LIVER CIRRHOSIS, ALCOHOLIC AND NON-ALCOHOLIC LIVER DISEASE, HEPATITIS, JAUNDICE AND ASCITES

CLINICAL FEATURES, EXAMINATION, INVESTIGATIONS AND DIFFERENTIAL DIAGNOSIS OF LIVER CIRRHOSIS, ALCOHOLIC AND NON-ALCOHOLIC LIVER DISEASE, HEPATITIS, JAUNDICE AND ASCITES

Liver is a vital organ involved in metabolism, detoxification, synthesis of proteins, and digestion via bile production. Pathologies like cirrhosis, alcoholic and non-alcoholic liver diseases, hepatitis, jaundice and ascites arise due to structural and functional derangement. In Ayurveda, Yakrit vikara (liver disorders) are mentioned under Yakritroga, and often associated with Pittaja vikara.

CLINICAL FEATURES

LIVER CIRRHOSIS

• General features: Fatigue, weakness, weight loss, anorexia

• Gastrointestinal: Nausea, vomiting, dyspepsia

• Hepatic signs: Jaundice, pruritus, hepatomegaly (early), shrunken liver (late), splenomegaly

• Portal hypertension: Ascites, caput medusae, esophageal varices

• Endocrine dysfunction: Gynecomastia, testicular atrophy

• Neurological: Hepatic encephalopathy (confusion, altered consciousness)

• Hematological: Anemia, bleeding tendencies

• Skin: Spider angiomata, palmar erythema

ALCOHOLIC LIVER DISEASE (ALD)

• Early: Asymptomatic, hepatomegaly

• Chronic: Jaundice, fatigue, anorexia

• Advanced: Ascites, encephalopathy, variceal bleeding

• Signs of alcohol abuse: Parotid swelling, Dupuytren's contracture

NON-ALCOHOLIC FATTY LIVER DISEASE (NAFLD)

• Often asymptomatic

• Hepatomegaly

• Mild abdominal discomfort

• Insulin resistance, obesity, diabetes mellitus (metabolic syndrome)

HEPATITIS (ACUTE AND CHRONIC)

• Acute: Malaise, nausea, vomiting, jaundice, fever, right upper quadrant pain

• Chronic: Fatigue, hepatomegaly, jaundice, elevated liver enzymes

JAUNDICE (ICTERUS)

• Yellow discoloration of skin, sclera and mucosa

• Pruritus (cholestatic)

• Dark-colored urine, pale stools

• Associated symptoms depend on underlying cause (e.g., fever in viral hepatitis, colicky pain in obstructive jaundice)

ASCITES

• Abdominal distension

• Shifting dullness, fluid thrill

• Early satiety, weight gain

• Shortness of breath (due to diaphragmatic elevation)

• Pedal edema

RELEVANT CLINICAL EXAMINATION

• Inspection: Icterus, muscle wasting, spider nevi, palmar erythema, abdominal distension

• Palpation: Tender hepatomegaly, splenomegaly, fluid thrill in ascites

• Percussion: Shifting dullness, liver span assessment

• Auscultation: Venous hum in portal hypertension

• Neurological examination: Asterixis (flapping tremor) in hepatic encephalopathy

• Other systemic signs: Gynecomastia, testicular atrophy, parotid enlargement

RELEVANT INVESTIGATIONS

BLOOD TESTS

• Liver Function Tests (LFT):

  • ↑ Bilirubin (direct and indirect)

  • ↑ AST, ALT, ALP, GGT

  • ↓ Albumin, ↑ PT/INR

• CBC: Anemia, thrombocytopenia

• Serology:

  • Hepatitis A, B, C, E viral markers

  • ANA, SMA (autoimmune hepatitis)

• Blood glucose, lipid profile (in NAFLD)

IMAGING

• Ultrasound abdomen: Fatty liver, liver size, nodularity, ascitic fluid

• Fibroscan: Measures liver stiffness (fibrosis score)

• CT/MRI: To detect structural changes, varices, mass lesions

OTHER TESTS

• Ascitic fluid analysis (SAAG, albumin, cell count, culture)

• Liver biopsy (in selected cases)

DIFFERENTIAL DIAGNOSIS

LIVER CIRRHOSIS

• Chronic hepatitis

• Hepatocellular carcinoma

• Congestive hepatopathy

ALCOHOLIC LIVER DISEASE

• NAFLD

• Autoimmune hepatitis

• Drug-induced liver injury

NAFLD

• Chronic viral hepatitis

• Hemochromatosis

• Wilson’s disease

HEPATITIS

• Acute viral hepatitis vs. drug-induced hepatitis

• Autoimmune hepatitis

• Alcoholic hepatitis

JAUNDICE

• Hemolytic anemia (pre-hepatic)

• Viral or alcoholic hepatitis (hepatic)

• Gallstones, carcinoma head of pancreas (post-hepatic)

ASCITES

• Peritoneal tuberculosis

• Ovarian malignancy

• Congestive cardiac failure

• Nephrotic syndrome

AYURVEDIC PERSPECTIVE

LIVER CIRRHOSIS – ‘YAKRITODARA’

• Considered under Udara Roga in Ayurveda

• Related Dosha: Predominantly Pitta and Kapha

• Involvement of Rakta, Yakrit and Agni dusti

• सप्तमे यकृत्स्प्लीनौ वाताद्याः क्लेशमावहेत्।
  यकृत्स्फीतं तथा स्प्लीनं स्फीतौ चोदरतां गतौ॥
  — Charaka Samhita, Chikitsa Sthana 13/42

ALCOHOLIC LIVER DISEASE – MADATYAYA JANYA VIKARA

• Chronic alcohol consumption = Madya Sevana

• मद्यं रुधिरपित्तघ्नं स्निग्धोष्णं मूर्छणं गुरु।
  दीप्ताग्न्यग्निवर्धनं तिक्तं सूक्ष्मं दीपनपाचनम्॥
  — Charaka Samhita, Sutra Sthana 24/30

  
  

HEPATITIS – KAMALA / PITTAJA YAKRIT ROGA

कामला नाम यत्पित्तं रुधिरं धातुमार्गगम्।
तेन पीताङ्गता देहे पीतमेव प्रसर्पति॥
— Madhava Nidana 5/1

JAUNDICE – KAMALA / HALIMAKA

कामला तु पुनर्वृद्धं पित्तं यद्रुधिरं नयेत्।
पीता लोचना त्वक् चास्य मूत्रं चापि तथा स्रवेत्॥
— Charaka Samhita, Chikitsa Sthana 16/89

ASCITES – JALODARA

उदराणां तु रोगाणां जलोदरमुदाहृतम्।
स्निग्धोष्णान्नं पिबतोऽल्पं विहितं मन्दवर्चसः॥
— Charaka Samhita, Chikitsa Sthana 13/60

MODERN PATHOLOGY CORRELATIONS
(Source: Robbins Basic Pathology, Harsh Mohan)

• Cirrhosis: Bridging fibrosis, regenerative nodules

• ALD: Macrovesicular steatosis, Mallory bodies

• NAFLD: Steatosis without alcohol history, associated with obesity and diabetes

• Hepatitis: Lobular inflammation, apoptotic hepatocytes (Councilman bodies)

• Jaundice: Disruption in bilirubin metabolism at pre-hepatic, hepatic or post-hepatic levels

• Ascites: Transudate in cirrhosis; exudate in malignancy/infection