Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick.Although we all prefer to use only the good passport, sooner or later each of us will be obliged, at least for a spell, to identify ourselves as citizen of that other place...

Liver disease affects people of all ages. Today, one in every 12 Indians suffers from some form of liver or biliary tract disease.There are over 100 known liver diseases.There are mainly 3 categories of liver diseases -Acute Parenchymal / Virul Disease(Acute Hepatitis), Non-Virul Infections of the liver and Tumours of the liver.Causes of the virul disease are Infections,Toxic substances and Circulatory disturbances.

Hepatitis : The virus is involved are described as type A, type B and type non-A, type non-B. The types are distinguished serologically, i.e., by the antibodies to combat the infection. The severity of the ensuring disease caused by the different virus types various considerably but the pattern is similar. The viruses and enter the liver cells causing degenerative changes by mechanisms not yet understood. An inflammatory reaction ensues, accompanied by production of an exudate containing lymphocytes, plasma cells and granulocytes. There is reactive hyperplasia of the reticuloendothelial kupffer cells in the walls of the sinusoids As groups of cells die, necrotic areas of varying sizes develop, phagocytes remove the necrotic material and the lobules collapse. The basic lobule framework becomes distorted and blood vessels develope kinks. These changes interfere with the circulation of blood to the remaining hepatocytes and the resultant hypoxia causes further damages. Fibrous tissue developed in the damaged area, and adjacent hepatocytes proliferate. The effect of those changes on the overall functioning of the liver depends on the size of the neurotic areas, the amount of the fibrous tissue formed and the extent to which the blood and bile channels are distorted. Type A virus(Infectious hepatitis) :This virus has only known as serological type. It occurs endemically effecting mainly children, causing mild illness infection is spread by hands, food, water and fomites contaminated by infected faeces. The incubation period is 15 to 40 days and the viruses are excreted in the faeces for 7 to 14 days before clinical symptoms appear and for about 7 days after. Antibodies develop and immunity persists after recovery. Subclinical disease may occur that carriers do not develop. Type B virus(Serum hepatitis) : This virus has the number serological types. Infection occures at any age, but mostly in adults. The incubation is 50 to 90 days. The virus enters the blood and is spread by blood and blood products. People at greatest risk of infection are those who come on contact with blood and blood products in their daily work, e.g., people in the health, ambulance and fire services. Others at risk include intravenous drug addicts and male homosexuals. Antibodies are formed and immunity persists after recovery. Infection usually leads to severe illness 2 to 6 weeks, often followed by a protected convalescence. Carriers may or may not, have had clinical disease. Type B virus may cause massive live necrosis and death. In less severe causes recovery may be complete. In chronic hepatitis which may develop, virus continue to the circulate in the blood. Type non-A non-B hepatitis (NANB) : These viruses are known to exist because of the occurrence of the virus hepatitis that cannot be attributed to type-A or type-B virus. Serological identity has not been yet established. One known method of spread is transfusion of infected blood. The incubation period is 10 to 90 days. Clinical illness of varying severity occurs and it may be followed by complete recovery or become chronic. Carriers may, or may not have had clinical disease.

Gallstones : Gallstones form in the gallbladder when cholesterol or pigments crystallize out of bile. They can vary in size from as small as grains of sand to as large as golf balls. Sometimes gallstones get stuck in the bile ducts causing attacks of severe abdominal pain. Gallstones occur in 20% of Indian women and 10% of men by the age of 60. The tendency to form gallstones is partially inherited and is more common in people who are obese, overeat or lose weight rapidly through extreme diets.

Liver Failure : This occurs when liver function is reduced to such an extent that other body activities are impaired. It may be acute or chronic and may be the outcome of a wide variety of disorders, e.g.: 1.Acute viral hepatitis 2.Extensive necrosis due to poisoning, e.g., some drug overdoses, hepatotoxic chemicals 3.Cirrhosis of the liver 4.Following some medical procedures, e.g, abdominal paracentesis , portacaval shunt operations Liver failure has serious effects on other parts of the body.

Cirrhosis : This is a type result of long-term inflammation caused by a wide verity of agents. The most common causes are: 1.Alcohol abuse 2.Following virus infections 3.The effect of bile retained in hepatocytes due to obstruction of bile flow or chronic inflammation 4.Congenital metabolic abnormalities As the inflammation subsidies: 1.Destroyed liver tissue is replaced by fibrous tissue 2.There is hyperplasia of hepatocytes adjacent to the damaged area, in an attempt to compensate for the destroyed cells. This leads to the formation of nodules consisting of hepatocytes confined within sheets of fibrous tissue. As the condition progresses there is the development of: 1.Portal hypertension, leading to congestion in the organs drained by the tributaries of the portal vein, to ascites and possibly to the development of vericose veins at the lower end of the oesophagus. 2.Liver failure when hyperpalsia is unable to keep pace with cell destruction.

Anaemia : This is usually due to the combined effect of a number of factors: 1.Upset in the metabolism of folic acid and vitamin B12 2.Chronic blood loss from oesophageal varices, causing iron-deficiency anaemia 3.Increased breakdown of red blood cells in the congested spleen, causing haemolytic anaemia.

Jaundice :The following factors may cause jaundice as liver failure develops: 1.Inability of the hepatocytes to conjugate and excrete bilirubin 2.Obstruction to the movement of bile through the bile channels by fibrous tissue that distorted the structural framework of liver lobules.

Tumours in Liver :Beningn tumours of the liver are very rare. But case is different for Malignant Tumours .In many cases cancer of the liver is associated with cirrhosis but the relationship between them is not clear. It may be that both cirrhosis and cancer are caused by the same agents or that the carcinogenic action of other agents is promoted by cirrhotic changes. Malignancy develops in a number of cases of acute hepatitis caused by type B virus. The most common sites of metastases are abdominal lymph nodes, the peritoneum and the lungs. Secondary malignant tumours in the liver are common, especially from primary tumours in the gastrointestinal tract, the lungs and the breast. The metastases tend to grow rapidly and are often the cause of death.

Hepatic Encephalopathy : The cells affected are the astrocytes in the brain. The condition is characterized by apathy, disorientation, muscular rigidity, delirium and coma. Several factors may be involved, e.g., 1.Nitrogenous bacterial metabolites absorbed from the colon, normally detoxicated in the liver, reach the brain via the blood 2.Metabolities, normally present in trace amounts, e.g., ammonia, may reach toxic concentrations and change the permeability of the cerebral blood vessels and the effectiveness of the blood-brain barrier 3.Hypoxia and electrolyte imbalance.

Liver Diseases in Children : Thousands of children - from infants to adolescents - have liver disease, and many die from it each year. Some are born with a liver disease, others contract it at birth or early in life. The more common types of liver diseases that affect children are: chronic active hepatitis, biliary atresia, galactosemia, Wilson disease, alpha-1 antitrypsin deficiency, tyrosinemia and Reye's syndrome. Advances in liver transplantation offer hope for children with severe, irreversible liver disease.

Drugs (Alcohol) related Diseases :Many drugs undergo chemical change in the liver before excretion in bile or by other organs. They may damage the liver cell in their original form or while in various intermediate stage.Some substances always cause liver damage (predictably toxic) while others only do so when hypersensitivity

develops(unpredictably toxic). In both types the extent of the damage depend on the size of the dose and/or the duration of intake.Predictable group (Dose related) contains Chloroform ,Tetracyclines, Cytotoxic drugs, Anabolic steroids, Alcohol, Aspirin, Some hydrocarbons and Some fungi .In Unpredictable group (Individual idiosyncrasy) Phenothiazine compounds , Halothane , Methyldopa , Phenylbutazone ,Indomethacine, Chloropropamide, Thiouracil and Sulphonamides are includes.

Blood Coagulation Defects :The liver fails to synthesis substance needed for blood clotting , i.e., prothrombine, fibrinogen and Factors ii, v, vii, ix and x. Platelet production is impaired but the cause is unknown.

Oliguria and Renel Failure : Portal hypertension may cause the development of oesophagel varices. If these rupture, bleeding may lead to a fall in blood pressure sufficient to reduce the renal blood flow, causing progressive oliguria and renal failure.

Oedema and ascites :These may be caused by the combination of two factors: 1.Portal hypertension raises the capillary hydrostatic pressure in the organs drained by its tributaries. 2.Diminished production of serum albumin and clotting factors reduces the osmotic pressure. Together these changes cause the movement of excess fluid into the interstitial spaces where it causes oedema. Eventually free fluid accumulates in the peritoneal cavity and the resultant ascites may be serve.

Circulary Disturbances : The intensity active hepatocytes are particularly vulnerable to damage by hypoxia which is usually due to deficient blood supply caused by 1.Fibrous in the liver following information 2.Comparison of the portal vein, hepatic artery or vein by a tumor. 3.Acute general circulatory failure and shock. 4.Venous congestion caused by acute or chronic rightsided heart failure. Chronic Hepatitis , Chronic persistent hepatitis and Chronic active hepatitis are under this category.Chronic Hepatitis is identified as any form of hepatitis, which persist for more than 6 months. It may be caused by viruses or drugs, but in some cases is unknown.Chronic persistent hepatitis is a mild, persistent information following acute virus hepatitis. There is usually little or no fibrosis. Chronic active hepatitis is a continuing progressive inflammation with cell necrosis and the formation of fibrous tissues that may lead to cirrhosis of the liver. There is distortion of the liver blood vessels and hypoxia, leading to further hepatocyte damage. This condition is commonly associated with type B virus hepatitis and with some form of autoimmunity

Pyogenic Diseases :They are Ascending cholangitis (Infection, usually by Escherichita coli, may spread from biliary tract. The most common predisposing factor is obstruction of the common bile duct by gallstones.) and Liver abscess (Septic emboli from septic foci in the abdomen and pelvis may lodge in branches of the portal vein and cause multiple abscesses or infect the vein, causing portal pylephlebitis. Common sources of this type of infection are acute appendicitis, diverticulitis and inflamed hemorrhoids.).

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