Frequently Asked Questions on Liver
 
 
Questions.
 
Q1.What is the prognosis without liver transplant?

Q2.Is there any way to avoid a liver transplant?

Q3.When should I get prepared for a liver transplant?

Q4.What is the success rate of liver transplant?

Q5.Whole liver or partial liver: which is better?

Q6.Will liver transplant restore all my functions and quality of life?

Q7.What is the long term effect of transplant and post transplant medications?

Q8.What is the cost of liver transplant and after care?

Q9.Is there any difference in liver transplant in India and abroad?

Q10. What is Liver Function Tests (LFT's) ?

Q11. What is Albumin (ALB) (4-6)?

Q12. What is Alkaline Phosphatase (ALK PHOS) (30-120)?

Q13. What is Alanine Aminotransferase (ALT or SGPT) (<35)?

Q14. Whats is Total Bilirubin (TOT BILI) (<1.0)?

Q15. How To Differentiate Alcoholic Hepatitis From Alcoholic Cirrhosis And Is The Differentiation Important?
 
 
Answers
 
Q1.What is the prognosis without liver transplant?
Patients with advanced chronic liver failure can survive for a median time range of 18 months from the time of diagnosis without liver transplant. However as the disease advances they will require frequent medical admissions, some of which may be fatal.

Q2.Is there any way to avoid a liver transplant?
Patients with alcohol related liver failure may stabilize if they stop alcohol consumption and show some clinical improvement. Some of the patients with early cirrhosis due to viral hepatitis may improve if the virus is eradicated from their system by treatment. By and large liver cirrhosis is a progressive disorder and does not reverse by medical treatment; hence liver replacement remains the only cure.

Q3.When should I get prepared for a liver transplant?
It is advisable to undergo an evaluation as soon as you meet at least 2 of the criteria listed under absolute indications. This allows the author to list you for a suitable cadaver liver straight away. The cadaver livers are offered on first come first serve basis when the offer comes from some part of the country. While on waitlist one can explore the option of living donor transplant if any suitable relative is available.

Q4.What is the success rate of liver transplant?
The success of liver transplant depends on the medical condition of the patient. Or good risk patients who go for the surgery early enough, the 5 year survival is 85%. Patients who have additional risk factors like kidney dysfunction, malnutrition, cancer, portal vein occlusion, previous abdominal surgery and hepatitis-C type I are bound to have lower survival rates.

Q5.Whole liver or partial liver: which is better?
Whole cadaver liver is any day preferable to a partial liver from living donors. Whole liver transplant is technically less complex and hence will have lower chance of technical complication. However in India, the availability of cadaver liver is very limited and the partial liver donation is a more practical option. The long term outcome is more or less comparable between the two types of transplant.

 

Q6.Will liver transplant restore all my functions and quality of life?
All the metabolic abnormalities are corrected by a liver transplant. Hence patients can have normal diet without restrictions soon after the transplant. Restoration of physical strength will be gradual and will take around three months to be restored fully. One can plan to return to work involving moderate physical strain by 4 months. Active sports can be resumed by six months. Education in school and college is usually commenced within 6 months after the transplant. Children will grow normally and may suffer attention deficit in academic pursuit which will improve with training. Normal sexual functions are restored in 60% by 3-4 months and some may require medical help.

Q7.What is the long term effect of transplant and post transplant medications?
Liver transplant per say does not have any sequel. Scar and rarely herniation from the wound can occur. However the life long medications do have certain effects.

Q8.What is the cost of liver transplant and after care?
It is now possible to have a successful liver transplant for 15 Lakh Rs (30000 USD), for patients who come early. With the author's effort it may be possible to lower the cost further for economically under privileged. There is an average monthly expense of Rs 10,000 per month (250 USD/pm), for medications and blood tests and this will be life long. In the long run the cost may come down by half (these figures are applicable to Indian citizens).

Q9.Is there any difference in liver transplant in India and abroad?
No hospital in India is as good as the best run hospitals in the West. To achieve such high standards will increase the cost of transplant. However the technical expertise of the doctors and nurses is comparable to that in the West. The infrastructure is also comparable. The results of liver transplant (in the author's series), is also comparable to the results of established centers. It is a very good deal for the price that is ten times cheaper than either the Western centers or those in Far East and Singapore. In any case 99% of Indian citizens cannot afford to spend > Rs 15 million that is required for liver transplant abroad.

Q10. What is Liver Function Tests (LFT's) ?
Liver function studies is a battery of tests that give your doctor an idea of how well your liver is working. From these studies, your doctor can identify possible liver disease or infections like hepatitis. Several different tests comprise LFT's.

Q11. What is Albumin (ALB) (4-6)?
Albumin is a protein produced by the liver that helps maintain osmotic pressure in the vascular space. By maintaining this pressure, fluid stays in the vascular system instead of leaking out into the tissues resulting in swelling (edema). Albumin also carries certain minerals in the blood stream.
Elevated: Usually indicates dehydration.
Below normal: Can indicate liver dysfunction or insufficient protein intake.

Q12. What is Alkaline Phosphatase (ALK PHOS) (30-120)?
Alkaline phosphatase is an enzyme found in many organs in the body, including the liver.
Elevated: A warning sign that there is some type of liver dysfunction resulting in liver tissue damage.
Below normal: Usually not significant.

Q13. What is Alanine Aminotransferase (ALT or SGPT) (<35)?
This protein is found primarily in the liver. It is released into the blood when there has been some sort of liver tissue damage.
Elevated: Indicates tissue damage as a result of such things as obstruction, hepatitis, or cirrhosis.
Below normal: Usually not significant.

Q14. Whats is Total Bilirubin (TOT BILI) (<1.0)?
Bilirubin is a normal component of red blood cells. When these cells break down free bilirubin is released in the blood. Bilirubin is then carried to the liver where it is broken down and excreted. When the liver is not functioning properly, bilirubin builds up in the body, causing jaundice (yellowing of the skin and eyes and darkening of the urine).
Elevated:Usually caused by a dysfunction of the system that breaks down bilirubin which includes the liver. Such an elevation can be caused by an obstruction or liver failure.

Q15. How To Differentiate Alcoholic Hepatitis From Alcoholic Cirrhosis And Is The Differentiation Important?
The association of alcohol abuse and liver damage is known since the times of ancient Greeks and is also recognised in Ayurveda. The clinical spectrum of alcoholic liver injury varies from asymptomatic hepatomegaly to profound hepatocellular failure with portal hypertension. The clinical picture tends to be more florid in individuals with more advanced liver injury. Alcoholic liver injury appears to progress from fatty changes through alcoholic hepatitis to cirrhosis. Majority of the individuals who abuse alcohol will develop fatty changes in their liver at some stage of their drinking career. However only 20% of such individuals will develop cirrhosis. The apparent predisposition of certain people to develop alcoholic cirrhosis is unknown. Fatty liver, though indicating a profound metabolic disturbance within the liver, is not necessarily harmful. Certainly, cirrhosis may develop in an alcoholic who has never had fatty change and isolated fatty change has not been shown to proceed directly to cirrhosis. Alcoholic hepatitis develops in only a proportion of drinkers even after decades of abuse and is assumed to be a precirrhotic lesion, although its natural history is not well understood. Thus in approximately 50% of individuals alcoholic hepatitis may persist for several years and in 10% of individuals the lesion may heal despite continued alcohol abuse. It has therefore been suggested that although alcoholic hepatitis may contribute, when present, to the evolution towards cirrhosis, it is not a sine qua non of such progression. Though most of the alcoholics may have a combination of alcoholic hepatitis and cirrhosis on biopsy and more or less similar clinical and biochemical features

Since alcoholic hepatitis is reversible and hepatic function improves over a period of time with abstinence, management consists predominantly of abstinence from alcohol and supportive care; whereas alcoholic cirrhosis once established is irreversible and hepatic function may not improve over time, management consists of abstinence from alcohol, treatment of complications and liver transplantation may be a viable option in carefully selected patients. Liver transplantation should not be done in patients with pure alcoholic hepatitis. Hence it is very essential to differentiate a patient having alcoholic from the one having alcoholic cirrhosis as the management and prognosis is different.
 
 
Summary

Alcoholic Hepatitis Alcoholic Cirrhosis
  • Acute debauch, continued alcohol consumption
  • Ill patient (may be febrile)
  • Presents usually with jaundice which may be deep (Cholestatic!)
  • Tender, large and smooth hepatomegaly
  • Florid spider angioma and palmar erythema
  • No major signs of portal hypertension
  • Arterial bruit over the liver
  • Polymorphonuclear leucocytosis
  • GGT, SGOT and SGPT elevated - usually upto 300 IU/L
  • Gold standard for diagnosis is liver biopsy
  • Poor prognosis for Maddrey’s score > 32.
  • Probably a past drinker
  • Relatively well preserved (unless severely decompensated)
  • Presents usually with ascites or GI bleeding
  • Non tender, firm, irregular and nodular liver
  • Spider angioma and palmar erythema present
  • Signs of portal hypertension present
  • Arterial bruit over liver only with hepatoma
  • Minimal polymorphonuclear leucocytosis
  • Liver enzymes usually in normal range
  • Gold standard for diagnosis is liver biopsy
  • Poor prognosis for Child class C.
 

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