Diagnosis of the liver and gallbladder

Among the diseases of the liver and biliary tract, chronic diffuse liver lesions are of the greatest clinical significance - chronic hepatitis and liver cirrhosis, as well as cholecystitis (stone and non-stone) and cholangitis. In addition, it should be borne in mind, including in differential diagnostics, the quite real possibility of focal liver lesions - abscesses, echinococcosis, but especially primary liver tumors and metastases of tumors of other localizations.

Currently, a number of genetically determined diseases are also known, in which progressive liver damage develops, resulting in cirrhosis: hepatocerebral dystrophy ( Wilson-Konovalov disease ) caused by a disorder of copper metabolism, hereditary hemochromatosis (iron accumulation in the liver can also be secondary - with some anemias, alcoholic disease), liver damage due to a deficiency of a1-antitrypsin.

Timely detection of the above diseases is currently of great practical importance, especially if it is possible to clarify the etiology or individual links in the pathogenesis of the disease - for example, for a real impact on the cause of the disease: the use of antiviral drugs for chronic viral hepatitis; drugs that remove copper from the body in Wilson-Konovalov disease; stopping the use of drugs that caused the development of hepatitis, and, of course, alcohol, which leads to severe liver damage.

Interrogation

When examining patients with diseases of the liver and biliary tract, constant “etiological alertness” is necessary, which, of course, should be demonstrated already when questioning the patient.

The epidemiological anamnesis is very important, for example, the possibility of infection with the hepatitis B, C, D, E, F, G and GV virus during blood transfusions and its components, donation, as well as in homosexuals, drug addicts, medical workers (for example, employees of chronic hemodialysis departments, blood transfusion stations), during surgical interventions, including dental, blood transfusions, various solutions. In epidemiological terms, it is necessary to keep in mind the patient's indications of staying in endemic foci of opisthorchiasis, leptospirosis, yellow fever. Of great importance is the identification of drug effects: long-term use of furadonin, tetracycline, some antihypertensive drugs (dopegit), anti-tuberculosis drugs (isoniazid, ethambutol) can cause chronic hepatitis, some psychotropic drugs - cholestasis, estrogens (including those in oral contraceptives) - Budd-Chiari syndrome and gallstone formation, as well as jaundice in pregnant women in the third trimester as a result of cholestasis. Alcohol should be specifically mentioned once again as the cause of a large group of chronic progressive liver diseases.

Important information is provided by studying the family history, since a number of progressive liver diseases, often detected already at the stage of advanced cirrhosis and manifested by common liver signs, have certain genetic features. Thus, it is important to identify the hereditary nature of Wilson-Konovalov disease, hemochromatosis, and a1-antitrypsin deficiency leading to liver cirrhosis; familial benign hyperbilirubinemia is specifically distinguished.

Complaints

Patients with liver diseases very often have no complaints until the stage of severe damage, but a thorough questioning allows you to detect some of them at an earlier stage of the disease. Common complaints, in addition to poor appetite, an unpleasant, usually bitter taste in the mouth, include complaints of belching, nausea, vomiting, often provoked by eating fatty or fried foods, they are bothered by unstable stool (constipation alternates with diarrhea), bloating. Pure blood may be present in the vomit, which usually indicates bleeding from varicose veins of the esophagus or the presence of erosive gastritis as a manifestation of portal hypertension caused by liver disease with blood stagnation in the portal vein system; the detection of scarlet blood in the feces ("upper" hemorrhoids) and tarry stools have the same genesis.

Bleeding may be caused by erosive esophagitis and alcoholic gastritis.

Painful sensations may be associated either with irritation of the peritoneum covering the liver, or with spastic contraction of the smooth muscles of the gallbladder and bile ducts; patients are also often bothered by a feeling of heaviness and pressure in the right hypochondrium.

Pain in the right hypochondrium occurs with perihepatitis (for example, due to a tumor, liver abscess) and pericholecystitis, they are usually intense, radiate upward (to the right shoulder area), and increase with palpation of the right hypochondrium. Stretching of the liver capsule due to an increase in the organ (hepatomegaly) also causes a similar nature of pain, which is most often observed with congestive liver (congestive heart failure).

Pain in patients with liver and biliary tract diseases may be associated with biliary dyskinesia or caused by spasmodically contracting smooth muscles of the gallbladder and bile ducts in biliary (hepatic) colic. Biliary colic is usually caused by the movement of a stone along the bile ducts. These pains usually appear suddenly, quickly become unbearable, often radiate upward, and are accompanied by nausea and vomiting, which do not bring (unlike other causes of vomiting) relief. Patients may also have aching or dull pain in the right hypochondrium, which intensifies with palpation of the gallbladder point (angle [between the right costal arch and the outer edge of the right rectus abdominis muscle) and the point on the neck on the right between the legs of m. sternocleidomastoideus - the so-called point of the phrenic nerve (phrenicus symptom).

In liver diseases, often accompanying chronic pancreatitis, gastric ulcer and duodenal ulcer can also be the cause of abdominal pain.

Skin itching is a fairly typical manifestation of liver diseases accompanied by jaundice. The extreme degree of skin itching - excruciating, intensifying at night, depriving the patient of sleep, with a mass of skin scratches, often becoming infected - is observed in the presence of intra- and extrahepatic obstruction of the bile ducts (cholestasis syndrome).

A number of complaints may be related to intoxication, which occurs as a result of disruption of the basic functions of the liver, which is usually manifested by disruptions of the central nervous system - fatigue, headaches, irritability. As intoxication increases, these symptoms intensify, sleep disorders are added (sleep inversion - nocturnal insomnia and daytime sleepiness), then loss of consciousness ( hepatic coma ). Patients with liver diseases may complain of decreased potency and libido, menstrual irregularities.

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