New approach could reverse liver failure

Liver Disease Survivors Guide

Renowned Health Specialist experienced in working with numerous people with liver disorders share with you and: Explains how the liver works and how liver disorders develop in Simple English without Medical Jargon. Shares the facts about cirrhosis of the liver. Explains complications and treatments in simple language. Talks about Nutrition in Liver Disease. Explains Alternative Treatments available. Talks about the latest research developments in liver disease treatment. Shares resources for Liver disease forums and help-lines. Gives you the true in-depth stories from survivors and how they coped with the challenges of liver disorder. Shares touching stories of family members who had to cope with their loved ones suffering from cirrhosis of the liver, and the strategies they used to cope with them. With Liver Disease Survivors Guide, you will discover : Credible information on Liver disease obtained from detailed interviews with specialist doctors, explained in simple language. Healthy steps in dealing with liver disorders. What to do and what not to do while learning to adapt to the liver disorder. Remarkable stories in patients own words. It gives you a real emotional experience of a person with serious liver disorder and how they view the world. Latest research on liver disorders. Best resources and direct links to forums. Direct links to get professional help and identify the best experts in your area. Alternative treatments and therapies available for liver disorders. No medical jargon or difficult language, the book is written in simple and easy to understand language.

Liver Disease Survivors Guide Summary


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Metabolic derangements that accompany liver failure

Portal hypertension seen with cirrhosis (chronic liver disease) causes hemorrhoids, varices, caput medusae. 8. Hepatorenal syndrome liver failure causes kidney failure (idiopathic). 4. Primary biliary cirrhosis middle-aged woman with no risk factors for liver or biliary disease, marked, pruritus, jaundice, and positive antimitochondrial antibodies rest of work-up is negative. Cholestyramine helps with symptoms, but no treatment (other than liver transplantation) is available.

Primary Biliary Cirrhosis

Primary biliary cirrhosis is an autoimmune disease where cytotoxic T-cells attack biliary endothelium causing granulomatous destruction of intrahepatic bile ducts. This destruction leads to cholestasis, then progressive cirrhosis, portal hypertension, and liver failure. Patients often complain of fatigue and pruritus and jaundice is evident. This process is most prevalent in middle-aged women, especially in those with other preexisting autoimmune disorders. Laboratory evaluation elicits an elevated alkaline phosphatase level and positive antimitochondrial antibody. Hepatic transplantation is the only method of long-term treatment.

Risk Factors and Cancer

Alcohol and tobacco smoking are the main cause of cancers of the upper respiratory and gastrointestinal tracts. Alcohol by itself plays a role in liver cancer (cirrhosis) and possibly in a proportion of colon and breast cancer.36 Poverty is associated with increased exposure to tobacco smoke, alcoholism, poor nutrition, and certain infectious agents. Thus, poverty can act as a carcinogen, which suggests that fighting cancer also requires fighting poverty.

Substrates of glutathione transferases

Quinones (ortho- and para-) and quinoneimines are structurally very similar to a,b-unsaturated carbonyls. They react with glutathione by two distinct and competitive routes, one of which is a reduction to the hydroquinone or aminophenol, where GSH does not react covalently with the substrate but emerges in the oxidized form (GSSG). The other route is relevant to the present context, being a nucleophilic addition to form a conjugate. The reaction has physiological significance since endogenous metabolites such as quinone metabolites of estrogens are conjugated to glutathione. A medicinal example is provided by the toxic quinoneimine metabolite (71, Figure 23 see 5.05 Principles of Drug Metabolism 1 Redox Reactions 5.08 Mechanisms of Toxification and Detoxification which Challenge Drug Candidates and Drugs) of paracetamol (30). Its glutathione conjugate (71) is not excreted as such in humans dosed with the drug, but as the mercapturic acid (67, Figure 22). The reaction is one of major...

Background Information

Whereas AGVHD models emphasize cellmediated immune processes, chronic GVHD (CGVHD) models focus upon the development of chronic, B cell-stimulatory autoimmune disorders (Goldman et al., 1991) AGVHD appears to be an inflammatory process mediated by TH1 cytokines, whereas CGVHD is mediated by Th2 cytokines. CGVHD is characterized by prolonged splenomegaly and lym-phadenopathy. Mice develop symptoms of systemic autoimmune disorders, including immune complex glomerulonephritis (Ito et al., 1992), primary biliary cirrhosis (Saitoh et al., 1991), and Sj0gren-syndrome- or scleroderma-like lesions (Fujiwara et al., 1991). Elevated levels of immunoglobulins, particularly IgG1 and IgE, and a variety of autoantibodies (including anti-DNA) are present in the serum. In general, the autoimmune syndrome of CGVHD is lethal within 6 months, due to development of immune complex-mediated glomerular nephritis. Murine CGVHD models share many of the pathologic features of the clinical disorder of chronic...

Urogenital and Gastrointestinal Tracts

Diseases of the urogenital and digestive organs caused 13 of the sudden and unexpected deaths in 1937.59 Nowadays, such cases are uncommon, with possibly the most common entity a massive hematemesis due to esophageal varices complicating cirrhosis of the liver. Occasionally, one will see a death following a duodenal ulcer eroding into a major blood vessel with massive GI hemorrhage. There are occasional deaths caused by peritonitis from a perforated duodenal ulcer or an acute peritonitis. These latter deaths are more common in alcoholics and psychotic patients on heavy doses of antip-sychotic medications that could mask the symptoms of these conditions and the patients' awareness of their illness.

Olfactory Disturbances Dysosmia

Cirrhosis And Cerebral Edema

Unilateral anosmia may be caused by a tumor (meningioma). Korsakoff syndrome can render the patient unable to identify odors. Viral infections (influenza), heavy smoking, and toxic substances can damage the olfactory epithelium trauma (disruption of olfactory nerves, frontal hemorrhage), tumors, meningitis, or radiotherapy may damage the olfactory pathway. Parkinson disease, multiple sclerosis, Kallmann syndrome (congenital anosmia with hypogonadism), meningoen-cephalocele, albinism, hepatic cirrhosis, and renal failure can also cause olfactory disturbances.

Extracutaneous Manifestations of Neonatal Lupus Erythematosus

Hepatobiliary disease of NLE apparently may assume several phenotypes. In a review of data from a national research registry, approximately 10 (19 219) of the cases in the registry had evidence of hepatobiliary disease (Lee et al. 2002). The three types of presentations noted were as follows (a) liver failure in utero or shortly after birth, often having the phenotype of neonatal iron storage disease (also known as neonatal hemochromatosis ) (b) transient conjugated hyperbilirubinemia occurring in the first few weeks of life and (c) transient aminotransferase elevations, occurring at 2-3 months of age. The latter two presentations eventuate in complete resolution, with no apparent residua. It has not been shown conclusively that each of these presentations truly represents a manifestation of NLE, but based on currently available information it seems likely.

Potassium Sparing Diuretics A

The mineralocorticoid aldosterone promotes the reabsorption of Na+ (Cl- and H2O follow) in exchange for K+. Its hormonal effect on protein synthesis leads to augmentation of the reabsorptive capacity of tubule cells. Spironolactone, as well as its metabolite canrenone, are antagonists at the aldosterone receptor and attenuate the effect of the hormone. The diuretic effect of spironolactone develops fully only with continuous administration for several days. Two possible explanations are (1) the conversion of spironolactone into and accumulation of the more slowly eliminated metabolite canrenone (2) an inhibition of aldosterone-stimulated protein synthesis would become noticeable only if existing proteins had become nonfunctional and needed to be replaced by de novo synthesis. A particular adverse effect results from interference with gon-adal hormones, as evidenced by the development of gynecomastia (enlargement of male breast). Clinical uses include...

Gender Ethnicracial And Life Span Considerations

Cirrhosis is most commonly seen in the middle-aged population it is the fourth leading cause of death in the population that is 35 to 55 years of age. It is more common in males than in females. Although the cause is obscure, liver disease appears to be more prevalent in preterm infants who have minimum enteral feedings and who were begun on total parenteral nutrition (TPN) at an early age. Hepatitis C is more common in minority populations, such as African Americans and Hispanic persons, than in other populations. Alcohol dependence and alcoholic liver disease are more common in minority groups, particularly among Native Americans. Primary biliary cirrhosis is more common in Northern Europeans and is less common in populations of African descent.

Primary Nursing Diagnosis

Patients are placed on a well-balanced, high-calorie (2500 to 3000 calories per day), moderate- to high-protein (75 g of high-quality protein per day), low-fat, low-sodium diet (200 to 1000 mg per day), with additional vitamins and folic acid. Accurate fluid intake and output are important to prevent fluid volume overload for most patients, intake should be limited to 500 to 1000 mL per day. Frequently, vitamin K injections are ordered to improve blood clotting factors. If coagulopathies worsen, treatment may require whole blood or fresh-frozen plasma to maintain the hematocrit and hemoglobin. If alcohol is the primary etiologic factor in liver cirrhosis, strongly encourage the patient to cease drinking. Commonly seen in cirrhosis patients are esophageal varices due to portal vein hypertension. Varices can rupture as a result of anything that increases the abdominal venous pressure, such as coughing, sneezing, vomiting, or the Valsalva's maneuver. To remedy bleeding of...

Discharge And Home Healthcare Guidelines

Emphasize to the patient with alcoholic liver cirrhosis that continued alcohol use exacerbates the disease. Stress that alcoholic liver disease in its early stages is reversible when the patient abstains from alcohol. Encourage family involvement in alcohol abuse treatment. Assist the patient in obtaining counseling or support for her or his alcoholism.

Mary Ann Cohen and David Chao

In 1967 Lipowski provided a classification of commonly encountered problems at the medical-psychiatric interface that is still relevant to AIDS psychiatry today. These problems (with a modification of the fifth item, discussed in Chapter 1 of this book) include psychiatric presentation ofmedical illness, psychiatric complications of medical illnesses or treatments, psychological response to medical illness or treatments, medical presentation of psychiatric illness or treatments, and comorbid medical and psychiatric illness. These five problems have been illustrated with casevignettes in Chapter 1. Somepersons withHIVand AIDS have no psychiatric disorder, while others have a multiplicity of complex psychiatric disorders that are responses to illness or treatments or are associated with HIV AIDS (such as HIV-associated dementia) or co-morbid medical illnesses and treatments (such as hepatitis C, cirrhosis, or HIV nephropathy and end-stage renal disease). Persons with HIV and AIDS may...

Peroxisome Proliferator Activated Receptory Key Regulator of Adipogenesis and Insulin Sensitivity

PPAR-y was first identified as a part of a transcriptional complex essential for the differentiation of adipocytes, a cell type in which PPAR-y is highly expressed and critically involved (6). Homozygous PPAR-y-deficient animals die at about day 10 in utero as a result of various abnormalities including cardiac malformations and absent white fat (7-9). PPAR-y is also involved in lipid metabolism, with target genes such as human menopausal gonadotropin coenzyme A synthetase and apolipoprotein (apo)-A-I (10,11). Chemical screening and subsequent studies led to the serendipitous discovery that thiazolidinediones (TZDs) were insulin sensitizers that lower glucose by binding to PPAR-y. Used clinically as antidiabetic agents, the TZD class includes pioglitazone (Actos) and rosiglitazone (formerly BRL49653, now Avandia) (12,13). Troglitazone (ReZulin) was withdrawn from the market because of idiosyncratic liver failure. Naturally occurring PPAR-y ligands have been proposed, although with...

Malignant Primary Tumors

Hepatocellular Carcinoma (HCC) is the most common abdominal tumor worldwide, primarily found in Asian and Mediterranean populations. In European countries, HCC is found mostly in patients with liver cirrhosis or Fig. 4. Spiral CT of small HCC. a Unen-hanced CT shows only changes of cirrhosis with nodular contour to liver. b Arterial phase image shows small enhancing HCC nodule (arrow) seen only on this phase of imaging. Note that this is a late arterial phase image, as evidenced by early enhancement in portal vein (P) and inferior vena cava (I). c Portal venous phase image shows wash-out of contrast in tumor such that the lesion is again isointense with liver. d Pathology specimen confirming small HCC with surrounding fibrous capsule Fig. 4. Spiral CT of small HCC. a Unen-hanced CT shows only changes of cirrhosis with nodular contour to liver. b Arterial phase image shows small enhancing HCC nodule (arrow) seen only on this phase of imaging. Note that this is a late arterial phase...

Diffuse Liver Disease

The role of imaging in cirrhosis is to identify effects of portal hypertension and to detect HCC. The liver in early cirrhosis often has a normal appearance on CT. Early CT features include hepatomegaly and heterogeneity of hepatic parenchymal attenuation. Advanced cirrhosis is characterized by decreased hepatic volume with prominence of the porta hepatis and intrahepatic fissures, decreased size of the right hepatic lobe and medial segment of the left lobe, with a corresponding relative increase in the size of the caudate lobe and left lateral segment 28 . Regenerative nodules are seen on CT in those patients with siderotic nodules (dense on unenhanced CT, and signal void on MRI) and are better appreciated on MRI than on CT due to greater MR susceptibility to iron 29 . Dysplastic nodules (DN) represent a continuum and transition between regenerative nodules and HCC, and therefore is an important imaging diagnosis. When large, they are characteristically hyperintense on Tl-weighted...

Differential Diagnosis

Arterially enhancing lesions include FNH, hepatocel-lular adenoma, HCC and metastases from carcinoid, melanoma, renal cell carcinoma, breast, sarcoma and islet cell tumor. In general, HCC is considered when there is a setting of cirrhosis, while FNH is considered in young women and hepatic adenoma in patients on oral contraceptives, anabolic steroids or with history of glycogen storage disease.

Etiologies of Hypoglycemia

Pathophysiological Endocrinopathy (Addi-son's disease, Sheehan's syndrome) neoplasms (insulinomas, multiple endocrine adenomatosis MEA type I) liver disease (alcoholism, cirrhosis) chronic renal failure (CRF) and hemodialy-sis miscellaneous (AIDS, autoimmune diseases, pregnancy).

Autoimmune Pancreatitis

Autoimmune pancreatitis (AIP) is a relatively new syndrome of clinical and histologic findings and has also been described as 'lymphoplasmocytic sclerosing pancreatitis with cholangitis', 'nonalcoholic duct-destructive chronic pancreatitis' and 'chronic sclerosing pancreatitis'. A number of features can be found, including hypergammaglobulinemia, elevation of serum IgG4, IgG4-containing immune complexes and a number of antibodies, such as antinuclear antibodies, antibodies against lactoferrin, carbonic anhydrase type II, and rheumatoid factors. Histological features include fibrosis with lym-phoplasmacytic infiltration of interlobular ducts. The majority of lymphocytes are CD8+ and CD4+ T-lympho-cytes, while B-lymphocytes are less frequent. In general, diagnosis of AIP is established by clinical signs and laboratory and morphological findings. An association with other autoimmune disease such as Sjogren-syndrome, primary biliary cirrhosis, primary sclerosing cholangitis, Crohn's...

Pharmacokinetics in Patients

Pharmacokinetic profiles have been studied in adult and pediatric hemophilia patients, as well as in adults with acquired FVII deficiency (i.e., healthy adult volunteers pretreated with acenocoumarol and patients with liver cirrhosis) 41-45 . The clearance and half-life values (range 2.4 to 3.2 h) after bolus administration of rFVIIa were in the same range in the adult populations studied. However, pediatric patients with hemophilia have been reported to have a shorter half-life (1.3 h) and higher clearance values than the adults with hemophilia 42,44 . A clinical trial to evaluate this possible difference in half-life and clearance between adults and pediatric patients with hemophilia is in progress.

Clinical evaluation

Variceal bleeding should be considered in any patient who presents with significant upper gastrointestinal bleeding. Signs of cirrhosis may include spider angiomas, palmar erythema, leukonychia, clubbing, parotid enlargement, and Dupuytren's contracture. Jaundice, lower extremity edema and ascites are indicative of decompensated liver disease.

Results from Finalized Trials Outside the Current Indication

The liver is the principal site of synthesis and clearance of coagulation factors, components of the fibrinolytic system, and anticoagulants. The most frequently encountered hemato-logical abnormalities in patients with liver disease include prolonged PT and hyperfibri-nolysis 78,79 . The progressive loss of liver parenchymal cells associated with cirrhosis results in a decreased synthesis of the vitamin K-dependent coagulation factors (FII, FVII most pronounced , FIX, FX), fibrinogen, and proteins C and S. When bleeding occurs, all Variceal bleeding is a medical emergency that has a 6-week mortality in the range of 5 to 50 , depending on the severity of the underlying liver disease, mainly because of the high rate of failure to control bleeding during the first days after the initial onset of bleeding 81 . The treatment modalities available for the patient with advanced cirrhosis and active variceal bleeding remains unsatisfactory in terms of a safe and fast correction of the...

Gallbladder Wall Thickening

Focal or diffuse gallbladder wall thickening is most commonly caused by cholecystitis. Noninflammatory conditions that may produce gallbladder wall thickening include heart failure, cirrhosis, hepatitis, hypoalbuminemia, and renal failure. Gallbladder carcinoma should be suggested when there are features of focal mass, lymphadenopathy, extension of the process to adjacent organs, hepatic metastases, or biliary obstruction at the level of the porta hepatis 1 . Xanthogranulomatous cholecystitis (XGC) is a pseudotumoral inflammatory condition of the gallbladder that ra-diologically simulates gallbladder carcinoma. There is a significant overlap in the CT features of XGC and gallbladder carcinoma. Both entities may demonstrate wall thickening, infiltration of the surrounding fat, hepatic involvement, and lymphadenopathy 2, 3 . Adenomyomatous

Lower Gastrointestinal Bleeding

Risk factors that may have contributed to the bleeding include and nonsteroidal anti-inflammatory drugs, anticoagulants, colonic diverticulitis, renal failure, coagulopathy, colonic polyps, and hemorrhoids. Patients may have a prior history of hemorrhoids, diverticulosis, inflammatory bowel disease, peptic ulcer, gastritis, cirrhosis, or esophageal varices.

Pharmacologic Highlights

The most common problem for patients with liver failure is fluid volume excess. Measure the patient's abdominal girth at the same location daily, and mark the location as a reference point for future measurements. Notify the physician if the girth increases by 2 inches in 24 hours. Provide the required fluid allotment over the three meals and at night. If the patient desires, reserve some fluids to be used as ice chips. Provide mouth care every 2 hours. Because areas of edema are likely to be fragile and prone to skin breakdown, provide skin care. One of the most life-threatening complications of liver failure is airway compromise because of neurological or respiratory deterioration. Keep endotracheal intubation equipment and an oral airway at the bedside at all times. Elevate the head of the patient's bed to 30 degrees to ease respirations, and support the patient's arms on pillows to decrease the work of breathing. It is essential to be at the bedside and to perform serial...

Clinical manifestations

Hepatic encephalopathy is a diagnosis of exclusion. Therefore, if a patient with acute or chronic liver failure suddenly develops altered mental status, concomitant problems must be excluded, such as intracranial lesions (hemorrhage, infarct, tumor, abscess), infections (meningitis, encephalitis, sepsis), metabolic encephalopathies (hyperglycemia or hypoglycemia, uremia, electrolyte imbalance), alcohol intoxication or withdrawal, Wernicke's encephalopathy, drug toxicity (sedatives, psycho-active medications), or postictal encephalopathy.

Cystic Dilatation of Intrahepatic Bile Ducts

Intrahepatic Bile Duct Fibrosis

Although intrahepatic bile duct dilatation is a feature of primary sclerosing cholangitis, the duct dilatation is typically fusiform and isolated. The degree and extent of duct dilatation in primary sclerosing cholangitis is not as severe as that in obstructive biliary dilatation, Caroli disease, or recurrent pyogenic cholangitis because fibrosis, stricture formation, and secondary cirrhosis are the major features of primary sclerosing cholangitis. Multiple peribiliary cysts in sequence may simulate bile duct dilatation that has a beaded or saccular appearance 12 . The bile ducts adjacent to peribiliary cysts are normal. Therefore, correct diagnosis depends upon visualization of a normal bile duct. Peribiliary cysts are usually associated with various hepatic diseases such as cirrhosis, polycystic liver disease, portal hypertension, portal vein obstruction, and metastatic disease.

Antithyroid Drug Therapy

An apparent difference between the adult and pediatric populations is the higher incidence of adverse side effects of antithyroid medications in the young. Published studies including 500 children 6, 13, 59, 108, 109 , show that complications of drug therapy include increases in liver enzymes (28 ) and leukopenia (25 ). Up to 0.5 of propylthiouracil (PTU) or methimazole (MMI)-treated children will develop serious complications 6, 10 . By 1998, 36 serious adverse events and two deaths from liver failure (from PTU) due to antithyroid drug therapy of childhood Graves' disease had been reported to the FDA MedWatch Program, which is very prone to under reporting 6 . In addition, at least five other deaths related to antithyroid medication therapy in children have been reported to me by professionals. Other rare and serious adverse effects of thionamide drugs include periarteritis nodosa, other forms of vasculi-tis, nephrotic syndrome, hypothrombinemia, and aplastic anemia 6 .

Erythropoietic protoporphyria

Perioral furrowing, and aged-appearing, thickened, or hyperkeratotic skin of the dorsal hands with sustained, more intense, or frequent exposures, waxy scleroderma-like induration and or weather-beaten or cobblestone textures of the face and dorsal aspects of hands progressive liver failure in rare instances, with hepatosplenomegaly and jaundice

Risk factors detection methods and control procedures

Susceptibility to Yersinia infection remains high, however, until about 14 years of age. Although there is a general susceptibility to Y. ente-rocolitica among the immunocompromised, the most important predisposing conditions involve cirrhosis, or other liver disorder, and iron overload. Liver disorders and iron overload also predispose to more serious systemic infections. Hospitalised patients, in general, are at enhanced risk of Yersinia infection. Bio-serotypes not usually considered pathogenic have been involved on some occasions. Hospitalised patients, especially children, may also be at risk from Y. frederickensii and other species not usually considered pathogenic.

Miscellaneous complications

Liver damage from drug abuse is often related to direct drug toxicity, allergic or idiosyncratic reactions, or various forms of hepatitis.4 Alcohol-induced fatty change, alcoholic hepatitis and cirrhosis are well-known entities which may exacerbate the effects of other drugs of abuse taken concomittantly. Hepatic damage from cocaine has been induced in laboratory animals5 but does not appear to occur in humans.1,6 Intravenous heroin addiction has been associated with a sometimes intense lymphoid infiltrate (occasionally with germinal centers) of the portal zones,7 often referred to as triaditis . This appears to be independent of viral hepatitis and may represent an immunologic phenomenon. These infiltrates are, however, not invariable with intravenous drug abusers and may be seen in apparently normal people (but usually to a lesser degree). Another nonspecific but fairly typical finding in heroin addicts is mild to moderate hepatosplenomegaly, sometimes associated with enlarged lymph...

Cause Manner and Mechanism of Death

One must also understand that sometimes the classification of manner of death is based on tradition. Thus, if two people are kidding around with a gun and one individual points the gun at another and pulls the trigger, in some localities, this is classified as an accident, in others, as a homicide. An individual walking down the street is hit by an automobile the driver stops. This is an accident. If the driver continues on his way, in a number of jurisdictions, this is classified as a homicide. If one drinks too much alcohol and dies of acute alcohol intoxication, this is an accident. If one drinks too much alcohol every day for 15 years and develops cirrhosis of the liver and chronic liver failure due to the alcohol, then the manner of death is classified as natural.

Carbon Tetrachloride May Alter The Hepatic Contents Of Antioxidants

Chronic CCl4 administration is known to induce cell necrosis by increased oxidative stress,46 and repeated injections of CCl4 initiate the fibrogenic process in the liver and may result in cirrhosis.47 Administration of vitamin E prevents CCl4-induced liver necrosis and cirrhosis, which supports the role of reactive oxygen species in liver damage associated with CCl4.48 CCl4 is metabolically activated by cytochrome P450 to form CCl3 free radicals, which initiate lipid peroxidation in the cell and decrease cellular ubiquinol-10.49 Kishi et al. demonstrated that administration of ubiquinone supplement attenuated CCl4-induced cell necrosis.49 In a study in which rats were exposed to diethylnitrosamine (DEN) as initiator, followed by repeated injections of carbon tetrachloride (CCl4)

Drug and disease interactions

The pharmacokinetics of several drugs have been shown to be influenced by concurrent disease processes.16 The clearance of many drugs decreases in those individuals with chronic hepatic disease such as cirrhosis. In contrast, in acute reversible liver conditions, such as acute viral hepatitis, the clearance of some drugs is decreased or the half-life increased and for others, no change is detected. The volumes of distribution of some drugs are unaltered in hepatic disease while an increase is observed for other drugs, especially those bound to albumin in individuals with cirrhosis. This phenomenon is due to the decreased synthesis of albumin and other proteins. The influence of liver disease on drug absorption is unclear. It is probable though that the oral bioavailability of drugs highly extracted from the liver is increased in cirrhosis. The reasons are decreased first pass hepatic metabolism and the development of portal bypass in which blood enters the superior vena cava directly...

Hepatic Form lethalinfantile

The second form presents as a lethal neonatal multiorgan deficiency of carnitine palmitoyltransferase II. Reduced CPT II activity in multiple organs is observed and reduced concentrations of total and free carnitine and increased concentrations of lipids and long chain acylcarnitine can be found. The accumulation of long-chain acylcarnitines has an arrhythmogenic effect on the heart. The patients presented with hypoketotic hypo-glycaemia, seizures, tachycardia, cardiomegaly, hepatomegaly, liver failure and died within the first two years.

Suggested Reading

Laheij RJF, J Buth (2000) for the European Collaborators. Participants report. Overview of the overall patients cohort of the EUROSTAR data registry Lammer J, Hausegger KA, Fluckiger F et al (1996) Common bile duct obstruction due to malignancy treatment with plastic versus metal stents. Radiology 201 167-172 Lee BH, Choe DH, Lee JH et al (1997) Metallic stents in malignant biliary obstruction prospective long-term clinical results. AJR Am J Roentgenol 168 741-745 Leertouwer TC, Gussenhoven EJ, Bosch JL et al (2000) Stent placement for renal artery stenosis where do we stand A metaanalysis. Radiology 216 78-85 Lencioni RA, Allgaier HP, Cioni D et al (2003) Small hepatocellular carcinoma in cirrhosis randomized comparison of radio-frequency thermal ablation versus percutaneous ethanol injection. Radiology 228 235-240 Lin SM, Lin CJ, Lin CC et al (2005) Randomised controlled trial comparing percutaneous radiofrequency thermal ablation, percutaneous ethanol injection, and percutaneous...

Calciphylaxis Calcific Uremic Arteriolopathy

Calciphylaxis Pictures

Patients developing calciphylaxis have end-stage renal disease, but some have milder renal insufficiency. Other cases have occurred in association with Crohn's disease (2), alcoholic cirrhosis (3), acute renal failure (4), metastatic breast cancer (5), and primary hyperparathyroidism (6). Most earlier literature on the subject regarded the disease as a form of metastatic calcification due to secondary hyperparathyroidism of end-stage renal disease. This view is not supported by data that show that only one third of patients with calciphylaxis have an elevated calcium-phosphate product. Additionally, the calcium-phosphate product of calciphylaxis patients and a control group of patients with end-stage renal disease without skin lesions is similar (7). Evidence of hyperparathyroidism is often lacking in patients with calciphylaxis, and treatment by parathyroidectomy results in clinical improvement in only a subset of patients. A group of patients with calci-phylaxis has been described...

Drugs Prescribed For Gun Shot Wounds

Autopsy findings may vary from obvious signs of drug abuse to a negative autopsy. Chronic intravenous drug abusers have easily recognizable needle tracks while chronic alcoholics may have cirrhosis of the liver and bleeding abnormalities. Drugs as a cause of death should be suspected in a negative autopsy in which there is no

Fields Of Expertise Within Toxicology

Cirrhosis of the liver is one of the most well-known adverse effects of chronic alcohol abuse. The cholesterol-lowering, life-prolonging statin drugs must be monitored routinely for hepatotoxicity and rhabdomyolosis. A Google search on the terms statins, hepatotoxicity, and review produced over 22,000 hits indicating this is a very active field of interest.

Medical Complications Of Alcoholism Gastrointestinal Tract and Pancreas

Alcohol causes decreased peristalsis and decreased esophageal sphincter tone, which leads to reflux esophagitis with pain and stricture formation (Bor et al., 1998). The Mallory-Weiss syndrome refers to a tear at the esophageal-gastric junction caused by intense vomiting. Another source of bleeding from the esophagus is esophageal varices secondary to the portal hypertension of cirrhosis.

Plasma Protein Binding

In diseased patients the albumin concentration can be significantly different. For patients with nephrotic syndrome, burns, or cirrhosis, the albumin concentration can be less than 10 gL_ 1, i.e., 20-30 of the normal concentration.4 In contrast, the normal plasma concentration (human) of a1-acid glycoprotein is 0.4-1.0gL_ 1 (10-30mM) (MW 44kDa), and in patients with inflammatory diseases, it can be elevated by up to 4-5-fold.4 Taking into account the significant variation in protein content and concentration in human plasma (and other species) it is useful to determine PPB using large plasma pools containing a statistically reasonable number of donors.2

Coenzyme Q And Atherosclerosis

In contrast to coronary artery disease patients, a significant decrease in the plasma coenzyme Q10 redox status has been reported for patients with hyperlipidemia, liver disease (hepatitis, hepatoma, cirrhosis), or treated with percutaneous transluminal coronary angioplasty.75,103 105

BOX 1 Bleeding Esophageal Varices

Esophageal varices (fragile, distended, and thin-walled veins in the esophagus) occur in patients with liver failure because of portal hypertension. Obstructed blood circulates to low-resistance alternate vessels around the portal circulation in the liver, which is a high-pressure system. One of these routes is through the esophageal veins, which become distended with blood, irritated from pressure, and susceptible to rupture. Treatment of esophageal varices includes develop massive hepatic cystic disease that results in liver failure. Wilson disease is a genetic disorder (autosomal recessive pattern) leading to a large liver accumulation of copper. About 5 of patients suffer from acute liver failure or fulminant hepatitis.

Surgical Liver Transplant

Cirrhosis is a chronic liver disease that is characterized by destruction of the functional liver cells, which leads to cellular death. Cirrhosis along with other chronic liver diseases result in up to 35,000 deaths each year in the United States and is the ninth leading cause of death. In cirrhosis, the damaged liver cells regenerate as fibrotic areas instead of functional cells, causing alterations in liver structure, function, blood circulation, and lymph damage. The major cellular changes include irreversible chronic injury of the functional liver tissue and the formation of regenerative nodules. These changes result in liver cell necrosis, collapse of liver support networks, distortion of the vascular bed, and nodular regeneration of the remaining liver cells. The classification of cirrhosis is controversial at present. However, most types may be classified by a mixture of causes and cellular changes, defined as follows alcoholic crypto-genic and postviral or postnecrotic biliary...

Poisoning with Nicotine Patches

The 24-h effect of TD GTN on splanchnic hemodynamics in nine patients with biopsy-proved liver cirrhosis was evaluated (148). GTN tape, capable of releasing 15 mg of drug in 24 h, was applied to chest skin at 7 am of the second day. After GTN application, the mean portal blood velocity and flow significantly decreased by 18 and 22 , whereas superior mesenteric artery velocity decreased and resistance indices increased. This indicated that GTN, from a transdermal long-acting system, significantly influenced portal hemodynamics in liver cirrhosis, and the use of GTN was proposed for long-term clinical studies to test efficacy in preventing gastrointestinal bleeding.

The Pathophysiology of Benign Prostatic Hyperplasia

The prostate of aging males can be stimulated to undergo excessive growth. This is characterized by a number of cellular and molecular alterations leading to increased cell proliferation and reduced apoptosis in the prostate epithelium and stroma. The 'remodeling' that occurs as a result of these processes can permanently alter the appearance of the prostate, and may result in symptoms, long-term damage, and prostate cancer. It is not clear why these changes occur in some males, although it has been suggested that they are linked to a number of risk factors such as smoking, racial differences, obesity, liver cirrhosis, cardiovascular risks, and genetic predisposition. The pathogenesis of BPH is discussed in this section.

Lupus Erythematosus and Sjgrens Syndrome

Anti-La SSB occurs in approximately 15 of patients, and most have SS and may be diagnosed as having SS-SLE overlap syndromes. Anti-Ro SSA (without anti-La SSB) occurs in approximately 30 of patients with SLE without dry eyes or mouth. SS can precede LE by years, but LE can precede the appearance of SS also. Anti-Ro SSA antibodies etc found in polymyositis, scleroderma, and primary biliary cirrhosis, and association with SS is invariably (Venables 1988). The skin changes associated with SS include dry eyes, dry mouth, and dry genitals as major clinical symptoms. Other clinical symptoms include annular erythema, Sweet's syndrome-like lesions, vitiligo-like changes, sarcoidosis, and LP-like and amyloidosis nodularis-like symptoms (Ueki 1994, personal communication). Annular erythema is one of the prominent clinical features of both SS and SLE. Katayama et al. (Katayama et al. 1991) subdivided annular erythema into three types. Type I is an isolated annular erythema with an elevated and...

Definition Classification and Diagnosis of Hypertension

Hypertension is usually systemic, but it may be limited to certain organs. The term 'pulmonary hypertension' is used to describe a selective elevation of pressure in pulmonary arteries. Portal hypertension, a persistent elevation of pressure in portal veins, is usually a secondary hypertension that often occurs as a consequence of liver cirrhosis.

Disorders of the Gallbladder the Pancreas and the Liver

Picture Composition Gallstones

Cirrhosis Cirrhosis is a progressive liver disease that results from long-term damage to liver cells. The liver is continuously exposed to potential toxins, including drugs (over-the-counter, prescribed, or illegal) and alcohol all of which can damage liver cells over time. Eventually the tissue becomes scarred, which blocks the flow of blood through the liver, causing liver failure and portal hypertension (high blood pressure in the veins from the intestines and spleen to the liver). In the United States, cirrhosis is among the leading causes of death. Men are more than twice as likely as women to die of chronic liver disease and cirrhosis. Heavy alcohol consumption is the most common cause of cirrhosis. Other causes of the disease include viral hepatitis, hemochromatosis (excess iron in the body), Wilson's disease (excess copper in the body), cystic fibrosis, blocked bile ducts, and adverse drug reactions. Cirrhosis does not always cause symptoms and may be detected during a routine...

Iron Overload Depletes Hepatic Antioxidants

Iron has been used as a model substance in the studies of oxidative liver damage, since iron is known to increase the production of free radicals and enhance oxidative stress.24,25 In humans, the most common diseases with iron overload are genetic hemochromatosis and transfusional iron overload. Genetic hemochromatosis is an inherited disorder of iron metabolism in which excess iron is absorbed via the gut and deposited in parenchymal organs, predominantly the liver.26,27 With time, deposition of intracellular iron in hepatocytes results in lipid peroxidation of cellular membranes, impairment of mitochondrial functions, leakage of lysosomal enzymes, and finally iron-induced necrosis (called sideronecrosis).26 Once sideronecrosis has occurred, Kupffer cells and lipocytes will become activated and collagen synthesis increased,28 eventually leading to fibrosis, cirrhosis, and an increased risk for the development of hepatocellular carcinoma.29-31 However, in spite of increased oxygen...

Carbon Monoxide Poisoning Caused Liver Disease

In alcoholics with cirrhosis of the liver, there is a relatively obscure entity characterized by massive non-traumatic intra-abdominal hemorrhage. Di Maio reported three cases74 in which no source for the bleeding was found. Of the three, one who was briefly hospitalized showed evidence of a disseminated intravascular coagulopathy. It was the author's opinion that this was the most likely cause of the intra-abdominal hemorrhage in the two other cases and could be attributed to the cirrhosis of the liver. Two of these deaths were obviously sudden and unexpected, with one 44-year-old woman observed to become rigid and collapse while seated in a chair at home. She was found to have 2750 mL of non-clotted blood in her abdominal cavity and advanced micro-nodular cirrhosis. A second individual was a 38-year-old man who collapsed while walking from a convenience store to a parked truck. Again, there was no evidence of trauma, and 4800 mL of non-clotted blood was found in the abdominal...

Liver Transplantation

Postoperative setting, a hypercoagulable state has also been reported, which can result in thrombosis. Thus, in the earlier phase of this procedure, large numbers of red cells are required and, associated with this, the transfusion of plasma and or platelets. If fibrinogen levels drop precipitously low, cryoprecipitate may also be transfused. Liver transplantation, when first initiated, can be associated with the transfusion of more than 100 blood components case. As experience is gained, however, the blood transfusion requirements frequently drop by more than two thirds. The indication for transplantation may also influence the transfusion requirements those undergoing transplantation for primary biliary cirrhosis or carcinoma use fewer blood products than those with other diagnoses, such as scle-rosing cholangitis.

Patterns of Psychoactive Substance

Traditional patterns of psychoactive substance use in most societies were episodic, coming at times of personal celebrations (e.g., birth and marriage), rituals (e.g., arrivals, departures, and changes in status), and seasonal celebrations (e.g., harvest and New Year). Exceptions to this pattern were daily or at least occasional use of alcohol as a foodstuff and use of various stimulants (e.g., betel-areca, tea and coffee, and coca leaf) in association with long, hard labor (e.g., paddy rice or taro farming and silver mining). Daily beer or wine drinking was limited to Europe, especially the para-Mediterranean wine countries and central grain-beer countries. Such daily or titer use is not without its problems, even when socially sanctioned. Hepatic cirrhosis and other organ damage (e.g., to brain, bone marrow, neuromuscular system, and pancreas) may result from long-term, daily use of more than 2-4 ounces of alcohol, depending on body weight (Baldwin, 1977). Daily use of stimulants,...


APAP is contained in over 100 over-the counter (OTC) preparations, and fulminant liver failure from APAP overdose is the second most common cause of liver transplantation in the United States (No. 1 cause hepatitis C). More than 100,000 analgesic overdoses per year, over 200 deaths, 46 due to APAP. APAP overdose hospitalizations are greater than all other overdose hospitalizations. APAP has replaced ASA as the analgesic-antipyretic of choice, especially for children secondary to safety profile, N-acetylcysteine (NAC) antidote, ASA toxicity, and Reye's Syndrome. APAP toxicity risk factors low hepatic gluta-thione stores in alcoholics and malnourished P450 enzyme induction from INH, rifampin, anticonvulsants, and chronic alcohol abuse.

Specific History

A careful medication history is essential, and any medication reported to cause an LP-like eruption should be discontinued. The features of these drug eruptions are sometimes strikingly similar to the idiopathic disease both clinically and microscopically, and offending drugs will be uncovered only by careful history. The list of medications that cause these reactions continues to grow and any agent should be suspect. These drug-induced eruptions are slow to clear and it is not unusual for improvement to take 2 or 3 months. LP has also been associated with an increased incidence of autoimmune diseases (Sjogren's syndrome, sicca syndrome, alopecia areata, vitiligo, ulcerative colitis, myasthenia gravis, and diabetes mellitus), chronic dermatophyte infections, and chronic liver disease (primary biliary cirrhosis, alcoholic cirrhosis, chronic active hepatitis B and C). The presence of a fungal infection is usually significant the authors have seen many cases of LP that clear and...


Contraindications Diabetic ketoa-cidosis, cirrhosis, inflammatory bowel disease, colonic ulceration, partial intestinal obstruction or predisposition to intestinal obstruction, chronic intestinal diseases associated with marked disorders of digestion or absorption, conditions that may deteriorate as a result of increased gas formation in the intestine. In significant renal dysfunction. Severe, persistent bradycardia. Lactation. Special Concerns Safety and efficacy have not been determined in children. Acarbose does not cause hypo-glycemia however, sulfonylureas and insulin can lower blood glucose

Blood at the Scene

Natural deaths may be associated with abundant blood near or away from the body. Chronic alcoholics may have such advanced disease that they may bleed from the mouth or the rectum or both. This is caused by liver damage (cirrhosis) in which blood begins to back up in the veins of the esophagus and the rectum. These thick and swollen veins are called varices. Varices have a tendency to rupture, and when they do, the bleeding may be quite extensive. The decedent may die within minutes, although the time is usually longer. There may be abundant blood in the toilet, bathtub, on towels, or in cups.

Native Americans

Alcohol-related motor vehicle fatalities are highest in the Native American population, with a 68.1 rate compared to 44.2 for whites (National Highway Traffic Safety Administration, 1999). Cirrhosis is the sixth leading cause of death in Native Americans (Stinson, Grant, & Dufour, 2001).

African Americans

A 1996 report by the Group for the Advancement of Psychiatry (GAP) on alcohol abuse among African Americans found little difference in the lifetime prevalence of alcoholism between African Americans and whites. The alcoholism prevalence for African Americans is low in the young adult group and then increases, in contrast to the alcoholism prevalence for whites, which starts at moderately high levels in the young group and then decreases. Deaths from alcohol-induced causes are about 2.5 times higher in the black population than in the white population. Cirrhosis death rates for African American males are 45.3 compared to 34.7 for whites (Caeteno & Clark, 1998b). Motor vehicle fatalities are essentially equal between blacks (45.2) and whites (44.2 ) (National Highway Traffic Safety Administration, 1999).

Hispanic Americans

Hispanic American men drink more than Hispanic American women regardless of age. Mexican American men drink more and abstain less than either Puerto Rican or Cuban American men. Hispanic American men and women drink more as their income increases (Group for Advancement of Psychiatry, 1996). Surveys in 1984 and 1995 revealed that alcohol-related problems increased in Hispanic males but remained stable in women of all ethnicities, and stable in black males and white males (Caetano & Clark, 1998b). Mexican Americans have a motor vehicle alcohol-related mortality rate of 54.6 , while that of Cuban Americans is 36.6 (National Highway Traffic Safety Administration, 1999). Cirrhosis rates for Hispanic males are 61.8 per 100,000, which is higher than that found in black or white males. The notion that machismo is related to drinking in Mexican American males is dispelled by statistics showing equal machismo influences in white and non-Hispanic minorities (Caetano & Clark, 1998a).

Imaging Techniques

MR examination of liver includes sequences providing T1, T2, and with contrast enhancement. Specific pulse sequences depend on the make of the scanner, patient compliance and the clinical question being addressed 3 . In-and out-of-phase T1 imaging is recommended to allow for maximal tumor detection and characterization of fat. In general, dynamic imaging with extracellular gadolinium-based contrast agents is used for lesion characterization and detection of tumors in a setting of cirrhosis, and tissue-specific agents are also used to maximize detection of metastases in a non-cirrhotic liver 4, 5 .

Nervous System

Rological effects, alcoholic dementia and Wernicke-Korsakoff syndrome were discussed earlier. Hepatic encephalopathy occurs in the setting of severe liver failure as a result of either severe alcoholic hepatitis or cirrhosis. Early manifestations of encephalopathy include inappropriate behavior, agitation, depression, apathy, and sleep disturbance. Confusion, disorientation, and depressed mental status develop in the advanced stages of encephalopathy. Physical examination may demonstrate asterixis, tremor, rigidity, hyperreflexia, and fetor hepaticus. Treatment requires the elimination of the offending condition, dietary protein restriction, and removal of nitrogenous waste from the gut with osmotic laxatives and antibiotics (lactulose and neomycin, respectively) (Adams & Victor, 1989).


Eyelid Contusion

The size and severity of a contusion is not always indicative of the amount of force applied, though, obviously, the greater the force, the greater the contusion. Certain factors influence the size of a contusion age, sex, the condition and health of the victim, and the site and type of tissues struck. Children and the elderly bruise more easily because of loose delicate skin in the former and loss of subcutaneous supportive tissue in the latter. Senile purpura (ecchymoses) on the forearms of the elderly may be mistaken for bruises. Women, especially if obese, seem to bruise more easily. Well-conditioned, muscular individuals are more resistant to bruising. Soft, lax, vascular tissue, such as in the eyelid, is more susceptible to bruising than areas such as the palm. Alcoholics with cirrhosis, individuals with bleeding diatheses, and individuals taking aspirin bleed more easily. A single therapeutic dose of aspirin irreversibly inhibits platelet function for the 7-d life of the...


The most serious complication of hepatitis is fulminant hepatitis, which occurs in approximately 1 of all patients and leads to liver failure and hepatic encephalopathy and, in some, to death within 2 weeks of onset. Other complications include a syndrome that resembles serum sickness (muscle and joint pain, rash, angioedema), as well as cirrhosis, pancreatitis, myocarditis, aplastic anemia, or peripheral neuropathy.


Erythema, and diabetes mellitus hypoami-noacidemia cheilosis normochromic, nor-mocytic anemia venous thrombosis weight loss neuropsychiatric signs and symptoms pseudoglucagonoma syndrome necrolytic migratory erythema without a glucogon-secreting tumor, but with another underlying cause such as cirrhosis, celiac sprue, or pancreatitis

Carolis Disease

Caroli's Disease is a congenital disease of the intrahepatic biliary tree characterized by multiple, saccular dilations of the bile ducts. Two types occur the simple type and the periportal fibrosis type. The simple type is associated with recurrent cholangitis, liver abscesses, abdominal pain, and fever. It is also associated with medullary sponge kidney, cystic lesions of the kidney, 60-80 of the time. The periportal fibrosis type has the same type of intrahepatic biliary dilation but also is associated with congenital hepatic fibrosis, cirrhosis, and portal hypertension. Cho-langitis and kidney lesions are also commonly seen with this type. Caroli's disease is highly premalignant.

Hepatitis B Virus

HBV can infect pregnant women but does not cause more severe disease than seen in the general population. Chronic carriers of the virus usually have uncomplicated pregnancies unless evidence of liver failure is present. The importance of HBV infection during pregnancy is the significant risk of transmission to the infant (2,3,5). If the mother is known to be HBV infected and is acutely infected or a chronic carrier, the infant is at risk not only for infection, but also to become a chronic HBV carrier.

Hepatitis C Virus

HCV is spread primarily by blood-borne contact with infected blood. The most common risk factors identified are intravenous drug use and blood transfusion or transplantation prior to 1992. Sexual acquisition of the virus is a very inefficient form of transmission and has not been proven definitively in the absence of confounding risk factors. The prevalence of HCV infection in the United States is approx 2 , and in 1999 chronic HCV infection and subsequent liver failure were the leading indications for liver transplantation (8,9).


17.3.2 Oxidative Stress in Patients with Hepatitis, Cirrhosis, and Hepatoma Human liver cancer often develops after the onset of chronic hepatitis and the subsequent cirrhosis. Measurement of oxidative stress at each stage is of interest since oxidative stress has been suggested as a causative factor in cancer. However, only a limited number of papers have documented the occurrence of oxidative stress in these liver patients. Therefore, we applied the above described method to plasma obtained from patients with hepatitis, cirrhosis, and hepatoma.8 Patients examined in this study were hospitalized at First Department of Medicine in Kyoto Prefectural University of Medicine and were diagnosed with chronic active hepatitis (18 men and 10 women), liver cirrhosis (10 men and 6 women), and hepatocellular carcinoma (15 men and 5 women). All were infected with hepatitis C virus except for 3 patients with hepatitis, 1 with cirrhosis, and 2 with hepatoma who had contracted the hepatitis B virus....

Telogen Effluvium

Telogen Effluvium Crown

Figure 5 (A) Severe thinning of the parietal scalp hair in a woman with severe acute telogen effluvium (TE) that occurred four months after hospitalization for pneumonia and cirrhosis. (B) Acute TE causing temporal thinning in a woman three months postpartum. (C) Same patient as in A demonstrating partial regrowth of hair after four months. (D) Photograph taken nine months after A demonstrating complete resolution of the patient's acute TE and full hair regrowth. Figure 5 (A) Severe thinning of the parietal scalp hair in a woman with severe acute telogen effluvium (TE) that occurred four months after hospitalization for pneumonia and cirrhosis. (B) Acute TE causing temporal thinning in a woman three months postpartum. (C) Same patient as in A demonstrating partial regrowth of hair after four months. (D) Photograph taken nine months after A demonstrating complete resolution of the patient's acute TE and full hair regrowth.

Endocrine System

Alcohol interferes with gonadal function even in the absence of cirrhosis by inhibiting normal testicular, pituitary, and hypothalamic function. Testicular atrophy, low testosterone levels, decreased beard growth, diminished sperm count, and a loss of libido result. However, testicular atrophy does not occur in all male alcoholics but is associated with alcohol dehydrogenase polymorphism in the testes, as reflected by the genetic variant of an increased frequency of the ADH21 allele (Yanauchi et al., 2001).


If potassium values are less than 15 meq L, then sodium values below 135 meq L and chloride values below 105 meq L indicate that one is dealing with low salt syndrome. This is seen most commonly in association with severe fatty metamorphosis of the liver or micronodular cirrhosis. Coe described six cases of profound salt depletion. In one case, sodium was106 meq L chloride 87 meq L, and potassium 6.2 meq L due to prolonged use of diuretic therapy.35 The same picture of a low salt syndrome can be caused by overhydration, or water intoxication. In a fatal case of water intoxication

Other Diseases

Taken together, currently available data indicate that decreased levels of ubiquinol-10 in human plasma may have two major causes the presence of liver dysfunction (hepatitis, cirrhosis, hepatoma) and or highly increased systemic oxidative stress (adult respiratory distress syndrome, infant asphyxia). Low plasma ubiquinol-10 levels might also reflect less pronounced oxidative stress in hyperlipidemia and diabetes. However, they may also (at least partly) be related to confounding liver dysfunction known to occur in hyperlipidemia58 and frequently present in diabetes. The latter explanation seems to be more probable, since comparable oxidative stress chronically present in atherosclerosis or neurological diseases such as Alzheimer's or Parkinson's disease, is unable to cause a decrease in plasma ubiquinol-10.


Becker, U., Gronbaek, M., Johansen, D., & Sorensen, T. I. (2002). Lower risk for alcohol-induced cirrhosis in wine drinkers. Hepatology, 35, 868-875. Stinson, F. S., Grant, B. F., & Dufour, M. C. (2001). The critical dimension of ethnicity in liver cirrhosis mortality statistics. Alcohol Clin Exp Res, 25, 1181-1187.


In interpreting the results of a neuropsychological evaluation, it is important to be cognizant of the multifactorial etiology of any identified impairment. Not only do alcohol and other drugs act directly on the brain but their habitual consumption may also induce organ-system injury, which in turn disrupts integrity of the brain. For example, cirrhosis, independent of alcoholism, causes hepatic encephalopathy, Thus, neuropsychological deficits commonly found in alcoholics may be, in large part, the result of advanced liver disease (Tarter, Van Thiel, & Moss, 1988). This fact is not inconsequential, because treatment of low-grade hepatic encephalopathy caused by alcoholic liver disease has been tentatively shown to improve cognitive capacities (McClain, Potter, Krombout, & Zieve, 1984). Thus, medically significant problems that potentially disrupt brain functioning should be recorded and incorporated into the treatment plan.

Trace elements

In general, toxicity from dietary sources is extremely rare. Liver cirrhosis and disturbances of brain functions (e.g., coarse tremor and personality change) have been reported. No adverse effects are to be expected from intakes of up to 35 mg day for adults. Storing or processing acidic foods or beverages in copper vessels can add to the daily intake and cause toxicity from time to time.

Important points

Hepatitis B prevention is best treatment (vaccination) acquired through needles, sex, or perinatally. Transfused blood is now screened for hepatitis B, but a history of transfusion years ago is still a risk factor. Use hepatitis B immunoglobulin for exposed neonates and health care workers. Serology HBsAg-positive with unresolved infection (acute or chronic). HBeAg is a marker for infectivity (HBeAb -positive patients have low likelihood of spreading disease). The first antibody to appear is IgM anti-HBc, which appears during the window phase, when both HBsAg and HBsAb are negative. Positive HBsAb means that the patient is immune (due either to recovery from infection or vaccination) and never appears if the patient develops chronic hepatitis. Sequelae are cirrhosis and hepatocellular cancer (only with chronic infection). 4. Hepatitis C the new king of chroni c hepatitis most likely cause of hepati tis after a blood transfusion (used to be hepatitis B before blood was screened). More...


Alcohol is the most common cause of cirrhosis and esophageal varices. Conditions commonly caused by alcohol include gastritis, Mallory-Weiss tears, pancreatitis (acute and chronic), peripheral neuropathy (via thiamine deficiency), brain damage, and cardiomyopathy (dilated). It also causes testicular atrophy, fatty change in the liver, hepatitis, cirrhosis, hepatocellular liver cancer, Wernicke Korsakoff syndrome (via thiamine deficiency), cerebellar degeneration, and rhabdornyolysis (acute and chronic).