Hepatic insufficiency - Causes, symptoms and treatment. MF.

Currently, hepatic insufficiency should be understood as a clinical syndrome that occurs as a result of failure of the compensatory capacity of the liver. In this case, the liver is not able to meet the body's metabolic needs and maintain the constancy of the internal environment.

There is no known type of metabolism that would not be controlled by the liver. In this regard, many urgent conditions are manifested and complicated by liver failure.40 years ago, liver failure was not diagnosed and was taken for intoxication, pulmonary insufficiency, cardiovascular insufficiency or other pathological conditions. This circumstance was due to the fact that clinically this pathology does not have pronounced symptoms peculiar only to it.

Causes of liver failure

The following conditions may be the cause of liver failure:

• Liver disease( acute and chronic hepatitis, portal and ciliary liver cirrhosis, malignant neoplasms, echinococcus and others);
• Biliary duct obstruction leading to an increase in the pressure of bile hypertension, which disrupts lymph and blood circulation in the liver and leads to the development of dystrophic changes in hepatocytes( liver cells);

• Diseases of other organs and systems - heart, vessels, endocrine glands, infectious and autoimmune diseases;
• Poisoning with hepatotoxic agents( drugs, poisonous fungi, dichloroethane, alcohol substitutes, antibiotics, aminazine, sulfonamides.);
• Extreme effects on the body( extensive injuries, burns, traumatic shock, massive blood loss, massive blood transfusions, allergization, septic shock).

Clinical and experimental studies show that, whatever the cause, the morphological changes in liver tissue are always the same. Since liver cells are very sensitive to lack of oxygen, pathological changes occur very quickly.

Symptoms of hepatic failure

In the clinical picture of liver failure, two main points that affect its manifestations are identified.

This cholestasis syndrome - occurs due to intrahepatic disorders of biliary excretion or extrahepatic obstruction of the bile ducts. In this case, jaundice is caused by a large amount of bound bilirubin( one of the indicators of a biochemical blood test).

Syndrome of hepatocellular insufficiency .This syndrome occurs when the liver cells are unable to perform their function. In them, a number of changes occur and the cells are destroyed, as a result of which a large number of intracellular components enter the blood. It is for them to judge the severity of the pathological process in the liver.

The first process causes one of the most vivid and noticeable symptoms of the liver disease - jaundice .It can have a different intensity from green to orange and depends on the level of bile duct obstruction. Jaundice may not be with a pronounced prolonged process, when the acute stage slowly flows into the chronic one.

The second syndrome gives most of the clinical picture. Necrosis of the hepatic tissue leading to cell death causes a severe condition of the patient, expressed fever .Due to edema, the size of the affected liver increases, appears as a discolored chair .On the part of the cardiovascular system, the changes the circulatory regime of the .There is tachycardia, blood pressure rises. In the future, there may be a sharp drop in blood pressure, due to a decrease in the volume of circulating blood, the liquid part of which will go into the tissue.

In acute process, when there is a rapid rate of cell death, a number of concomitant syndromes arise, since the liver is very closely related to all organs and systems. She has so many functions that she does in everyday life. The lungs are the first to suffer from a violation of the protein-synthetics function. The liquid part of the blood begins to sweat through the walls of the capillaries into the lumen of the alveoli( lung tissue elements) causing a gradual swelling of the lungs.

The nervous system begins to suffer due to a violation of the purifying function of the liver, manifested by loss of consciousness, lethargy, drowsiness, nausea and vomiting, and there can also be an opposite reaction in the form of hyperexcitability, tremor of extremities or seizures. The relationship between the liver and kidneys, leading to a gradual decrease in the filtration capacity of the kidneys, and the next contamination of the body with foods that normally should go with urine.

The chronic process that occurs as a result of continued exposure to the pathological factor leads to the formation of more distant and non-amenable symptoms. There is portal hypertension syndrome .This syndrome is characterized by an increase in pressure in the venous system of the liver, due to the violation of blood circulation by altered liver tissue. There is ascites - accumulation of fluid in the abdominal cavity. All superficial venous plexuses are enlarged, forming a characteristic symptom of "jellyfish" on the stomach of the patient. On the chest in the area of ​​the shoulders and nipples appear vascular asterisks. The patient develops anemia, a violation of the synthetic function of the liver.

All these symptoms progress until the full replacement of the liver with a connective tissue develops and cirrhosis develops.

Diagnosis of hepatic failure

There are several stages of this process.

1. The initial compensated.(It is characterized by insomnia, rastrojstvami behavior and mood, adynamia, fever, rashes on the body., Jaundice increases).
2. Severe decompensated.(Increased symptoms of the first stage: drowsiness, inadequacy of behavior, sometimes aggression, disorientation, dizziness, fainting, slowing and indistinctness of speech.) "Flapping tremor", sweating, liver odor from the mouth).
3. Terminal dystrophic.(Stupor, awakening with difficulty., Excitation, anxiety, screams.) Confusion of consciousness, violation of contact while maintaining adequate response to pain.
4. Hepatic coma.(Loss of consciousness: Spontaneous movements and reaction to pain in the beginning of a coma also disappear in the future, divergent strabismus, lack of pupillary reactions, pathological reflexes, convulsions, stiffness, EEG - slowing of the rhythm, decrease in amplitude as the coma deepens).

Diagnosis of liver failure is based on the totality of all the activities that your doctor should take. If you have severe symptoms and acute condition, contact an ambulance if you have had poisoning episodes. It is necessary to accurately describe the drugs that you used, or liquids that were drunk. The doctor should examine you and pay attention to external symptoms that have already been described.

Paraclinical measures include blood sampling for determination of biochemical parameters such as ALT and AST, bilirubin, alkaline phosphatase, lactate dehydrogenase( LDH) - these indicators reflect the degree of activity of the process in the liver and the higher they are, the more actively the process of disintegration takes place in the liver. The liver ultrasound can see both acute and chronic process, describe the size of the liver its structural and morphological changes.

Additional techniques such as ECG, general blood count, general urine analysis, functional tests and indicators of the coagulating and anticoagulant system, will give an idea of ​​the involvement of other organs and tissues in the pathological process.

Treatment of hepatic failure

Treatment of this process is very complex and time-consuming and depends on the severity of the process. In the patient's diet, the consumption of the total amount of protein and table salt is reduced. From medicamentous preparations it is necessary to immediately appoint antibacterial agents( cephalosporins of 2-3 generations depending on the proposed flora), hepatoprotective preparations of Gepa-Merz. The purpose of Lactulose reduces the process and the amount of absorbed ammonia as a product of the breakdown of protein structures. With mild bleeding, vitamin K( Vikasol), with severe bleeding, the appointment of freshly frozen plasma is necessary taking into account the blood group and the Rh factor. It is necessary to prescribe vitamin D and folic acid in order to maintain adequate mineral metabolism in the prevailing conditions. When the severity of the process is eased, it is necessary to start treating the immediate cause that caused the development of insufficiency.

When viral hepatitis requires the administration of interferon( Ribavirin) according to the scheme of treatment of viral hepatitis. With obstruction of the bile duct by a stone, an operative intervention is necessary. In severe ascites syndrome, it is necessary to carry out a paracentesis for the evacuation of fluid from the abdominal cavity.

Prophylaxis prognosis and complications of liver failure

The best way to prevent the development of liver failure is to limit the risk of developing cirrhosis or hepatitis. Here are some tips to help prevent these conditions:

Vaccinate against hepatitis by injecting immunoglobulin type A or B. Observe proper nutrition and eat all food groups. Use alcohol in moderation. Avoid drinking alcohol when you take antibacterial drugs and drugs with increased toxicity. Practice respecting the rules of personal hygiene. Since microorganisms usually spread through dirty hands, do not forget to wash your hands thoroughly after using the bathroom. Also, wash your hands before touching food. Be wary of transfusion and blood donation. Do not use other people's personal belongings, personal care items, including toothbrushes and razors. If you are going to do yourself a tattoo or piercing, make sure that the organization that provides these services complies with all material handling measures. Be sure to use condoms during sexual intercourse.

Complications of hepatic impairment and prognosis

• Infection is a big problem. Spontaneous peritonitis occurs in most cases with an infectious lesion of the hepatic tissue. Opportunistic infection can lead to the development of severe pneumonia.
• Bleeding from varicose-veins of the esophagus can be a serious problem.
• Hepatic coma is formed very quickly, since the protein decay products( ammonia and metabolites of its own amino acids) are not excreted from the body as a result of kidney damage and lead to an increase in the acidity of the blood, causing hypoxia of the brain tissue.
• The main complications that cause death even after transplantation are bleeding, sepsis, cerebral edema, renal failure and respiratory failure.

Prognosis depends on the cause of liver failure:

Hepatitis A has a good prognosis with 50% to 60% survival. It accounts for about 20% of pediatric liver transplantation. With Wilson-Konovalov's disease, liver failure is almost an inevitable fatal outcome, if there is no transplantation. In the United States, in 1995, it was reported that 7% of all liver transplants were associated with chronic hepatic insufficiency and that the survival rate during the year was 63%.

Doctor therapist Zhumagaziev E.N.