All About Liver

All About Liver

Your liver is for life. You have only one and though it is unique in its ability to regenerate, it can only survive limited damage - so it does need looking after.

Place your right hand over the area under your ribs on the right side of your body and it will just about cover the area of the liver. The liver is the largest gland, and solid organ in the body, weighing some 1.8 kgs in a men and 1.3 kgs in women. It holds approximately 13% (about one pint or 0.57 liters) of the total blood supply at any given moment, and it has over 500 estimated functions. Position of the liver in the body

The liver is dark reddish brown in color and is divided into two main lobes (the much larger right and the smaller left), which are further subdivided into approximately 100,000 lobules. About 60% of the liver is made up of liver cells (hepatocytes), and each of these have an average lifespan of 150 days. In every milligram of liver tissue there are approximately 202,000 cells. Two-thirds of the body of the liver is the parenchyma, which contains the hepatocytes, and the remainder is the biliary tract. The liver receives its blood supply via the hepatic artery and portal vein (which transports nutrients from the intestine (gut)).

The Biliary System

The Liver and Biliary Tract

The biliary tract contains the right and left hepatic ducts, which meet to form the common hepatic duct. This is joined by the cystic duct from the gall bladder, which then forms the common bile duct. The common bile duct joins the intestine at the duodenum through a valve called the Sphinter of Oddi.

The gall bladder is a pear-shaped bag 9cm long with a capacity of about 50ml. Breakdown products, such as bile salts, bilirubin, cholesterol, phospholipids, proteins, electrolytes and water are secreted by hepatocytes, and they are eventually transported down the bile ducts (this is bile and it is modified by cholangiocytes lining the bile ducts). The gall bladder stores bile, a greenish-yellow colored liquid, which is delivered during a meal into the gut to assist with the breakdown (emulsifying) of fat in the food digested to allow easier absorption of fat and vitamins A, D,E and K. The liver produces approximately one pint (or 0.57 liters) of bile a day.

Disease of the biliary tract will interfere with this important function, as well as causing damage to the hepatocytes producing the breakdown products. About 10% of the populations of Western countries suffer with Gallstones, but less common diseases, such as Primary Biliary Cirrhosis and Primary Sclerosing Cholangitis can cause serious liver disease in some people suffering from them.

The parenchyma contains the hepatocytes, which absorb nutrients, and also detoxify and remove harmful substances from the blood. This is a relatively soft tissue, with a unique ability to regenerate after injury. Approximately three-quarters of the parenchyma needs to be damaged before sufficient hepatocytes are lost to impair liver function. When the liver suffers long term damage, scar tissue (fibrosis) forms and this disturbs hepatocyte function further. If the whole of the liver is scarred (fibroses), then this is known as cirrhosis. Initially a cirrhosed liver will continue to function, and this is known as compensated cirrhosis. If the liver function fails this is known as decompensated cirrhosis and without transplantation the outcome is likely to be fatal. Alcohol induced liver disease accounts for half of all adult liver disease, with about a third caused by viral hepatitis, and the remainder caused by a significant variety of diseases related to dysfunctional immune responses, metabolic disorders and inherited diseases.

A Brief Summary of the Liver’s Functions Follows, But Remember There are More Than 500 Functions:

Some of the Most Important Functions Include:

Producing Quick Energy

One of the liver’s most important functions is to break down food and convert it into energy when needed. When energy is required in an emergency the liver rapidly converts its store of glycogen back into glucose ready for the body to use. Carbohydrates such as bread and potatoes from our diet are broken down to glucose and stored mainly in the liver and muscles as glycogen.

The liver also helps the body to get rid of waste products. Waste products which are not excreted by the kidneys are removed from the blood by the liver. Some of them pass into the duodenum and then into the bowel via the bile ducts.

People with liver damage may sometimes lose the ability to control glucose concentration in the blood and need a regular supply of sugar.

Fighting Infections

The liver plays a vital role in fighting infections, particularly infections arising in the bowel. It does so by mobilizing part of the body’s defence mechanism called the macrophage system. The liver contains over half of the body’s supply of macrophages (known as Kuppfer cells) which literally destroy any bacteria that they come into contact with. If the liver is damaged in any way its ability to fight infections is impaired.

What can Go Wrong?

The liver is a very uncomplaining organ with an enormous reserve. There is very little evidence of an ageing problem and in the absence of disease the liver functions fully right into old age. Most liver disease is symptom less and when there are symptoms they are often vague. There are hundreds of liver disorders but some are quite rare.

The Commonest Ones Are:

Hepatitis

Hepatitis literally means inflammation of the liver. Viruses are the commonest cause but there are others which are non viral, such as alcohol excess, the side effects of some drugs, both illegal and prescribed medicines. There is also a disease called autoimmune hepatitis.

Viral Hepatitis

The liver can fall prey to an alphabet of viruses, namely hepatitis A, B, C, D, E and possibly G. There isn’t a hepatitis F - it’s been missed out so far! The main difference between the viruses is how they are spread and the effects they have on your health. Hepatitis A, B and C are the most common in the UK.

Hepatitis A is spread by eating food or drinking water which is contaminated with the hepatitis A virus, usually in countries where hygiene standards and sanitation are poor. There is a vaccine for this virus.

Hepatitis B is mainly passed on by blood to blood contact (blood borne) but also sexually. Worldwide hepatitis B kills between 1 - 2 million people annually, yet there is a vaccine to prevent infection. Blood transfusions have been screened in the UK since the 1970s. Hepatitis B is considerably more infectious than HIV.

Hepatitis C is also a blood borne virus. Prior to September 1991 a few people were infected by contaminated blood transfusions and blood products. Since then all blood donations have been screened for the virus. In some people the route of infection is not known but in many others injecting drugs is the cause. Users are thought to become infected by sharing injecting equipment. It takes just a tiny amount of blood from someone who carries the virus to spread the infection if it gets into someone else’s bloodstream.

Most people recover from hepatitis A with no lasting liver damage but B and C can cause long term liver disease, leading to cirrhosis and even liver cancer. In many cases there are no early warning symptoms until liver damage is far advanced.

Autoimmune Hepatitis

This disease mainly affects women, usually just after the onset of puberty or around the time of the menopause. It is thought to be caused by the body’s defence system malfunctioning and attacking the liver. The commonest symptom in the early stages is fatigue and generally feeling unwell. However, the condition can be controlled with drugs which work by dampening down the immune system’s reaction to the liver.

Cirrhosis

Cirrhosed LiverIt is a popular misconception that cirrhosis and hence liver disease only affects men who drink too much alcohol over the years. Cirrhosis can affect both men and women and can result from long term infection with hepatitis B and C viruses, inherited liver disorders such as haemochromatosis, bile duct diseases like primary biliary cirrhosis, as well as alcohol misuse.

The onset of cirrhosis is usually silent with few early warning symptoms. Cirrhosis is a result of long term continuous liver damage. If the liver is damaged for a short time some of the cells die and the liver regrows to its original size and shape. When the inflammation is severe and continuous, scar tissue called fibrosis develops. Smooth liver tissue is replaced by irregular nodules and the liver becomes much harder than normal. The combination of modules and fibrosis is called cirrhosis.

Once cirrhosis has developed it is usually considered irreversible, even if the inflammation which caused it improves. Recent studies in treating hepatitis C with interferon alpha or pegylated interferon alpha have suggested that there can be some reversal in fibrosis and even cirrhosis, but more studies are required and it is not known if this also applies to other liver diseases.

Alcoholic Liver Disease

Not everyone who drinks too much alcohol develops liver damage. It is still unclear why only some do but there is some evidence that it could be due in part to a combination of factors including a genetic susceptibility.

Consistent heavy drinking can lead to what is known as a fatty liver in which the liver cells become engorged with excess fat, more seriously an inflamed liver - alcoholic hepatitis - or, most seriously, a permanently scarred and damaged liver - cirrhosis.

In general the more you drink, and the greater the frequency and duration of heavy drinking, the more likely you are to develop cirrhosis.

Gallstones and Gallbladder Disease

Around 5 million people in the UK, approximately 10 per cent of the population, develop gallstones or another gallbladder disease at some time in their lives. Gallstones are lumps of solid material that form in the gallbladder and usually resemble small stones or gravel, although some can be as large as pebbles. Most are the size of a pea and may take many years to grow.

Anyone can get gallstones but middle aged, overweight women have the highest risk - fair, fat and forty traditionally describes a typical patient!

Inherited Liver Disease

It is possible to be born with a liver disease which may not produce symptoms until adulthood.

Haemochromatosis is an inherited metabolic disorder in which the body absorbs and stores more iron from food than it actually needs. It can prove fatal if not recognized and treated early enough. For many years haemochromatosis was thought to be rare. But recent research has discovered that the disease is much more common than first realized. In fact it is one of the commonest inherited disorders among people of Northern European origin and is estimated to affect 1 in 300.

Wilson's disease is also inherited and causes excessive amounts of copper to accumulate in the body. Copper, unlike other damaging metals such as lead and mercury, is essential to health. However, in Wilson’s disease the body’s inability to get rid of the excess results in an accumulation of copper in several organs. The liver is the first organ to store copper. When its storage capacity is exhausted, the overflow passes from the liver to the bloodstream and is carried to other organs, including the brain and the cornea of the eye. In a few cases the copper accumulation can result in psychiatric disorders or physical symptoms such as slurred speech, drooling or tremors.

Primary Sclerosing Cholangitis

Primary sclerosing cholangitis (PSC) is a bile duct disease in which the bile ducts inside and outside the liver become narrower because of inflammation and scarring. This causes the bile normally carried away by the ducts to stay within the liver, resulting in damage. It is not known what causes PSC but it often occurs in people with an inflammatory bowel disease, usually ulcerative colitis. Men are twice as likely to be affected as women, usually between the ages of 25 and 45, but it can also affect children as young as two years.

Primary Biliary Cirrhosis

In primary biliary cirrhosis (PBC) the patient’s immune system damages the small bile ducts inside the liver, so that bile cannot be efficiently secreted. The term PBC is really a misnomer because cirrhosis does not always follow, and if it does it can take many years to develop. Middle-aged women are most commonly affected, but the disease can affect anyone.

Paracetamol Poisoning

Accidental or deliberate self-poisoning with paracetamol has been a serious cause of liver disease and transplantation in the UK, but in recent years it has declined - possibly due to a change in pack sizes on sale to the general public. A useful resource on this issue is the Paracetamol Information Centre, which can be accessed via the Treatment section in Links on this web site.

Cancer of the Liver

Cancer of the Liver is Divided into Two Main Types:

Primary Cancer (hepatocellular carcinoma) which means cancer that starts in the liver, and Secondary or Metastatic Cancer which means cancer that spreads to the liver from another part of the body. There is estimated 2,500 new cases of Primary Liver Cancer and 70,000 new cases of Secondary Liver Cancer every year in the UK.

In the UK most people who develop primary liver cancer have cirrhosis which can be from any cause. Primary liver cancer is not easy to diagnose in the early stages because its symptoms are usually vague. Typical symptoms include loss of appetite, weight loss, a general feeling of poor health, jaundice, fever, fatigue and weakness.

Always Prepare a List of the Questions You Want to Discuss, and Try to Keep to 2 Or 3 of Your Most Important Concerns

Here are a few things to bear in mind when you go to see your doctor. They may help you to get the best from your visit.

  1. To help your doctor, it is a good idea before your visit to think through all the information you believe your doctor needs to know, e.g. when did the symptoms start, how have they changed, how is your life affected and, most importantly, how you feel. Don’t be afraid to say what you think is behind the problem or causing it.
  2. Write down your questions and even hand them to your doctor if this will help you.
  3. Take a relative or friend with you if this will make you feel more comfortable. Briefly ask if your doctor minds more than one person.
  4. Listen to what your doctor says. If you don’t understand, or if you feel that he or she has not answered your questions, do not be afraid to ask again.
  5. Note down important points in writing.
  6. Check your list at the end of the appointment to make sure that you have covered all the points you want to.
  7. If you feel you still need to discuss your concerns make a further appointment.
  8. Remember that there are other health professionals available to help you who may have more time to talk through your particular problem. Most GP surgeries have a nurse health visitor or even a counselors who would be happy to talk to you about how you feel, about your medication or about any social benefits you may be entitled to.
  9. Remember, don’t be afraid to say how you really feel - after all, you are the only person who knows.
  10. Lastly, don’t forget the chemist. The pharmacist dispensing your prescription will be able to explain what it is you are taking and its possible side-effects, and to give advice on general medical matters.

This information is designed to help you understand more about diet and to provide practical advice about eating for people who have liver disease.

There are many types of liver disease, some with no symptoms and others causing very severe illness. Many people with liver disease can eat a well balanced diet, whilst others may need more detailed advice that may not be covered by this information. Therefore, it is important, in addition to reading this information that you talk to your doctor.

If you have any queries about your diet and cannot find the answers to them in this information, or if you need further help, please ask to be referred to a State Registered Dietitian with expertise in this area. You may already have been given dietary advice, and if so, you should follow this and talk to your doctor or dietitian before making any changes.

At the end of this information there is a list of organizations that can offer further advice. The British Liver Trust has a range of leaflets which cover specific areas of liver disease which may be helpful too.

The Role of Your Liver in Nutrition

The food you eat is broken down in your stomach and intestine. The nutrients from the food pass through your intestine where they are absorbed into the bloodstream and transported to your liver. Here they are either stored or broken down further, ready for your body to use, depending on your needs at the time. When someone has a liver problem these processes continue, but may not be carried out as well as in a healthy person.

Food is made up of three main sources of energy or calories - carbohydrate, fat and protein. Carbohydrate and fat are the main sources of energy and protein is used by the body for growth and repair.

Carbohydrate in our diet comes from starch and sugar and is found in food such as bread, potatoes, rice, pasta, cereals, fruit and sweets. Carbohydrate is broken down in the liver to glucose. Any glucose not used immediately for energy is stored as glycogen in the liver and some in the muscles. The liver quickly converts glycogen back into glucose when the body needs extra energy.

As well as being a storehouse for glycogen, the liver helps to control the level of glucose in the blood and prevents it from rising and falling too far.

Fat in our diet comes from butter, cheese, cooking oil, animal fat and from many ‘invisible’ sources, for example biscuits, pastry, crisps and cakes.

Fat cannot be digested without bile, which is made in the liver and stored in the gallbladder. Bile is released when needed into the small intestine and acts as a detergent, breaking fat into tiny droplets so it can be absorbed by the body. Fat can be used as a long-term energy store.

Protein in our diet comes from foods such as meat, fish, eggs, cheese, nuts and dairy. Protein is made up of units called amino acids and once these reach the liver they provide building blocks to make cells and tissues.

A Well-Balanced, Healthy Diet

At present, experts agree that a well balanced diet is one that is low in fat, sugar and salt and high in fiber. Fiber is the part of fruit, vegetables or cereal that passes through your body undigested and helps to prevent constipation. Your diet should contain sufficient protein and a wide range of vitamins and minerals. Healthy eating means getting the right balance between different foods. A diet which includes lots of vegetables, fruit, beans and whole-wheat cereals (including bread) and is low in fat is considered the best. It is also the best diet for many people who have liver disease.

There are Five Food Groups:

  1. bread, cereal, potatoes, rice, pasta
  2. fruit and vegetables
  3. milk, yogurt, eggs and cheese
  4. meat, fish, nuts, pulses and beans
  5. high calorie foods, such as fried and sugary foods

It is important to choose a variety of foods from the first four groups every day to get a wide range of nutrients. Foods in the fifth group may be useful for people who are underweight, but should be avoided or eaten in only very small quantities by anyone who is overweight.

We differ in the amount of calories or energy we require according to our sex, age, weight and level of physical activity. For example, a small, elderly woman will need less food than a young, active man. If we eat fewer calories than our body needs, we lose weight, and if we eat too many, our weight increases.

Calories can be written as kcal or kilocalories, kJ or kilojoules - they all mean energy.

If you have been ill or have lost a lot of weight, eating a well balanced diet may be difficult. If so, it is important to try to keep eating and, if necessary, to ask your doctor or dietitian for advice.

Vitamins and Minerals

Our bodies need a variety of vitamins and minerals. They are essential for the millions of chemical reactions which occur in our bodies every day. They enable our bodies to carry out all the processes necessary for life. Most people get all the vitamins and minerals their bodies need by choosing a variety of foods from the first four food groups although in some types of liver disease the body needs more vitamins.

If you are worried that your diet is short of vitamins, your doctor may prescribe vitamins or suggest you buy multivitamin tablets from your chemist. Individual vitamins and minerals sold as separate supplements are not recommended unless advised by your doctor.

Alcohol

A high intake of alcohol is toxic to the liver. The liver protects your body from the toxic effects of alcohol by breaking it down to less harmful substances.

Some people with liver problems can drink within the recommended guidelines, whilst others should not drink at all. The latest thinking on alcohol and liver disease suggests:

Some people can no longer tolerate alcohol and do not fancy a drink, whilst others can drink a little on special occasions. Sensible drinking advice will vary from person to person, even if they have the same liver disease.

This is because their disease may take a different form or is more severe.

It will also depend on the type and stage of liver disease and your general health. It may also be because doctors take different views. If you are unsure whether it is advisable for you to drink, you should ask your doctor.

Some people find eating a well balanced diet difficult, especially if they have been seriously ill. Two common reasons for this are loss of appetite and nausea. However, it is important to eat as well as possible. The following tips may help:

Loss of Appetite

Nourishing drinks include homemade milkshakes and products such as Build Up, Complain and Recovery. These are a good idea, but you must check with your doctor or dietitian whether they are suitable for you. A nutritious homemade milkshake can include semi-skimmed milk, honey, banana or pureed fruit and a little Build Up or Complain. You can buy the above products from most chemists and drink them between meals, especially if you are only eating small amounts. Your doctor may prescribe other, ready-made supplements if you have been ill and are malnourished.

Nausea

If nausea continues for more than a few days, or if you start vomiting, then it is important to consult with your doctor.

The following advice may help with a few of the common diet related problems in liver disease. The information is by no means exhaustive. You may have other questions or worries about your particular problems and the best person to talk to is your doctor or dietitian. If you have already been advised to follow a special diet, it is essential to discuss any changes with them.

Acute Viral Hepatitis

People with acute viral hepatitis who are relatively well should try to eat a normal diet. As people with acute hepatitis generally need more protein and energy, they may benefit from eating a high protein, high calorie diet.

However, if you develop nausea and vomiting, which make eating difficult, the suggestions given earlier can help.

Chronic Hepatitis

Generally, people with chronic hepatitis (lasting longer than six months, sometimes coming and going) can eat a normal well balanced diet and do not need to change their food intake. Occasionally poor appetite, nausea and vomiting occur, but this only becomes a nutritional problem if it lasts longer than a few days, in which case you should consult your doctor.

Some people who are prescribed steroids for autoimmune hepatitis may find their appetite increases and that they gradually gain weight. If this happens it is still important to eat a varied and well balanced diet. However, you should try to reduce calorie-rich foods - these include foods such as sugar, sweets, cakes, biscuits, butter, margarine, oil and cream.

If weight gain is a problem your doctor may suggest specialist help from a dietitian.

Primary Biliary Cirrhosis And Primary Sclerosing Cholangitis.

Many people with primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) do not need to change their diet. Others have difficulty tolerating fatty good such as chips, full fat milk and cheese.

They can develop a type of diarrhoea known as steatorrhoea that causes bulky, pale stools that are difficult to flush away. It can cause nausea and an unpleasant feeling in the stomach. If this occurs, it may be necessary to reduce the amount of fat in your diet. People vary in the amount of fat they can tolerate and not everyone will need to eat a strict low fat diet. Most people can work out how much fat they can tolerate by trial and error.

If you are reducing fat in your diet and do not need to lose weight, top up calories with snacks between meals i.e. toast, crackers, crumpets or tea cakes.

How to Eat Less Fat

Fat in the diet is not only the visible fat seen on meat and greasy goods, but also includes:

Fat is a useful source of calories and provides fat-soluble vitamins A, D, E and K and essential fatty acids. So a person who restricts fat in their diet should try to eat extra carbohydrate, such as starch and sugar (for example bread and honey).

Some people may also need monthly injections of fat-soluble vitamins. Others are prescribed medium chain triglycerides (MCT) which are fats that are easier to digest. Your doctor or dietitian will advise you on how and when to use these.

People with PBC seem to be prone to heartburn, oesophageal reflux and a horrible acid taste in their mouth. These can all be symptoms of acid from the stomach going back up into the gullet, causing an uncomfortable sensation.

With all of these conditions it helps to eat little and often

It is a good idea to get into the habit of carrying food around with you, in case you need to eat. It should preferably be a food that contains carbohydrate.

If Symptoms Persist Try:

Some Cooking Suggestions on Using Less Fat:

Cirrhosis

People with cirrhosis generally need more protein and energy and should eat a well balanced diet. This could be achieved by adding in snacks between meals to add extra calories and protein.

The damaged liver may be unable to store glycogen, the carbohydrate that provides short-term energy.

Eating food regularly, say every 2 to 3 hours, may help.

Many people with cirrhosis do not experience complications and therefore do not feel they need to follow a special diet.

However, changing your diet may be necessary if complications, such as fluid retention (ascites and oedema) or mental slowness or confusion (encephalopathy) develop.

Fluid Retention

Some people with cirrhosis retain large volumes of fluid in the abdomen (ascites) and swelling of the feet and legs (oedema). This may be treated by drugs called diuretics and by reducing salt in the diet and, sometimes, water.

Sodium chloride (NaCl) is the chemical name for common salt. A reduction in salt intake can help control fluid retention. If this is required your dietitian can offer further help.

Your taste buds become more sensitive to salt as you eat less, it is easy to stop adding salt ourselves but most of the sodium we eat is added to foods by the manufacturers.

It is often difficult to tell which foods are high in sodium as they may not necessarily taste salty. Different specialist liver units advise different levels of sodium and it is important that you discuss the level of restriction with your own doctor or dietitian.

A dietitian will tell you what foods to eat and will help you work out recipes and menus that suit your individual needs.

An Idea of Foods to Avoid On a No-Added Salt Diet:

To Help Disguise the Lack of Salt the Following Flavorings May help:

In hospital, some people may be asked to restrict their fluid intake as well. This is only done under medical supervision and fluid is gradually increased by the time the person goes home.

Effects on the Brain

Some people with cirrhosis develop poor memory and concentration and even confusion, disorientation and coma. This condition is known as hepatic encephalopathy. It is thought to be caused by toxic substances that are formed when protein in the diet is broken down. They enter the bloodstream because they are not effectively detoxified by the damaged liver.

In the past, treatment including a low protein diet. It is now realized that restricting protein is unnecessary and harmful because it contributes to malnutrition and weakness. Low protein diets are not recommended except in some rare situations in severely ill people in hospital. Some dietary changes, however, may help if you have encephalopathy. Again they should be discussed with your doctor before starting.

Hyperglycaemia

Some people with cirrhosis have hyperglycaemia, which means high blood sugar levels, and may be advised to follow a diabetic type diet. This involves eating a well balanced diet but avoiding foods containing a lot of sugar such as jams, cakes, pastries, chocolate, puddings, ice cream, and sweets.

People with hyperglycaemia have different needs and will need individual advice from a dietitian.

Enjoy What You Eat

You may find it helpful to discuss diet and food problems with other people who have the same liver disease. It is a good opportunity to share cooking hints, recipes and menus. However, it is important to realise that dietary restrictions and special needs vary between people, and even if you have the same disease as someone else, you needs may be different.

Also, if you have been ill, you may not feel like eating your usual meals.

So taking an interest in what you eat is a very practical way to look after yourself when you are ill, and eating well can only be helpful. There may be occasions when you want to eat foods which are considered unhealthy, but very enjoyable.

It is important to enjoy what you eat and to discuss any problems you may have with your doctor or dietitian.

Who Else can Help?

The following organizations may be useful to find out more about healthy eating, nutrition and diet:

Food Standards Agency in USA: http://www.fda.gov
Food Standards Agency in UK: http://www.food.gov.uk

Supermarkets:

Most major supermarkets provide free copies of a wide range of leaflets on nutrition and healthy eating, based on the Health Education Authority’s Balance of Good Health advice. Ask at your local store.

State Registered Dietitian:

Your local State Registered Dietitian can be contacted through your doctor or nearest large hospital. You will need a referral from your GP or Specialist for individual advice.

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