Hepatic insufficiency is a pathology in which liver cells (hepatocytes) do not fully perform their functions, which leads to an increase in intoxication of the body.
Pathology develops on the background of numerous factors, and can be fraught with serious consequences, including hepatic coma, liver failure, damage to the central nervous system and brain.
Despite the variety of provoking factors, in 15% of cases it is not possible to establish the cause of such a violation. The most common causes of the disease are hepatitis viral etiology, alcohol and drug intoxication.
Causes of liver failure
Liver failure can develop against the background of liver disease:
- viral hepatitis;
- portal and ciliary hepatic cirrhosis;
- cancer diseases;
- liver echinococcosis, etc.
In addition, liver failure may result from:
- obstruction of the bile ducts, accompanied by biliary hypertension (such a violation leads to deterioration of lymph circulation and hepatic circulation, resulting in dystrophic processes in hepatocytes);
- cardiovascular pathologies;
- endocrine disorders;
- infectious or autoimmune processes;
- intoxication caused by mushrooms, medicines, alcoholic beverages, narcotic substances and other toxins;
- extensive injuries or burns;
- traumatic shock;
- massive bleeding or blood transfusions;
- intense allergic reactions;
- septic shock.
Regardless of the cause of liver failure, structural changes in the tissues of an organ are always the same. Hepatocytes are extremely sensitive to oxygen deficiency, so pathological changes develop fairly quickly.
The clinical course of liver failure is divided into:
- Ostrum. This form of the disease develops within 2 months from the moment of liver damage. In most cases, the disease becomes a consequence of fulminant forms of viral hepatitis, as well as alcohol, drug and other types of intoxication.
- Chronic. Such liver failure usually becomes a consequence of progressive chronic pathologies - fibrosis, cirrhosis, tumor processes, etc.
According to the mechanism of development of the disease is:
- Endogenous. Such liver failure is accompanied by the “shutdown” of work in excess of 80% of the liver parenchyma. This violation is observed in hepatitis and toxic organ damage.
- Exogenous. This form of liver failure develops when blood flow is disturbed in the liver. As a result, the blood, saturated with toxic elements, immediately goes from the portal vein into the general circle, without being filtered in the liver. Often exogenous liver failure occurs after shunting with portal hypertension, as well as with cirrhosis.
- Mixed In such a situation, the disease develops under the influence of exogenous and endogenous factors simultaneously.
Hepatic failure develops in 3 stages:
- initial (compensated);
- severe (decompensated);
- thermal dystrophic.
Then comes the hepatic coma, which also has its stages of development:
- threatening coma;
- clinically severe coma.
Symptoms of liver failure
Hepatic failure is accompanied by the development of several syndromes on which the symptoms of the disease depend.
In this case, there is stagnation of bile caused by blockage of the biliary tract. Most often, they are occluded stones or tumor neoplasms. Such a process provokes the appearance of such a symptom as obstructive jaundice.
The intensity of the severity of the symptom depends on the degree of obstruction of the duct. The skin and mucous membranes may acquire different shades of yellowness — from pale yellow to orange, or even greenish. With a long course of pathology jaundice may not manifest.
With the defeat of hepatocytes there is a violation of their activity, or complete death. As a result, a high concentration of toxins, which should have been disposed of in the liver, is released into the blood. This pathological disorder is called cytolysis syndrome, the development of which explains the appearance of the main symptoms:
- general weakness;
- loss or loss of appetite;
- nausea, which can sometimes be accompanied by vomiting.
In some cases, an increase in liver size, lightening, or complete discoloration of feces is recorded. At the same time, the cardiovascular system suffers, which is manifested by tachycardia or hypertension.
The prolonged course of the disease symptoms grows slowly, and over time they mask themselves as signs of the underlying disease. Metabolic disorders gradually occur, endocrine disorders develop (instability of the menstrual cycle, gynecomastia in men, impaired sexual activity).
If untreated, the nervous system is affected. The patient becomes lethargic, apathetic, and tormented by drowsiness. But the occurrence of opposite reactions is also possible: increased excitability, irritability, tremors in the limbs, convulsions.
Hepatic dysfunction entails impaired renal activity. As a result, harmful substances that normally excrete with urine begin to accumulate in the body. This entails increased severity of symptoms. Under the influence of a violation of the secretion of proteins, anemia develops.
Portal Hypertension Syndrome
The syndrome of portal hypertension develops against the background of long-term progressive liver failure, and is almost not amenable to correction. In the veins of the patient's body, pressure builds up, resulting in ascites (accumulation of fluid in the abdominal cavity) and swelling.
Parallel to this, an overflow of superficial venous plexuses on the abdomen is recorded. Such a deviation was called the head of a jellyfish. Varicose esophageal veins can lead to the discovery of bleeding.
With PN, the formation of a “vascular grid” on the patient’s shoulders and chest is noted, and erythema appears on the palms.
Acute Liver Failure
Acute liver failure develops in several stages:
- Latent. At this time, the patient does not notice any disorders in the state of health. Visual changes are also not observed, but during the examination the doctor may record the first disturbing deviations.
- The first stage is precoma. At this time, the symptoms of liver failure begin to increase. More pronounced signs of cholestasis, portal hypertension, intoxication. Then the symptoms of nervous lesions in the form of inhibition of the central nervous system.
- The second stage is accompanied by an even more pronounced aggravation of the clinical picture of hepatic encephalopathy. However, at this time, the inhibition of the nervous system is replaced by its increased excitability, and certain pathological reflexes arise. The symptoms of coagulation disorder and intoxication become brighter. At the same time, the liver decreases in size and cannot be palpated even with careful palpation (the so-called “hypochondrium” symptom). At this stage, there is a characteristic "liver" smell from the mouth.
- Coma. This is a threatening condition, accompanied by loss of consciousness. The patient manifests reflex activity only on the effects of strong stimuli. During this period, symptoms of multiple organ failure, manifested in the failure of the renal, pulmonary, hepatic and cardiac types simultaneously in conjunction with cerebral edema, appear.
- Deep coma. In this case, the unconscious state is not stopped by even the most powerful stimuli. Multiple organ failure and cerebral edema are the main obstacle to the restoration of consciousness, but, unlike the usual coma, in a deep comatose state, these processes are irreversible. As a result, death occurs.
In acute liver failure, each phase can last several hours or days, less often several weeks.
Chronic liver failure
Chronic liver failure also has its stages of development:
- At the initial, first stage of development, the functional properties of the liver are still preserved. At this stage, digestive disorders are manifested, symptoms of mild intoxication appear, expressed in drowsiness and general weakness.
- In the second phase, dyspeptic disorders increase, intoxication is aggravated, a violation of memory and coordination of movements appears. The occurrence of hepatic breath is noted. Possible short-term memory loss. During the second stage, the liver is partially, but still copes with its main functions.
- At the third stage, the functioning of the body is significantly impaired. Symptoms increase, symptoms of cholestasis and portal hypertension appear, coagulation is disturbed. In parallel with this, the work of the nervous system is severely inhibited, which is expressed in severe weakness and speech disorders.
- The fourth stage is the phase of hepatic coma. The body gradually ceases to function. There is a loss of consciousness, first with partial, then with the complete disappearance of reflexes. Marked development of cerebral edema and multiple organ failure. In most cases, this process is irreversible, and ends with the death of the patient.
In the latent stage, it is extremely difficult to make a correct diagnosis. But as liver failure progresses, even an ordinary physical examination, a test for reflexes, and a determination of the level of ALT and AST in the blood will be sufficient to confirm the presence of this pathology.
To build a scheme of therapy and determine further predictions, it is necessary to carry out:
- Proteogram. When PN reduced indicators of total protein and albumin.
- Biochemical blood tests show a decrease in uric acid levels and an increase in creatine phosphokinase. With concurrent development of renal failure, an increase in the level of creatinine and potassium in the blood is observed.
- Coagulogram, in which a decrease in indicators of all clotting factors is recorded. The index of fibrinogen B, when the diagnosis is confirmed, ranges from 1 to 4 plus points.
- EEG. On the electroencephalogram there is an increase in the amplitude and a decrease in the frequency of the waves. Then the appearance of three-phase waves is recorded. In a state of deep coma, brain activity is completely absent.
Be sure to find out the reasons Mon, for which they do:
- blood tests for hepatitis markers;
- herpes infection research;
- examination of a thick drop of blood for the presence of malaria plasmodia;
- bacteriological examination of blood to exclude sepsis.
Equally important is the collection of anamnesis, including family history.
How to treat?
Treatment for liver failure is long and complicated. In addition to the appointment of medicines, the patient is assigned a special diet, which is developed individually. It must be adhered to full recovery, plus everything, you should radically change your lifestyle.
In the acute form of liver failure, the patient is hospitalized in the hospital, where he is undergoing intensive therapy. To fully restore the BCC, the physiological or other saline solutions are administered by the intravenous method. In parallel with this medical staff, a thorough control of the volume of urine is carried out.
With the development of hemorrhagic syndrome, hemostatic agents are used to help to stop the bleeding. If they are ineffective, the patient is given a blood transfusion.
In case of intoxication, medications are prescribed that improve intestinal peristalsis. For detoxification of the body, Reosorbilact or Neogemodez is used.
It is important to improve blood circulation in the liver and eliminate swelling. Osmotic medicines are used for this (for example, Sorbitol). In order to expand the ducts prescribed Eufillin or Thiotriazolin. Hypoxia is relieved with Cocarboxylase or Cytochrome.
In parallel with this, glucose and albumin are introduced to maintain the body’s energy balance. To speed up the regeneration processes in the liver cells, they resort to the use of:
- hepatoprotectors (Essentiale, Essliver Forte, Liv-52, Gepabene, etc.);
- preparations that promote the formation of urea from ammonia (Arginine, Hepa-Mertz, etc.);
- amino acids;
- B vitamins (including vitamin PP).
It is important and the maintenance of brain activity. To do this, prescribed medications that stimulate cerebral circulation - Actovegin or Cerebrolysin. Diuretic drugs are prescribed (Lasix, Mannitol) to reduce swelling, and sedatives.
In the chronic form of the disease, first of all, the causes of hepatic encephalopathy are investigated and, if possible, eliminated. Equally important is the correction of lifestyle and nutrition for the normalization of metabolism. As for pharmacotherapy, in this situation, doctors prescribe:
- broad-spectrum antibacterial drugs that do not provoke toxic liver damage (Neocin);
- amino acids that bind and remove ammonia from the body (glutamic acid);
- lactulose-based drugs that inhibit the activity of pathogenic microflora and neutralize the toxic effect of ammonia (Dufalac, Portalac);
- vitamin-mineral complexes containing potassium, ascorbic acid, vitamins B: such means increase the strength and tone of blood vessels, accelerate the regeneration of hepatocytes, have an antioxidant effect);
- hepatoprotectors (Essliver, Gepabene, Heptral, Essentiale Forte), based on amino acids and phospholipids, and contributing to the speedy restoration of damaged areas of the liver and the protection of healthy hepatocytes.
If necessary, detoxification of the body is carried out by means of an infusion infusion of Ringer's solution, glucose, sodium chloride. With bile stasis, choleretic drugs are prescribed - Holosas or Allohol.
Many patients complain of pain in the right hypochondrium. In this case, antispasmodic drugs are used - no-silo, baralgin, etc.
At the stage preceding the development of hepatic coma, hemodialysis or plasmapheresis is performed, which are necessary to filter the blood from toxins.
Diet and Regimen
Diet and lifestyle changes are the components of treatment that play practically the key role. The main general recommendations regarding dietary regime include:
- refusal of alcohol;
- exclusion of hepatotoxic medications (paracetamol, etc.) without a doctor's prescription;
- compliance with the drinking regime;
- rejection of excessive physical activity;
- ensuring full sleep;
- normalization of psycho-emotional state;
- avoiding constipation (this may require cleansing enemas twice a day);
- spend more time in the fresh air, but avoid being in direct sunlight.
Diet therapy for liver failure implies:
- eating a minimum amount of protein foods;
- the preparation of food that looks attractive and taste, since many patients with this disease have an appetite disturbance;
- food frequent and fractional;
- calories consumed per day - no more than 1500;
- eating foods rich in easily digestible carbohydrates (fruits, vegetables, berries, honey, and even sugar);
- taking vitamin food containing high concentrations of trace elements;
- consumption of a sufficient amount of plant fiber;
- restriction of fat in cholestasis.
After stabilization of a condition of the patient return to a former diet is allowed. Protein food is introduced gradually, starting with proteins of plant origin (it can be obtained from different types of cereals). Then dairy products are introduced, followed by meat.
In case of violation of the swallowing function or the development of coma, the patient is provided with parenteral nutrition. For this purpose, solutions based on amino acids, carbohydrates, lipoproteins, and multivitamin complexes are used. They are administered exclusively intravenously.
Diet is an integral part of the treatment of liver failure, and significantly increases the patient's chances of recovery. But therapy should be comprehensive, so the patient must strictly follow all the recommendations of his doctor.