Liver disease
The liver is patient to a dangerous degree. It can keep working after losing a large share of its tissue and can partly rebuild itself, so disease runs for…
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The liver is patient to a dangerous degree. It can keep working after losing a large share of its tissue and can partly rebuild itself, so disease runs for years without a single complaint. Usually it is found not through symptoms but by accident: in blood tests before an operation, at a health check, on an ultrasound done for something else entirely. That is not a trifle and not merely "enzymes a bit up" — it is precisely the moment when almost everything can still be turned around. What follows is why the liver suffers, how to notice it, and what genuinely changes the outcome.
What damages the liver most often
- Fatty liver disease linked to metabolism. This is now the commonest liver disease in the world: fat builds up inside the cells of people with excess weight, type 2 diabetes, high triglycerides and high blood pressure. It was long thought harmless, until it turned out that in some people it leads to inflammation and scarring.
- Alcohol. Damage begins long before binges and dependence: what counts is not the episode but the total amount over years. The level at which risk clearly rises is around 30 g of pure alcohol a day for men and 20 g for women, but for a liver that is already damaged there is no safe amount at all.
- Viral hepatitis. B and C become chronic and destroy the liver silently over years; A and E run an acute course and usually settle on their own, though they can be severe in pregnancy and in people whose liver is already diseased.
- Medicines and supplements. The liver is harmed by some antibiotics, antituberculosis and antifungal drugs, and by herbal products: green tea in capsules, high-dose turmeric, "fat burners", liver-cleansing blends. A category of its own is an overdose of the ordinary antipyretic, one of the leading causes of acute liver failure.
- Obstruction to bile flow: a stone in the duct, a stricture, a tumour. Here the liver suffers not from a poison but from stagnation.
An important caveat: one person usually has several causes at once, and they do not add up, they multiply. Excess weight together with alcohol, or hepatitis together with diabetes, destroys the liver faster than either cause alone.
Causes that turn up less often
They are worth knowing not for the sake of a complete list but because almost all of them are treatable — and almost all are missed, because nobody looks for them.
- Wilson's disease, an inherited build-up of copper. It shows up in teenagers and young adults, and sometimes not through the liver at all but with tremor, slurred speech and changes in personality, which sends the person to a psychiatrist. Untreated it is fatal; treated, it is compatible with an ordinary life, so in a young person with unexplained liver disease it is always looked for.
- Inherited iron overload: tiredness, joint pain, darkening of the skin, diabetes. It is treated by taking off blood at intervals, a simple and highly effective method.
- Autoimmune hepatitis, in which the immune system attacks the liver's own cells, responds to drugs that damp the immune response.
- Primary biliary cholangitis and primary sclerosing cholangitis, autoimmune damage to the bile ducts. The first sign is often not jaundice but an exhausting itch and fatigue.
- Alpha-1-antitrypsin deficiency, an inherited condition that strikes the liver and the lungs alike.
- Congestion of blood in the liver in severe heart failure, and thrombosis of the hepatic veins.
How it shows itself
The early signs are so ordinary that nobody connects them with the liver: tiredness that rest does not fix, heaviness under the right ribs, loss of appetite, nausea. Often there is not even that.
Later come signs that cannot be mistaken for anything else:
- yellow skin and whites of the eyes, dark urine, pale stools;
- itching skin with no rash at all;
- spider naevi on the chest and shoulders, blotchy redness of the palms;
- bruises and bleeding gums from the slightest cause;
- an abdomen swollen with fluid, swelling of the lower legs;
- absent-mindedness, day and night swapped round, slowed speech;
- loss of muscle from the shoulders and thighs; in men, breast enlargement; in women, disrupted periods.
The often-repeated claim that the appearance of symptoms means cirrhosis has already formed is only half true. For slow chronic disease it holds. But acute hepatitis, drug-induced damage or a blocked bile duct produce a vivid picture in a liver without a single scar, and there everything is reversible. Jaundice, then, is not a sentence but a reason to be investigated — and investigated quickly.
When urgent help is needed
Call an ambulance (in European countries, the single number 112) if someone with liver disease develops:
- vomiting of blood or of material the colour of coffee grounds, or black tarry stools;
- confusion, drowsiness, odd behaviour, or being hard to wake;
- fever and abdominal pain where fluid has collected — that fluid can become infected, and without antibiotics it is lethal;
- severe pain under the right ribs with a high fever and shivering in the setting of jaundice;
- rapidly deepening jaundice in a previously healthy person, especially with confusion: that is how acute liver failure begins.
Separately: after an overdose of the ordinary antipyretic you must go to hospital straight away, even if you feel perfectly well. In the first hours that poisoning cannot be felt at all, while liver damage develops a day or more later; the antidote works better the earlier it is started. Waiting for symptoms is the most dangerous course possible here.
How the liver is checked
Investigation usually starts with a blood test and an ultrasound, and those two already answer most of the questions.
- Liver blood tests: enzymes, bilirubin, albumin, clotting, platelets. Their weak spot is worth knowing: with established cirrhosis they can be normal, so "the blood tests are fine" is not the same as "the liver is healthy". Persistently low platelets are often the first hint.
- Ultrasound shows fat, the texture of the tissue, the bile ducts, the spleen and the blood flow.
- Elastography measures the stiffness of the liver with a probe, without a needle, in a few minutes, and has replaced biopsy in most cases.
- Tests for the cause: viral hepatitis, iron and copper metabolism, autoimmune markers. This is exactly the step most often skipped.
- Biopsy is now rarely needed: mainly when the cause remains unclear.
If a blood test once showed moderately raised enzymes, the sensible response is to work out why, not to repeat it in a year. In most people a cause is found.
What can be stopped
Treatment starts not with the liver but with the cause, and that is where the main hope lies: remove the cause and the destruction halts, while in some people the scarring partly recedes.
Losing a tenth of body weight reduces both the fat and the inflammation in the liver, and sometimes clears early scarring. Giving up alcohol produces an improvement visible in the blood tests within months. Chronic hepatitis C is now cured with tablets in almost everyone and within months; hepatitis B is fully suppressed by long-term antiviral treatment. Autoimmune disease responds to drugs that damp the immune response; iron overload is dealt with by taking off blood, copper build-up by drugs that bind it. A stone in the duct is removed endoscopically. And if the liver has already failed, transplantation is discussed — better in good time than in the middle of a crisis.
What is up to you
- Alcohol, with any liver disease, is stopped completely rather than cut down.
- Weight and diabetes are, in fatty liver, what works better than any tablet; exercise helps even without weight loss.
- Hepatitis A and B vaccination is needed by everyone with chronic liver disease and can be given at any age.
- The ordinary antipyretic is safer than anti-inflammatory drugs, but its daily dose is reduced in liver disease: check it, and watch that the same active ingredient is not also hidden in a cold remedy.
- Liver-cleansing supplements are best avoided: there is no proven benefit and there are described cases of serious damage.
- Hepatitis B and C travel in blood: other people's razors, shared manicure sets and unsterile tattoo studios are real routes of infection.
- With cirrhosis, raw seafood and especially shellfish are avoided: infection runs a severe course.
- If there has been liver disease at a young age in your family, say so — some of the causes are inherited.
Online consultation
The liver is one of the uncommon cases where a remote appointment covers almost the whole path. The commonest reason for one: blood tests or an ultrasound have shown changes and it is not clear whether that is frightening or not. The doctor will explain what the numbers mean, which investigations are needed to establish the cause, and in what order to do them — and here the established cause is the treatment. Online it is convenient to go through the list of medicines and supplements you take from the point of view of the load on the liver, agree a safe dose of pain relief, plan vaccinations, sort out eating and weight in fatty liver, and get support in giving up alcohol, where regular contact works better than one-off conversations. If the diagnosis is already made, such appointments are a good way to keep the follow-up calendar: when the next ultrasound is due, when the elastography, what the latest blood tests show. The situations in the urgent section are not dealt with online: for those, call an ambulance.
This material is for information only and does not replace medical advice.
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