staining of the skin, you can determine the approximate severity of the disease.

Be sure to look at the color of the sclera in order to exclude false (carotene) jaundice, which occurs in patients with an overdose of drugs containing beta-carotene, as well as when eating a large amount of carrots, tomatoes, orange fruits (oranges, tangerines, persimmons). False jaundice often occurs in children, since their vascular permeability for beta-carotene is higher. With carotene jaundice, the sclera will be pink, the skin yellow.

In severe cases of the disease, patients develop a clinic of encephalopathy, hepatic coma, accumulation of fluid in the abdominal cavity, bleeding from the gastrointestinal tract (stomach, esophagus). In this case, the patient needs urgent help, hospitalization.

Instrumental Methods

Additional methods for examining the liver include ultrasound examination of the liver tissue, scintigraphy, computed tomography and magnetic resonance imaging. The most popular method is an ultrasound of the liver.

Ultrasound

Ultrasound is non-invasive, safe method, does not give complications. This examination requires preparation. Diagnosis may be hindered by increased gas formation in the intestinal loops, therefore, 3 days before the procedure, all products that increase the amount of gas in the intestinal cavity should be excluded. Meals should be frequent, in small portions. Prohibited products include:

If the patient has a tendency to constipation, laxatives are prescribed (Guttalax, Lactulose). Often, against the background of taking laxatives, gas formation increases. In this case, the patient is shown to drink Simethicone (Espumizan) preparations.

3 hours before the ultrasound procedure, the patient should not eat, water should be drunk in small portions, no more than 1.5 liters per day. The examination is carried out on an empty stomach in the morning, and also 8-12 hours after the last meal.

During ultrasound diagnostics, the contours of the organ are evaluated, anatomical structure vessels, the liver itself, look at the echogenicity of the liver tissue (the ability to absorb ultrasonic waves), the size of the liver. At healthy patient the structure of the organ is homogeneous, the edges are even, the right lobe is 12 cm, the left lobe is 7 cm, the diameter of the portal vein is 1.2 cm, gallbladder in diameter - 0.7 cm.

With cirrhosis, the following picture is observed on ultrasound:

an increase in the size of the organ due to the predominance of connective tissue;
uneven contours of the edges of the liver (tuberosity of the surface);
heterogeneity of the parenchyma of the organ, there are both hypoechoic and hyperechoic foci distributed throughout the organ;
poor visualization of the portal vein, the vascular pattern is changed;
with portal hypertension syndrome, expansion of the portal and splenic veins is observed;
possible enlargement of the spleen.

Scintigraphy

This technique is based on the introduction of a labeled radioisotope into the patient's body intravenously. The study is carried out using a gamma camera, which directs beams at radioisotopes. During the study, the isotopes are highlighted, showing an image of the organ. Scintigraphy is used to detect cirrhosis, tumor neoplasms.

In healthy people, the liver has a normal size, the accumulation of the substance is distributed evenly, the contours of the organ are even. The liver has a triangular shape. The right lobe normally accumulates more isotopes, since its function is higher than the left one. In patients with cirrhosis of the liver, the contours are not even, the accumulation of isotopes is strongly expressed in the right lobe, the liver is enlarged. In the presence of portal hypertension syndrome, the accumulation of a radioisotope substance is observed in the bone marrow.

Computed (CT) and magnetic resonance imaging (MRI)

CT scan of the liver is an examination method that uses X-ray irradiation of the tissue of the organ. The image is displayed on the screen or electronic media. Pictures are taken in layers. This technique allows you to identify the structure of the liver, size, condition of the vessels. The procedure helps to see liver tumors. To conduct a CT scan, a special device is used - a tomograph.

Magnetic resonance imaging has a different mechanism of work. Here, not X-rays are used, but magnetic waves. A special magnetic tomograph generates a powerful flux of magnetic radiation, which causes the molecules of hydrogen (water) to move in the organs. Depending on the saturation of the tissue with water (hydrogen ions), the organs have different staining.

The liver on MRI images also looks like layered cuts, which allows you to clearly determine the localization of damage, assess the structure and size of the organ, blood vessels, and find a neoplasm. MRI and CT, according to indications, are performed with and without contrast. Contrast can improve the diagnosis of diseases.

Invasive techniques

Invasive diagnostic methods include laparoscopic surgery, as well as biopsy. The second technique is a procedure for taking a piece of liver tissue for histological examination.

The histological material of the liver is cut into thin pieces, placed on a glass slide. In patients with cirrhosis, a lymphocytic infiltration (accumulation of lymphocytes) is visible under the microscope, as well as a large number of connective tissue cells. A biopsy is necessary to substantiate the diagnosis or if a cancerous degeneration of the liver is suspected.

If non-invasive examination methods are ineffective, the patient needs a diagnostic operation (laparoscopy). The intervention is carried out general anesthesia. Carbon dioxide is injected into the abdominal cavity for better visualization of the organs. With the help of a laparoscope, the liver, vessels, adjacent organs, and the presence of a tumor are examined. During the operation, you can take a biopsy of liver tissue.

Differential Diagnosis Biopsy can help distinguish cirrhosis from:

fatty hepatosis;
liver tumors;
metastases in the liver;
mechanical jaundice;
cystic formations of the organ.

Laparoscopy is necessary for increased intestinal gas formation, which is not stopped by diet and Espumizan, as well as in the presence of contraindications to CT, MRI, including when the methods are not informative.

Laboratory diagnostics of pathology

Laboratory methods for diagnosing the liver include:

general analysis blood;
biochemical research.

Complete blood count (CBC) is carried out in the morning. Blood is taken from the ring finger, making a small puncture. No special training is required for the analysis. The patient can have breakfast.

KLA is a non-specific diagnostic method. To obtain the results, a microscopic examination of blood cells is carried out or using a special apparatus that automatically counts the cells, as well as the level of hemoglobin. The doctor assesses the degree of deviation of the indicators of the norms presented in the table (Table 1).

Table 1 - Normal values UAC

With cirrhosis in the KLA, you can see a decrease in hemoglobin, red blood cells. With bleeding from the esophagus and stomach, severe anemia is possible. Leukocytes in the analysis increase in response to the inflammatory response of the liver tissue. An increase in the erythrocyte sedimentation rate is also an indicator of inflammation. If young forms are found in leukocyte formula, then cancerous degeneration of cirrhosis of the liver can be suspected.

A biochemical blood test is more indicative, reflecting the functional activity of the liver. Before taking the test, you need to exclude tea, coffee, sweet, fatty, fried foods, if possible, stop taking medicines. A biochemical blood test must be carried out in the morning on an empty stomach.

Blood is taken from a vein in the treatment room. Diagnostic indicators of biochemistry are alkaline phosphatase, bilirubin, liver enzymes (alanine aminotransferase (ALT), aspartate aminotransferase (AST)). Their norms are presented in the table (Table 2).

Table 2 - Normal indicators biochemical research blood

With cirrhosis of the liver, the levels of transaminases (ALT, AST) increase by 10 or more times. Alkaline phosphatase increases several times. With jaundice, total and direct bilirubin increase. During treatment with hepatoprotectors, a biochemical analysis must be monitored to assess the effectiveness of therapy. During treatment, laboratory values decrease.

Which method is the most informative?

Examination for cirrhosis of the liver includes a very large number of methods. The first stage of diagnosis is the collection of anamnestic data, as well as a physical examination. Examination of the patient is an important period of examination, as it leads the doctor to the idea of the presence of cirrhosis of the liver. Any practitioner owns the methods of percussion and palpation. They are necessary to determine the approximate size of the liver, the contour of the lower edge of the organ.

The color of the skin also helps to suspect liver disease, since jaundice of the skin is an objective diagnostic criterion for an increase in bilirubin. The higher the bilirubin level, the more intense the jaundice. Before the advent laboratory methods the severity of the condition was determined by skin color.

A complete blood count is not considered a specific method for diagnosing cirrhosis. It helps to identify anemia, signs of inflammation. KLA allows you to suspect oncology. Blood biochemistry is a more informative method for detecting liver diseases. It reflects the functional activity of the organ, and also allows you to control the effectiveness of treatment with hepatotropic drugs.

The safest and most objective is an ultrasound examination of the liver. It is allowed even for newborns and pregnant women. The informativeness of the method is sufficient for the formulation, as well as the justification of the diagnosis of cirrhosis.

MRI and CT are considered more informative procedures. They give a layer-by-layer study of the liver tissue, allow you to determine the exact dimensions of the organ, gallbladder, spleen, vascular bed. CT and MRI have contraindications for pregnancy, especially with a contrast agent, they are also done for children strictly according to indications. Scintigraphy also has its limitations for the method. It is not prescribed for severely ill patients. The introduction of a radioisotope is not well tolerated by some patients. Pregnant women do it only when absolutely necessary.

Invasive procedures are the latest diagnostic step ( diagnostic laparoscopy, biopsy). They are the most informative. During a biopsy, pathology can be seen at the cellular level, confirm or exclude a tumor-like process. The disadvantages of the methods is their invasiveness (an operational way of obtaining information).

Proper diagnosis allows early detection of liver disease, as well as initiation of treatment. Modern techniques increase the likelihood of tumor detection, which is often the case in patients with cirrhosis. This allows you to start antitumor therapy in time, perform a liver transplant, and save the patient's life.

Instrumental examination reveals tumors, necrotic areas and foci of inflammation in the liver (digestive gland). Other analyzes provide a clear image of the surface of the organ. According to changes in the morphological structure of the parenchyma, small-nodular, large-nodular and mixed forms of the disease are diagnosed. The article discusses the main types of laboratory and instrumental studies, by which it is possible to determine the type, form and stage of the disease.

Diagnosis by anamnesis

How to diagnose cirrhosis of the liver? Unfortunately, it is quite difficult to identify the disease in the initial stages of development. There are no pain receptors in hepatocytes, therefore, in the first couple degenerative changes in the liver are almost asymptomatic. Over time, she ceases to cope with her functions, as evidenced by the appearance of dyspeptic symptoms.

Patients suffering from cirrhosis may present with various complaints. Clinical manifestations pathologies are determined by the degree of damage to the digestive gland. You can identify cirrhosis by the following symptoms:

CPU stage	Development features	Clinical manifestations
compensated	most of the hepatocytes function without failures, so the manifestations of the pathology are mild	discomfort and heaviness in the abdomen, weakness and loss of appetite, flatulence and nausea, fatigue, low temperature (up to 37.2 ⁰С)
subcompensated	the vast majority of hepatocytes cease to function, due to which irreversible changes occur in the body	yellowing of the skin, sleep disturbance, dull pain in the hypochondrium, skin itching, stool disorders (diarrhea, constipation), increased gas formation
decompensated	the digestive gland is almost completely covered with connective tissue scars, as a result of which it ceases to function	subfebrile fever (temperature 37.5 ° C), nosebleeds, muscle atrophy, internal bleeding, abdominal enlargement (abdominal dropsy), confusion (a sign of encephalopathy)

Decreased appetite, chronic fatigue, heaviness in the abdomen and flatulence are symptoms that may indicate the development of cirrhosis.

Non-alcoholic forms this disease triggered by exogenous endogenous causes which can be learned from the lips of the patient himself. Unbalanced diet, previous diseases (hepatitis, cholangitis, cholelithiasis) negatively affect the functioning of the digestive gland and can cause irreversible processes in it. The classification of liver cirrhosis according to the type of morphological changes makes it possible to predict the course of the disease and draw up the most appropriate treatment regimen. It is possible to suspend unwanted processes in the organ at the stages of compensation and subcompensation.

Diagnosis by physical examination

The second stage of diagnosis is a physical examination of the patient, based on the results of which the specialist prescribes additional types of laboratory and hardware examinations. Changes in the liver early stage CP are weakly expressed, so the manifestations of the disease may be absent. In the later stages of the development of cirrhosis, the symptoms manifest themselves in full.

During a visual examination of the patient, the doctor pays attention to the presence of the following signs:

yellowing of the sclera of the eyes and skin;
atrophy of muscle tissue;
weight loss;
the formation of spider veins;
expansion of veins in the abdomen;
swelling of the lower extremities;
an increase in the abdomen;
hemorrhagic rashes on the skin;
dull sound when tapping the abdomen;
inguinal and umbilical hernias.

Palpation during examination reveals changes in the size of the liver and spleen, which indicate the development of cirrhosis. During the procedure, the specialist determines the degree of compaction of the organ and the presence of irregularities on its surface. If an illness is suspected, the patient is sent for laboratory tests.

Laboratory research

Diagnosis of cirrhosis of the liver involves the delivery of several types of laboratory tests. Dynamic monitoring of biochemical parameters of blood makes it possible to assess the course of the disease and the rate of its progression. If, according to the results of the examination, it turns out that the patient has developed anemia, leukocytosis and microhematuria, he is sent for an additional hardware examination.

Clinical blood test

If cirrhosis is suspected, a clinical blood test is performed, during which the number of platelets and formed elements - erythrocytes and leukocytes is counted. When the liver tissue is replaced by fibrous adhesions, the number of formed elements in the blood decreases. The formation of scars in the digestive gland leads to stagnation of venous blood, as a result of which hypersplenism syndrome develops - hypertrophy (enlargement) of the spleen, accompanied by a decrease in the number of leukocytes and erythrocytes in the blood.

Hypertrophy of the liver and spleen is manifested in the subcompensated and decompensated stages of cirrhosis.

The spleen destroys aged blood cells, but with an increase in its activity, the concentration of formed elements decreases sharply. As a result, this leads to the development of thrombocytopenia, anemia and leukopenia. An increase in the erythrocyte sedimentation rate (ESR) signals the presence of sluggish inflammation in the body. In addition, ESR can be triggered by a change in the amount of protein components in the blood.

Biochemical indicators

The liver is the organ that produces most of the proteins and enzymes. If during laboratory research in the blood, a change in its biochemical status is detected, this indicates a violation of the functions of hepatocytes. If hepatic cirrhosis is suspected Special attention is given to the study of the following indicators:

bilirubin is a toxic substance that is inactivated by the digestive gland; an increase in its concentration signals a malfunction of the organ (the range from 8.5-20.5 μmol / l of bilirubin in the blood is considered the norm);
alanine aminotransferase (AlT) - an enzyme, the maximum concentration of which is concentrated in the liver cells; a decrease in the amount of the enzyme indicates the destruction of hepatocytes;
alkaline phosphatase - an enzyme that is localized in cells bile ducts; an increase in the amount of phosphatase in the blood signals the development of cholestasis, in which biliary cirrhosis is most often diagnosed (the norm of alkaline phosphatase is 80-306 U / l);
albumin - a protein substance that is produced in the digestive gland; with the development of cirrhosis, the amount of albumin in the bloodstream decreases sharply, as a result of which the intercellular fluid seeps into the surrounding cavities and tissues ( normal rate albumin - 35-50g/l).

Sometimes it is necessary to differentiate liver cirrhosis with alveolar echinococcosis, hepatocellular carcinoma (liver cancer) and other pathologies. To make sure that the diagnosis is correct, a number of additional biochemical analyzes, during which attention is paid to the concentration serum iron and gamma globulins in the blood.

Analysis of urine and feces

If cirrhosis is suspected, urine and stool tests are no less indicative. If in chemical composition bilirubin, erythrocytes, platelets and proteins are found in urine, in most cases this indicates the progression of cirrhosis. At healthy person these substances are practically absent in the urine.

Fecal analysis can provide valuable information about the rate of development of cirrhotic processes. Even a visual examination of the biomaterial can indirectly indicate dysfunction of the digestive gland. The discoloration of feces or the appearance of a clay shade is due to the absence of stercobilin in the body, an enzyme that stains feces brown.

blood clots in feces indicate bleeding hemorrhoidal veins. The appearance of the symptom is associated with varicose veins, which often accompanies cirrhosis. Instability of the stool, frequent constipation or diarrhea are indirect evidence of disorders in the digestive gland.

Blood clots in the feces are a symptom indicating the development of portal hypertension, which is the cause of severe complications - ascites, splenomegaly, internal bleeding.

Additional types of surveys

Diagnostic research methods are not limited to physical examination and laboratory tests. If there are characteristic changes in biochemical indicators The patient's blood is sent for instrumental examination. Hardware visualization of the liver, bile ducts and blood vessels provides comprehensive information about the state of the organ and the pathological processes occurring in it.

Laparoscopy

Laparoscopy is a minimally invasive operation that is performed to confirm cirrhosis. The differential diagnosis of liver cirrhosis is practically not difficult. During the examination, it is differentiated from echinococcosis, cancer and syphilis, in which changes similar to cirrhotic ones occur in the digestive gland.

During laparoscopic diagnostics, the specialist sees the surface of the affected organ and evaluates the visual picture. In macronodular (macronodular) cirrhosis, large nodes are found irregular shape, whose diameter is 3 mm or more. If the surface of the liver is furrowed with small nodules, micronodular cirrhosis is diagnosed, and if large-nodular inclusions occur between them, mixed cirrhosis is diagnosed.

ultrasound

Ultrasound is one of the most informative methods of hardware examination, according to the results of which a final diagnosis can be made, but only with the development of a decompensated form of the disease. At the stage of compensation, ultrasound will show a slight increase in the digestive gland, but its surface will be uniform and smooth. With subcompensated and decompensated cirrhosis, the image will show nodular formations, tuberosity, and an inhomogeneous structure of the organ.

Determining the unevenness of the liver lobes most often indicates the rapid progression of the disease. As a rule, it is the left side of the liver that greatly increases in size. With an increase in symptoms of liver failure, the shape and size of the organ change. In the last stages of cirrhosis, it is completely covered with fibrous adhesions and greatly reduced in size.

Biopsy - excision of a small piece of parenchymal tissue, which is performed for the purpose of carrying out histological analysis. The presence of cirrhotic changes in the liver is indicated by:

dense nodular formations surrounded by connective tissue;
uneven expansion of the bile ducts;
swelling of liver cells and a change in their shape;
expansion of venous vessels and necrosis of hepatocytes;
weak severity of the border between the connective and parenchymal tissue (active cirrhosis);
a clear boundary between the parenchyma and fibrous adhesions (inactive cirrhosis).

A biopsy is the most accurate diagnostic method that gives an idea of the stage of development of the disease and the causes of its occurrence.

Differential Diagnosis

Many diseases of the digestive gland have a similar clinical picture with CPU. In order to accurately diagnose and prescribe the most effective treatment regimen, specialists conduct a differential diagnosis of liver cirrhosis. The results of puncture biopsy and laparoscopy provide serious assistance in making a diagnosis. In addition, the following information is taken into account:

coagulogram - laboratory analysis, which determines the rate of blood clotting;
proteinogram - a study, the results of which determine which protein fraction provoked a decrease or increase in total protein in the blood serum;
immunogram - a comprehensive laboratory study, which is carried out to assess the performance of the immune system.

Without help differential diagnosis it is almost impossible to accurately determine the type of disease. The study of the above clinical and biochemical data allows us to differentiate cirrhosis from fibrosis and liver cancer, constrictive pericarditis, myelofibrosis, hemochromatosis, echinococcosis, etc. A detailed formulation of the diagnosis of "cirrhosis of the liver" may sound like this:

micronodular regressive cirrhosis with minimal symptoms of portal hypertension and liver failure;
mixed progressive cirrhosis with mild liver failure;
macronodular progressive cirrhosis in outcome viral hepatitis B with pronounced signs of portal hypertension.

The diagnosis is formulated with an indication of the causes of the development of the disease, structural and functional changes in the liver.

Conclusion

Diagnosis of cirrhosis of the liver involves several types of examinations. At the appointment with a specialist, the anamnesis of the disease and the patient's complaints about the state of health are studied. If cirrhosis is suspected, an examination is performed, during which the abdomen is palpated for an increase in the digestive gland and a change in its density. In addition, the presence of local manifestations of the disease is taken into account - yellowing of the skin, swelling of the lower extremities, an increase in the abdomen, skin itching, etc.

To determine the severity of cirrhotic processes in the liver, laboratory tests are carried out - a coagulogram, an immunogram, a coprogram (fecal analysis), a hemogram, etc. Additionally, a hardware examination is carried out - liver biopsy, laparoscopy, ultrasound or computed tomography. In order to determine for sure the cause of the development of cirrhosis, the patient can be sent for a consultation with an endocrinologist, gastroenterologist, immunologist, etc.

Cirrhosis of the liver is the final stage of all chronic diseases liver, associated with a deep irreversible structural restructuring and with the gradual loss of its function.

The liver is the largest of the digestive glands, it occupies the upper part of the abdominal cavity, located on the right under the diaphragm. It has a lobed structure. Its main functions:

1. Removal of toxins, poisons, allergens entering the body from the external environment.
2. Synthesis of proteins, fats, carbohydrates.
3. The formation of bile involved in digestion.
4. Removal of excess hormones, vitamins, metabolic intermediates.
5. Synthesis of vital biologically active substances(albumin, coagulation factors).

The liver lobule is made up of hepatocytes. It is the violation in the structure of the hepatic lobule, its degeneration into abnormal structural nodes surrounded by fibrous tissue, that is cirrhosis.

Causes of cirrhosis of the liver

The most common causes:

1. Viral hepatitis "B", "C" and "D" are the most frequent and common causes of cirrhosis in the world. Worldwide, there is an increase in infection with viral hepatitis, which can quickly transform into cirrhosis of the liver.
2. Alcoholic liver disease.
3. Cryptogenic cirrhosis. This is a diagnosis of exclusion, it is made when the cause of the disease cannot be established.

Rare causes of cirrhosis:

1. Non-alcoholic steatohepatitis. Liver damage against the background of metabolic disorders (primarily a violation of fat metabolism - in obesity and carbohydrate metabolism - in diabetes mellitus).
2. Autoimmune hepatitis. Occurs when there is a violation immune system when the body produces its antibodies against its own liver cells - hepatocytes.
3. Primary biliary cirrhosis of the liver. It occurs with long-term cholestasis - a violation of the outflow of bile through the tubules from the liver.
4. The use of drugs (anti-tuberculosis and anti-cancer drugs) and hepatotoxic substances (mercury, gold and lead).

Extremely rare causes of cirrhosis:

1. Hemochromatosis. Hereditary disease resulting from the accumulation of iron in organs and tissues
2. Konovalov-Wilson disease. A hereditary disease that leads to the accumulation of copper in the tissues of the liver and brain.
3. Insufficiency of alpha 1 - antitrepsin. hereditary disease. Lack of synthesis of this protein in the liver leads to chronic bronchitis and cirrhosis of the liver.
4. Secondary biliary cirrhosis of the liver. It develops with obstruction (narrowing, compression) of the biliary tract by a stone, a tumor. Budd-Chiari Syndrome. Develops with thrombosis of the hepatic veins.

Symptoms of cirrhosis of the liver

The rate of occurrence and development of cirrhosis of the liver depends on the severity of the course of the hepatitis that caused it. In the initial stages of the disease, moderate pain occurs, a feeling of discomfort in the right hypochondrium, as a rule, after eating, physical activity. Accompanied by bitterness in the mouth, bloating. In the future, nausea and vomiting, loss of appetite join the pain.

In men, potency is impaired, in women - a violation menstrual cycle. The skin, sclera of the eyes become icteric due to increased levels of bilirubin and cholesterol in the blood. The skin becomes dry, intense itching worries. Due to violations of blood coagulation processes, nosebleeds and bleeding from the gums occur, bleeding from wounds does not stop for a long time. Vascular "asterisks" appear on the skin of the body. As cirrhosis develops, swelling occurs in the legs, the abdomen increases due to ascites - accumulation of fluid in the abdominal cavity. Due to the accumulation of toxic metabolic products in the blood, there are signs of hepatic encephalopathy (damage to the cerebral cortex) - intense headaches, memory loss, sleep disturbance, hallucinations, coma development. Appetite sharply decreases, patients weaken, lose weight to the point of exhaustion.

Examinations for suspected cirrhosis of the liver

1. Biochemical research methods show violations of the functional state of the liver (hepatic complex): total protein and protein fractions– decrease in total protein and albumin protein. An increase in enzymes (AlT - alanine aminotransferase and AST - aspartate aminotransferase, alkaline phosphatase), bilirubin - indicates the activity of the process.
2. Coagulogram - shows a violation of the blood coagulation system.
3. Complete blood count - signs of anemia - a decrease in hemoglobin levels, a decrease in the number of platelets and leukocytes.
4. Serological markers of viral hepatitis B, C, D, G, markers of autoimmune hepatitis (antimitochondrial and antinuclear antibodies) - to determine the cause of the disease.
5. Analysis of feces for occult blood- to detect gastrointestinal bleeding.
6. Determination of the level of creatinine, electrolytes (renal complex) - to identify complications of liver cirrhosis - development kidney failure.
7. Blood alpha-fetoprotein - if a complication is suspected - liver cancer.
8. Ultrasound examination of the abdominal organs and vessels of the portal system. Shows an increase and change in the structure of the liver, an increase in the spleen. Increase in vessel diameter. The presence of fluid in the abdominal cavity - ascites.
9. Esophagogastroduodenoscopy (FEGDS) - detection of varicose veins of the esophagus and stomach.
10. Liver biopsy. Helps to establish an accurate diagnosis and stage of the course of the disease.
11. CT scan and liver scintigraphy - prescribed according to the doctor's indications. They help to more accurately and accurately identify the nature of changes in the liver.

Consultation of specialists, according to indications:

Infectious disease doctor, when establishing the viral nature of liver cirrhosis;
- a hepatologist, for other causes of liver cirrhosis;
- oncologist - if you suspect the development of liver cancer;
- surgeon - if complications (bleeding) are suspected.

The severity of the course of the disease is determined by the attending physician using the Child-Pugh (CP) criteria scale. Indicators of the criteria are laboratory data, signs of manifestations of cirrhosis. Patients in class A are compensated, while those in class B and C are decompensated.

Treatment of cirrhosis of the liver

Patients with compensated cirrhosis should be treated for the underlying disease (viral hepatitis, alcoholic or nonalcoholic steatohepatitis) to prevent worsening of the course of the disease and the development of complications. Patients are recommended a balanced diet, with sufficient levels of protein and fat. Exclusion of alcohol, products containing chemical preservatives, extremely careful use of medications - only vital ones. Vaccination is carried out only for health reasons. Limitation of heavy physical activity. Avoid hypothermia, overheating, insolation (sunbathing). Not recommended mineral water, physiotherapy and thermal procedures. Fasting should be avoided medicinal herbs, treatment by means of traditional medicine.

Patients with compensated cirrhosis of the liver are observed by the attending physician (therapist or doctor general practice), with a frequency of visits every three months. They undergo a complex of examinations (ultrasound examination of the abdominal organs, complete blood count, examinations for the liver complex, renal complex).

With the development of decompensation, patients are referred for treatment to specialized departments of the hospital, due to the high risk of complications.

The main goal of treatment at this stage is to stop the progression of the disease and treat the complications that have arisen. Drug therapy patients with cirrhosis of the liver should be prescribed only by the attending physician. In each individual case, the need to prescribe the drug and the potential danger of its side effects are assessed.

The use of hepatoprotectors (drugs that improve liver function) is strictly individual and limited, due to their unproven effectiveness in the treatment of liver cirrhosis.

With the development of cholestasis (impaired outflow of bile from the liver cells - hepatocytes), the manifestation of which is jaundice and pruritus, ursodeoxycholic acid preparations are used to reduce the load and damage to hepatocytes with bile acids. The duration of taking the drug depends on the patient's condition and the severity of cholestasis.

With the development of portal hypertension (increased pressure in the blood supply system of the abdominal organs), resulting in ascites and edema, varicose veins veins of the esophagus, reduce pressure by prescribing nitrates and b-blockers (propranolone group).

Complications of cirrhosis of the liver

1. Acute varicose bleeding. It arises from varicose veins of the esophagus and stomach. The patient becomes weak, falls arterial pressure, the pulse quickens, vomiting appears with an admixture of blood (the color of coffee grounds). Treatment is carried out in the department intensive care, in case of inefficiency, apply surgical methods treatment. Used to stop bleeding intravenous administration octropida (to reduce blood pressure abdominal vessels), endoscopic treatment(ligation of varicose veins, sclerotherapy). Carefully transfuse solutions and blood components to maintain required level hemoglobin.

2. Spontaneous bacterial peritonitis - inflammation of the peritoneum due to infection of the fluid in the abdominal cavity (ascites). In patients, the temperature rises to 40 degrees, chills, intense pain in the abdomen appears. Prescribe long-term broad-spectrum antibiotics. Treatment is carried out in the intensive care unit.

3. Ascites - accumulation of fluid in the abdominal cavity. Assign a diet with protein restriction (up to 0.5 grams per kg of body weight) and salts, diuretics, intravenous administration of albumin (protein preparation). If necessary, they resort to paracentesis - the removal of excess fluid from the abdominal cavity.

4. Hepatorenal syndrome - the development of acute renal failure in patients with cirrhosis of the liver. Stop the use of diuretics, prescribe intravenous administration of albumin. Treatment is carried out in the intensive care unit.

5. Hepatic encephalopathy. Manifested from minor neurological disorders (headache, fatigue, lethargy) to severe coma. Since it is associated with the accumulation of protein metabolism products (ammonia) in the blood, protein is limited or excluded from the diet, a prebiotic, lactulose, is prescribed. It has a laxative effect and the ability to bind and reduce the formation of ammonia in the intestines. When expressed neurological disorders treatment is carried out in the intensive care unit.

6. Development of hepatocellular carcinoma - malignant neoplasm liver.

The cardinal treatment of hepatocellular carcinoma and decompensated cirrhosis of the liver is liver transplantation. Replacement of a patient's liver with a donor's liver.

Prevention of cirrhosis of the liver

Timely detection and treatment of diseases that can lead to the development of cirrhosis. Prevention of viral liver damage (vaccination against viral hepatitis B, compliance with individual funds protection and hygiene). Exclude the abuse of alcoholic beverages.

Video about cirrhosis of the liver, its causes, symptoms, diagnosis and treatment

The doctor's consultation

Question: Are there any contraindications for a liver biopsy?
Answer: A contraindication is the presence of hemorrhagic syndrome (increased risk of bleeding), the presence of ascites, impaired consciousness (hepatic encephalopathy).

Question: Is a patient with liver cirrhosis contagious to others?
Answer: No. But for a patient with cirrhosis of the liver, any transferred bacterial, viral infection(colds, pneumonia) - are the risk of developing decompensation and complications.

Therapist Vostrenkova I.N.

It is necessary to determine the activity and degree of compensation of cirrhosis.

The inflammatory-necrotic activity of cirrhosis is evidenced by:

conjugated hyperbilirubinemia;

Increasing the rate - thymol sample up to approximately 8 U;

Hypergammaglobulinemia (up to approximately 30%);

Hyperfermentemia - an increase in ALT and AST, not as high as in chronic hepatitis, and insignificant in coma and end-stage cirrhosis.

Additional criteria:

Increased levels of IgA, M, G;

Detection of antibodies to the components of the liver cell;

Decreased complementary activity of plasma;

Inhibition of blast transformation of lymphocytes (RBTL);

Inhibition (RTML - inhibition reaction of lymphocyte migration in the presence of HBs Ag and other antigens);

Increase in the number of suppressor cytotoxic cells (OCT 8+).

Morphological assessment is necessary to assess the degree of activity of the inflammatory reaction in the liver, which is identified histologically and the activity is manifested by the same signs as in chronic hepatitis - lymphohistiocytic infiltration, dystrophy and necrosis of hepatocytes.

Decompensation of cirrhosis is determined on the basis of signs of hepatocellular insufficiency and / or complications of portal hypertension.

Parenchymal decompensation (hepatocellular insufficiency) is a consequence of a decrease in the number of functioning liver cells and manifests itself:

Decrease in the synthetic and neutralizing function of the liver;

Microcirculation disorders;

Bleeding from varicose veins of the gastrointestinal tract;

The appearance of ascites and peripheral edema that does not disappear without the use of diuretics;

The development of systemic portocal encephalopathy.

Methods of instrumental, serurgical, virological, immunological, instrumental diagnostics are the same as in chronic hepatitis, only added:

Laparoscopy to visualize the abdominal organs and take a biopsy;

Examination of ascitic fluid during abdominal paracentesis;

Blood test for -fetoprotein (in order to exclude primary hepatocellular carcinoma);

Blood for carcinoembryonic antigen (in order to exclude neoplasms in the gastrointestinal tract);

FGDS and RRS - for the purpose of diagnosing varicose veins of the esophagus and rectum;

Study of acid-base balance (ABR) and blood electrolytes;

Doppler sonography of the vessels of the liver and spleen (for the purpose of verifying portal hypertension and differential diagnosis of portal hypertension and circulatory failure);

But the main and decisive in the diagnosis of cirrhosis is still a puncture biopsy of the liver, which plays a leading role in verifying the diagnosis. With cirrhosis, destructive processes appear in the liver: regenerated nodes and false lobules are formed with a violation of the architectonics of the organ.

Flow

The course of cirrhosis is usually chronic and progressive. According to the Child-Puge nomenclature, compensated (class A), subcompensated (class B) and decompensated (class C) LC are distinguished. . With hemochromatosis, the course of the disease is even longer. Regardless of the form and stage of the disease, all patients with liver cirrhosis are severely disabled.