Treatment Information Centre

 

 

 

 

 

 

 

 

 

 

 

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Liver is a bright red colored organ located in the right side of the abdomen, just below the ribs. It has  two main lobes, the right lobe and the left lobe, which are in turn made up of thousands of lobules. These are connected to the hepatic duct, which transports the bile produced by the liver cells. A healthy liver can repair and recover from many conditions such as infections, the effects of drugs, alcohol and other toxins. However, if this healthy liver is tested and prone too long to toxins, or by disease, the healthy liver cells are destroyed. After which liver undergoes a series of damage from reversible fatty change, or hepatitis (inflammation of liver) or cirrhosis (an irreversible scarring of the liver) to cancer.

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A healthy liver stores important substances like vitamins and minerals. It acts as a filter and removes impurities in the blood. Finally the liver metabolises and detoxifies substances ingested by the body. A liver disease occurs when the normal functions of the liver are disrupted. And a liver transplant is needed when the liver is severely damaged which affects the person's health and quality of life. The liver regulates most of the chemical levels in the body and excretes a product called bile, which helps to carry away the waste products from the liver. All the blood leaving the stomach and intestines, passes through the liver. The liver processes this blood and breaks down the nutrients and drugs into forms that are easier to use for the rest of the body.

 

Some well known functions of the liver are the following :

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• Its a powerhouse that produce varied substances in the body including glucose – a sugar and a energy source, proteins – the building blocks for growth, blood clotting factors – substances that aid in the healing wounds, a bile – fluid thats stored in gall bladder and necessary for absorption of fats and vitamins.

• Regulation of blood levels of amino acids, which form the building blocks of proteins, processing of hemoglobin for use of its iron content ( liver stores iron )

• Conversion of poisonous ammonia to urea.

• Clearing the blood of all toxic substances.

• Regulating blood clotting.

• Making heparin: this is a substance that prevents the blood from clotting as it travels through the blood system.

• Forms plasma proteins: the plasma proteins are used in blood clotting and in keeping the blood plasma constant.

• Storage of vitamins such as vitamin A and D. Vitamin A is also made in the liver from carotene, the orange-red pigment in plants. Vitamin B12 s also stored in the liver.

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How to check Liver Health

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Liver Function Tests or commonly called LFT, are used to determine or diagnose liver health or extent of damage. The normal functions of the liver, like producing protein, clearing bilirubin, and the fight response during infection or damage are measured through these general tests. Based on the presented medical condition of the patient, the hepatologist or liver specialist will guide and explain the need of these tests or additional tests.

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Liver function tests can be used to:

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• Screen for liver infections, such as hepatitis

• Monitor the progression of a disease, such as viral or alcoholic hepatitis, and determine how well a treatment is working

• Measure the severity of a disease, particularly scarring of the liver (cirrhosis)

• Monitor possible side effects of medications

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Liver function tests check the levels of certain enzymes and proteins in your blood. Levels that are higher or lower than normal can indicate liver problems. Some common liver function tests include:

 

Liver proteins

The main proteins measured in a liver function test are:

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• Albumin and total protein : Albumin is one of several proteins made in the liver. Your body needs these proteins to fight infections and to perform other functions. It helps transport nutrients and hormones, as well as helping grow and repair tissues in your body. Lower-than-normal levels of albumin and total protein may indicate liver damage or disease.

• Bilirubin : Bilirubin is a substance produced during the normal breakdown of red blood cells. It helps your blood to clot and fights infections Bilirubin passes through the liver and is excreted in stool. Elevated levels of bilirubin (jaundice) might indicate liver damage or disease or certain types of anemia.

• Total Protein : This is your albumin and globulin levels combined.

 

 Liver enzymes

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The main enzymes measured in a liver function test are:

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• Alanine transaminase (ALT) : ALT is an enzyme found in the liver that helps convert proteins into energy for the liver cells. When the liver is damaged, ALT is released into the bloodstream and levels increase.

• Alkaline phosphatase (ALP) :  ALP is an enzyme found in the liver and bone and is important for breaking down proteins. Higher-than-normal levels of ALP may indicate liver damage or disease, such as a blocked bile duct, or certain bone diseases.

• Gamma-glutamyl transpeptidase (GGT) - It helps to detoxify drugs and alcohol.

• Aspartate transaminase (AST) : AST is an enzyme that helps metabolize amino acids. Like ALT, AST is normally present in blood at low levels. An increase in AST levels may indicate liver damage, disease or muscle damage.

• Prothrombin time (PT) : PT is the time it takes your blood to clot. Increased PT may indicate liver damage but can also be elevated if you're taking certain blood-thinning drugs, such as warfarin.

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Types of Liver Diseases and Treatments

 

This can be classified into two main types, one is the lifestyle related diseases and the other one is viral hepatitis.

 

Lifestyle Related Diseases

 

Alcoholic Liver Disease – Usually caused by the long – term use of alcohol use that causes widespread liver damage and destruction. Alcoholic Hepatitis is the inflammation of the liver ( hepatitis ), although effects of alcohol vary among individuals. Over time, Chronic Alcohol use can also lead to scarring of liver ( cirrhosis )

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Non Alcoholic Fatty Liver Disease – Most often it is caused due to obesity and sometimes with people who have diabetes, elevated cholesterol and triglyceride levels . A recent statistics shows, that the number or fatty people are increasing in all leading countries and resulting in fatty – liver and ends in liver disease.

 

Biliary Disease

 

Primary Sclerosing Cholangitis (PSC) is a disease where the bile ducts inside and outside the liver become inflamed and scarred and resulting in blocked ducts overtime. The ducts are important, as they carry the bile from the liver, so as a result, the bile gets stored in the liver and results in liver failure.

 

Primary Biliary Cirrhosis (PBC) it’s a chronic liver disease that causes slow, progressive destruction and loss of bile ducts in the liver. This again interferes with the ability to move bile out of liver. Resulting in Liver Failure, and cirrhosis.

 

Autoimmune Hepatitis  Its an inflammation of the liver where the body’s immune system attacks the liver.  It’s a chronic condition that can lead to cirrhosis of the liver and eventually liver failure.

 

Metabolic Disorders  Hemochromatosis is an inherited disorder that causes the body to absorb or store too much if iron in the system.  A healthy person, usually absorbs about 10 % of the iron contained in the food they eat, so their body functions are met accordingly. People with hemochromatosis absorb more than the body needs. So as a result the extra iron is stored in the body, especially the liver, heart, pancreas. Without treatment, the individual will suffer from failure of these organs.

 

Wilson’s Disease  It’s a hereditary disease, which causes the body to retain copper. The liver of the person who has wilson’s disease doesn’t release copper into bile. As we intake food, and so the intestine absorb copper from food, it keeps building in the liver and injures liver tissue. It may also lead to damage to other organs, if not treated at the right stage, it may lead to severe brain damage, and liver failure and death.

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Viral Related Hepatitis

 

Hepatitis A Virus (HAV) Its caused by virus which causes inflammation of the liver. Its is acquired through food or water, or contaminated by feces from an infected person. Its commonly spread through person to person. It can be prevented by Hepatitis A Vaccine, and practicing good hygiene and sanitation.

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Hepatitis B Virus (HBV) Its caused due to infected blood and body fluids and from mother to newborn. It causes inflammation of the liver, which leads to scarring of liver ( cirrhosis ) Transmitted through – sexual contact with the infected person, contact with infected body fluids and contaminated needles, including tattoo/body piercing, mother to newborn at the time of delivery. It can be prevented by Hepatitis B Vaccine, avoidance of contaminated tattoo, safe sex, avoidance of intravenous drug use.

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Hepatitis C Virus (HCV) It’s a silent killer, which is caused by a virus. Its one of the leading causes of liver disease. Most of the patients are symptom free, even during the replication of virus in the body, which causes the ongoing damage. And as the virus replicates it causes the scarring of liver, and it may also lead to liver cancer.  And drinking alcohol may accelerate the speed at which this occurs.

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Hepatocellular Carcinoma – HCC

 

It’s a cancer arising from liver. It is also known as primary liver cancer or hepatoma. Liver cancer that’s spread to liver, having originated in other organs ( such as colon, stomach, pancreas, lungs ), is called metastatic liver disease or secondary liver cancer.  HCC is the fifth most common cancer in the world, and sadly majority of the patients with HCC will die within one year as a result of cancer. A combination of an imaging study – ultrasound, CT or MRI , can detect and diagnose HCC. A liver biopsy is very helpful in detecting the extent of disease, but it requires a skilled liver pathologist, and its not necessary for all patients. The treatments for HCC includes, chemotherapy, chemoembolization, ablation. But surgical removal of the tumor may be very effective, for a select group of patients, especially for those with small tumors and excellent liver functions. But patients with small HCC, and significant liver disease, liver transplantation is the option

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Liver Transplant Surgery

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A liver transplant will only be considered if other treatments are no longer effective or if liver damage is too advanced or irreversible and is a risk to life. There are two kinds of Liver Transplant, Living Donor Transplantation, Cadaver Donor Transplantation. In a living donor transplantation, a segment of a healthy person's liver is transplanted into the sick patient. This can be done because the liver is the only organ that can regenerate itself. Both the donated segment and the remaining section of the donor liver will grow to normal size within weeks. Livers for transplantation can come from deceased donors or living donors. In both the cases, blood type and body size are the most important factors in determining whether a donated liver maybe a match for the patient. Deceased Donors typically die of accidents or head injuries and their family grants permission for organ donation when the victim is declared brain dead.There are more people who need liver transplant than there are livers available for donation. Patients are examined by a team of specialists to determine if a liver transplant is appropriate and likely to succeed.

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Most of the times the donor and recipient surgery will start simultaneously. In essence, a living donor liver transplant actually involves two overlapping surgeries between the healthy donor and the recipient.

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Donor Surgery

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An inverted T shaped incision is made in the abdomen. The liver is mobilised and assessed for suitability for use. Sometimes a biopsy is done to check for the amount of fat. A final x-ray to identify the bile ducts to aid in surgery is done. A portion of the donor liver, either the right lobe or left lobe, is removed with its blood supply intact in one operating room while the recipient's diseased liver is removed in its entirety in another operating room. During the donor’s surgery, the gallbladder is also typically removed as part of this procedure. Once either the right or left lobe of the liver is removed, it is washed with a special preservation solution called HTK to remove the blood that is in it. It is then packed for use in the recipient. All blood vessels are repaired in the donor and a stent may be placed in the bile duct that will be removed in 3 weeks post-operatively. The skin incision is then closed. The donor operation usually takes between 6 and 8 hours. 

 

Recipient Surgery

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The surgical team removes the failed liver. This can be the most difficult part of the operation and can take several hours because of the liver’s impaired clotting and multiple blood vessels. A clamp is then placed on remnant right hepatic vein entering the inferior vena cava. Clamps are also placed on the artery to the liver (hepatic artery) and on the portal vein. The liver is cut out and all bleeding is stopped. The donor liver is kept cold while it is sewn in place. This usually takes 1-1.5 hours. Five anastomoses must be made (tubes sewn together). The first is the vena cava above the liver, the second is the vena cava below the liver, and the third and fourth are the portal vein and hepatic artery, (not necessarily in the same order in each case). Once all four of these are done, the clamps are released and blood is allowed to flow through the liver. The fifth and final step involved is sewing the bile ducts together, sometimes placing drainage tubes and closing the incision. The recipient operation can take between 6 to 16 hours.

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Both will wake up in the Recovery Room where blood pressure and other vital signs will be closely monitored by the nursing staff. They might have some discomfort. A catheter will be draining urine from their bladders and frequent urinary output measurements will be taken. The recipient will also have two tubes coming out of your abdomen to drain excess fluid for a few days. The donor will probably have one tube draining form the abdomen. Once they are sufficiently awake and their vital signs are stable, the donor will be transferred to the High dependency unit while the recipient will be transferred to the Intensive care unit. Their family members may visit with them. They may have some discomfort the first couple of days, which is completely normal. They will remain in the hospital for approximately seven days and will be given an appointment to follow up in the Transplant clinic before they go home

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The liver possesses amazing regenerative properties. Within two months of the surgery, the remaining portion of your liver grows back to full size. Note that the liver does not assume its former complete anatomy. Instead, the remaining portion (e.g., the right lobe) simply enlarges. On the average most people return to work by the 3rd month.

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Liver Donors

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A suitable liver will be one which is matched to the recipient by blood grouping and by the shape and size of the donor. The donor also has blood tests and imaging studies of the liver performed to make sure it is healthy. The living donors, must have the same blood type as the recipient.  The part of the liver which was donated, regenerates itself and completes as full organ in few months. With the recent advances of non-invasive imaging, living liver donors usually have to undergo imaging examinations for liver anatomy to decide if the anatomy is feasible for donation. People who have liver disease or alcoholism are not allowed to donate part of their liver. Those who smoke chronically or who are obese or pregnant also cannot make such donations. Family donors are always preferred, due to the blood group match and emotional support rendered which plays a major role in such high risks surgery. It also helps the patient to proceed for surgery immediately and avoid further complications and not wait for deceased donors. If family donors are not available, then cadaver donor is the available option.

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Transplant Approval Committee

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In India, Organ Transplants are governed by Transplant Act, which has a state and Nation wide registry. Any organ transplant is conducted in the state only with the approval of state transplant committee. An authorisation committee was constituted by the Government for the regulation of transplant of human organs and to prevent any commercial dealings.

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This committee consists only of  Director of Medical Education, Director of Medical and Rural Health Services, Dean of Madras Medical College ( committee in chennai ) ( Additional committee is at Coimbatore and Madurai for the whole state of TN )The approved transplant centres, submit the total legal and ethical documents of their patients to this committee. They verify all the documents, including identification, verification, notary and magistrate signatures, relationship evidence, patient and recipient affidavits, nativity, clinical documents etc, and personally interview the recipient and donor to check the final genuinity. After this process, the approval is sent to hospital and the medical team proceeds for the surgery.

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This committee as per the act, will approve only Live Donor Related Organ Transplants. Live donor is usually the first degree relative ( husband / wife / parents / brother / sister / son / daughter ) and in case first degree donors are not available, then proven second degree related donors are accepted. Unrelated Donors are not permitted , according to our Organ Transplant Laws

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