In order to treat liver cirrhosis with maximum effectiveness, it is necessary to do as much as possible accurate diagnosis. Diagnosis of liver cirrhosis is very complex and certainly not fast process, a variety of approaches and techniques can be used here.

Before choosing one or another diagnostic approach, you need to know exactly how to identify liver cirrhosis. This is what etiology does, but despite significant progress, etiology It is not always possible to accurately answer why a person got sick, but research into hepatic-renal diseases continues.

The doctor selects such methods clinical examination to know as much as possible about the patient’s health, which will allow you to choose the maximum effective treatment. Like many other ailments (for example, hepatitis), cirrhosis is first diagnosed based on a patient interview, thus identifying the most important complaints.

However, it is very important to know that in order to definitively identify such a disease, it is necessary to conduct a full comprehensive examination, tests are especially important for liver cirrhosis. Treatment must be comprehensive, quality is very important nursing process with cirrhosis of the liver. This disease has several forms, the classification of any cirrhosis of the liver according to Child Pugh is one of the most common. Thus, the most common liver cirrhosis is class A C according to Child classification.

When we're talking about about why such an illness occurs, it must be said that here a significant role is played hereditary factor. In this regard, when examining a patient, you must immediately find out whether any of his close relatives suffered from cirrhosis of the liver or not. The specialist must find out as accurately as possible exactly when the first painful signs began to manifest themselves, and how they developed. Thus, it is possible to find out whether the patient really has cirrhosis or hepatitis, and the stage of the disease is also determined.

It should be noted that people who have such a disease progresses very often complain about a variety of things, here everything is directly dependent on the level of damage to the organ, as well as on whether there are any complications. If the disease is compensated, then negative symptoms there may not be one at all and the diagnostic card records this. However, there are signs that in any case deserve close attention:

• on the right under the ribs sometimes there are slight painful sensations, they are dull in nature, appear as quickly as they disappear;
• a person loses weight, but not much, so he doesn’t pay attention to it;
• some weakness is felt, tone decreases;
• sometimes nausea suddenly occurs, and obvious reasons for this purpose no;
• the temperature rises (but only slightly, which also often does not give cause for concern).

If we are talking about the stage of subcompensation, then the symptoms are more pronounced:

• a person’s performance decreases, he gets tired very quickly;
• pain in the abdominal area becomes stronger and longer lasting;
• nausea is common, this is accompanied by vomiting, there may be diarrhea, digestive problems, diarrhea;
• the person does not want to eat;
• skin itches and itch;
• the skin changes color to yellowish;
• the temperature is significantly increased.

At the stage of decompensation, the signs are already as follows:

• the temperature is very high;
• body weight drops rapidly, all this is multiplied by constant severe fatigue;
• bleeding is observed in the abdominal cavity and esophagus;
• as a result of ascites, the abdomen grows rapidly (against the background total loss weight is noticeably strong);
• Problems with consciousness begin.

About the general medical examination

The diagnostic procedure should begin with a survey of the patient; all existing symptoms and complaints should be recorded as accurately as possible. It must be taken into account that the liver has increased compensatory abilities, which makes it possible for cirrhosis long time generally develop without any symptoms. However, the vast majority of people complain of weakness, lack of desire to eat, severe weight loss, itchy skin. And it also happens that the joints ache, and in groin area hair falls out. If we are talking about women, then the violation menstrual cycle is very common. Here it is necessary to note the nursing process in liver cirrhosis; a lot depends on it.

More about the signs of the disease - the stomach and intestines work abnormally, which is reflected in vomiting, nausea, constipation and diarrhea. The feces become colorless, and the person cannot tolerate alcoholic drinks and fatty foods. The temperature is elevated, the right side of the body constantly hurts. This is all characteristic of cirrhosis. The pain is most often aching in nature, and the liver also enlarges, this can be seen even with general medical examination. The examination should also take into account the condition of the skin, hair and nails. It should be noted that the skin very often acquires an unpleasant yellowish tint (since jaundice very often accompanies this disease).

If we talk about signs of cirrhosis on the skin, they often appear in the form of so-called stars - small spots that are located on the upper side of the body. This is explained by the fact that the liver, under the pressure of the disease, is unable to inactivate hormones, and they dilate blood vessels. The patient's hair and nails most often become thin, weak, and brittle. This is due to problems in metabolism.

About analyzes and research methods

• general clinical research. Here it is accepted for research feces, urine (the color of urine may change) and blood. If there is cirrhosis, then a blood test can reveal anemia, since there is not enough iron and acids in the body. Cirrhosis is a very serious pathology, therefore negative impact turns out to affect the entire body, which can be seen by examining the patient’s urine;
• blood test ( biochemical analysis), for staging accurate diagnosis such analysis is often necessary. A blood test for liver cirrhosis is very important; the fact is that when a person has such a disease, the protein fraction decreases, which can be detected with such a study. Blood counts in severe liver cirrhosis are very important;
• enzyme assays;
• A caulogram is often used, with the help of which it is possible to differentiate the patient’s blood coagulation rate. This technique is very effective, with its help you can assess the condition of the whole organism, which in turn allows you to choose the most effective healing technique. The fact is that these blood indicators can give a picture of the relative course of the operation, if it is to be performed. You can also figure out how quickly you can stop bleeding in a person;
• immunological and serological studies. The serological method can determine the virus that caused the disease, and the immunological method can determine antibodies or the presence of hepatitis. If traces of antibodies were not found in the blood, then there is no point in talking about infection;
• other research. Here it is necessary to note the study of hormonal detection, to determine how low the testosterone level is. For liver cirrhosis, what other tests are needed? Only the doctor can decide this.

Diagnostic methods

1 radiographic method, by which the size of the liver is differentiated, this method is the simplest; 2 radionuclide method, consists of introducing into the body radioactive substance, after which monitoring of its fixation in different organs. Of course, unlike ultrasound, this method does not make it possible to see clear pictures, but it is possible to assess the level of liver functioning, which cannot be done with ultrasound. The resulting image can determine that the spleen is also enlarged; if the radiopharmaceutical element is located in the area of ​​the spine or pelvis, then the liver is not working properly; 3 computed tomography. Using this method, it is possible to evaluate the tumor (cancerous) focus in the affected liver. When the effect of ultrasound begins, the lesions begin to be punctured, then all the data obtained are carefully studied and based on this, treatment is prescribed. Complications may be identified, such as malignant tumors, here we can already talk about oncology; 4 ultrasound examination. Liver cirrhosis is easily recognized by ultrasound. A common method by which you can determine the stage of the disease, you can also obtain data on the size of the organ. You can also find out if there is fluid in the stomach (this is called ascites). Ultrasound is also effectively used to find lesions that can cause cancer; 5 laparoscopic method, which is surgery, which can confirm the presence of the disease or refute it. The doctor examines the surface of the liver and evaluates it. If a person has large-nodular cirrhosis, then on top of the liver there are nodules that may have a reddish or brownish tint. Their shape may be round, or they may have no shape at all; 6 histological examination and biopsy. Using these methods, there is an excellent opportunity to determine the presence of the disease, as well as find out at what stage it is. After this, doctors prescribe the most suitable treatment, and the nursing process for liver cirrhosis must be carried out at a high level.

Differential diagnosis of liver cirrhosis

Differential diagnosis of cirrhosis of a diseased liver is very effective. Using this diagnostic method, you can understand whether we are really talking about cirrhosis of the liver, or whether there are other ailments such as cancer. To determine the pathology, ultrasound examination and biopsy are used. It is with the help latest diagnostics turns out to be as accurate as possible.

It is possible to understand whether the pathogenesis of liver cirrhosis is pronounced or not. The good news is that sometimes severe liver cirrhosis syndromes can be predicted , such as ascites. Formulation of any diagnosis of liver cirrhosis may be different and treatment is always prescribed individually.

Diagnostic tasks are to recognize liver cirrhosis, determine the degree of hepatocellular failure and portal hypertension, as well as establish the etiological or pathogenetic type of the disease. The diagnosis is made on the basis of anamnesis, data clinical picture, biochemical parameters blood and instrumental examination.

Compensated liver cirrhosis is usually detected incidentally in connection with the examination of patients for other diseases (based on detected hepatomegaly and splenomegaly unknown origin). Therefore, a number of researchers propose calling this form of cirrhosis “latent”. To confirm the diagnosis in compensated liver cirrhosis, it is always necessary to carry out instrumental examination, since the changes in stress test indicators in these cases are nonspecific.

At the subcompensation stage of the process leading value for diagnosis have following symptoms: hepatomegaly and splenomegaly, " spider veins", palmar erythema, minor nosebleeds, flatulence, as well as data laboratory tests– accelerated ESR, dysproteinemia, decreased sublimate test, increased level total bilirubin(mainly due to associated), moderate increase in aminotransferase activity. A reliable diagnostic sign is a decrease in the content of reduced glutathione in the blood below 24 mg% (0.78 mmol/l).

Diagnosis of decompensated liver cirrhosis, in addition to the listed symptoms, is based mainly on the presence of jaundice, ascites and severe hemorrhagic diathesis. With decompensated cirrhosis of the liver, hypoproteinemia, a pronounced decrease in the albumin content in the blood, a decrease in the mercuric test, a further increase in total (bound) bilirubin, a decrease in the content of blood coagulation factors (changes in the coagulogram), a low coefficient of cholesterol esterification, alkalosis - respiratory and (or) metabolic .

In the presence of these symptoms, it is of paramount importance for diagnosis to identify signs of portal hypertension, in particular esophageal varices, using esophagoscopy and x-ray examination esophagus. Depending on the magnitude of portal pressure, two degrees of portal hypertension are distinguished:

• I degree – moderately expressed (portal pressure 150-300 mm water column), manifested by flatulence, dyspeptic disorders, splenomegaly;
• II degree – pronounced (portal pressure above 300 mmH2O), characterized by visible venous collaterals, varicose veins of the esophagus, ascites.

To diagnose liver cirrhosis, non-invasive (ultrasound, radiological, radioisotope) and invasive - morphological (laparoscopy, targeted biopsy) research methods are used. The most informative non-invasive methods for liver cirrhosis are echography and scintigraphy.

Using echography in liver cirrhosis, an enlarged liver is detected, changes in its contours (rounded, uneven), as well as splenomegaly, ascites, dilatation of the portal and splenic veins.

X-ray examination of liver cirrhosis can detect abnormalities in the structure of the liver, as well as changes in its hemodynamics. Using plain radiography, changes in the size (increase or decrease) and shape of the liver are detected, as well as signs of ascites. A pronounced enlargement of the organ is accompanied by a high location of the right dome of the diaphragm and a deepening of the right costophrenic sinus.

With ascites, there is limited mobility and upward displacement of the diaphragm, as well as downward displacement right kidney, colon, down and to the left - stomach. Pneumoperitoneum allows you to obtain a relief image of the surface of the organ. Introducing gas into abdominal cavity also makes it possible to detect small amounts of ascitic fluid. Using computed tomography, the size of the liver, a small amount of ascitic fluid, and a decrease in portal blood flow are determined.

Significant changes in the liver in cirrhosis are determined using angiographic research methods. Thus, with cavography, displacement and deformation of the venous trunks are noted, caused by the development of false lobules, sometimes a circular narrowing of the inferior vena cava; with celiacography in the case of severe portal hypertension, there is an expansion of the celiac trunk, splenic and left gastric arteries and at the same time a narrowing of the common hepatic and proper hepatic arteries, the arterial pattern of the liver is depleted, the segmental arteries are narrowed and tortuous, the branches of the splenic artery, on the contrary, are expanded; intensive accumulation is observed in the spleen contrast agent.

According to X-ray cinematography, carried out in combination with celiacography, volumetric blood flow in the splenic artery in liver cirrhosis increases by 2-2.5 times, and in the proper hepatic artery decreases by 1.5-2 times. The ratio of these indicators is normally 0.7-1.4, and in cirrhosis with portal hypertension this ratio increases to 3-6. The greatest diagnostic value has splenoportography. Carrying out this study in liver cirrhosis allows us to determine a more vertical location of the portal vein, deformation and reduction in the caliber of its branches, and a depletion of the pattern due to the reduction of small veins. The outflow of blood from the portal system is compensated by expanded collaterals. Collateral blood flow through anastomoses and varicose veins veins can be detected indirectly by introducing a contrast agent into the esophagus, stomach, and intestines. In the case of expansion of the submucosal venous plexuses along the folds, rounded surface contrast defects are visible.

X-ray examination of the biliary tract - cholegraphy, which allows you to detect narrowing of the intrahepatic bile ducts, mainly used for differential diagnosis primary and secondary biliary cirrhosis of the liver.

Radioisotope diagnostics of liver cirrhosis is carried out to determine the functional and morphological state of the liver and assess the state of the organ’s blood circulation. Radioisotope hepatography, scanning and scintigraphy, radiocirculography, radioisotope cholegraphy and portography are used. Scintigraphy with various hepatotropic drugs has the greatest diagnostic value. Scintigrams of patients with liver cirrhosis reveal a decrease in the inclusion of the radiopharmaceutical drug and its uneven distribution, changes in the shape and size of the liver.

Research carried out using colloidal radiopharmaceuticals makes it possible to conduct quantification their redistribution in the reticuloendothelial system and thereby determine the nature and extent of liver damage. Large nodular cirrhosis on liver scintigrams is characterized by alternating areas of increased inclusion of a radiopharmaceutical drug (foci of regeneration of liver tissue) with areas of reduced inclusion or its complete absence ( fibrotic changes). In small-nodular cirrhosis of the liver, there is a relatively uniform decrease in the accumulation of the drug, more pronounced along the periphery of the organ. For more detailed research emission therapy is used for liver cirrhosis computed tomography, which allows, based on scintigraphic sections in various sections, to obtain volumetric information about cirrhotic changes in the deep structures of the organ.

To assess the state of the absorption-excretory function of hepatocytes in liver cirrhosis, as well as as a differential diagnostic test for intrahepatic and extrahepatic cholestasis, the radioisotope xvlegraphy technique is used. The radiopharmaceuticals based on iminodiacetic acids used for this purpose make it possible to conduct research in the presence of high performance blood bilirubin. To identify the causes of portal hypertension and determine portocaval anastomoses, the most informative are radioisotope portography and intrarectal administration of a cooled xeno-air mixture of 133Xe with subsequent registration of the passage of the radiopharmaceutical through the inferior vena cava system.

TO morphological methods include peritoneoscopy and targeted biopsy. Characteristic features liver cirrhosis are diffuse granularity and (or) tuberosity of the surface of the liver, microscopically - pseudolobular structure of the organ.

Differential diagnosis

Cirrhosis of the liver in initial stage differentiated from chronic active hepatitis, fatty hepatosis. For chronic active hepatitis the liver is moderately dense, with a pointed edge, painful on palpation. At fatty hepatosis the liver is slightly enlarged, has a dense consistency, is sometimes sensitive to palpation, has a blunt edge and a smooth surface. Due to the fact that the development of liver cirrhosis occurs gradually, a clear distinction between them is impossible in some cases. About the transition pathological process in cirrhotic indicates the presence of signs of portal hypertension.

In the advanced stage of the disease, liver cirrhosis is differentiated from malignant tumor liver, alveococcosis, subleukemic myelosis, liver amyloidosis.

Liver cancer is more common rapid development diseases, severe progressive course, exhaustion, fever, pain syndrome, rapid enlargement of the liver (the spleen remains normal sizes), which has an uneven surface and “stony” density, leukocytosis, anemia, sharply accelerated ESR. Most reliable signs liver cancer (primary and cirrhosis-cancer) are positive reaction Abeleva-Tatarinov – detection of fetal serum globulins (alpha-fetoproteins) using the precipitation reaction in agar, as well as data from targeted biopsy, angiography (for cholangioma).

With alveococcosis, liver enlargement occurs gradually over a long period of time; the liver becomes lumpy, acquires an “iron” density, and is painful on palpation; the diagnosis is made on the basis of a latex agglutination reaction, in which specific antibodies are detected; in some cases they resort to laparoscopy.

In subleukemic myelosis with a benign course, an enlarged spleen precedes hepatomegaly, portal hypertension is not typical; There is a dissociation between pronounced splenomegaly and a slightly changed blood picture (moderate neutrophilic leukocytosis with a predominance of mature forms). Reliable diagnostic criteria are the data obtained from trepanobiopsy - pronounced cellular hyperplasia, an abundance of megakaryocytes, proliferation of connective tissue.

Cirrhosis is a diffuse process characterized by fibrosis and transformation of the normal structure of the liver with the formation of nodes. It serves as the end stage of a number of chronic liver diseases. Heaviness and cirrhosis prognosis depend on the volume of the remaining functioning mass of the liver parenchyma, the severity of portal hypertension and the activity of the underlying disease that led to impaired liver function.

ICD-10 K74 Fibrosis and cirrhosis of the liver K70.3 Alcoholic cirrhosis of the liver K71.7 With toxic liver damage K74.3 Primary biliary cirrhosis K74.4 Secondary biliary cirrhosis K74.5 Biliary cirrhosis, unspecified K74.6 Other and unspecified cirrhosis of the liver K72 Chronic liver failure K76. 6 Portal hypertension.

An example of a diagnosis formulation

Epidemiology

Liver cirrhosis ranks first among the causes of death from diseases of the digestive system (excluding tumors). The prevalence is 2–3% (based on autopsy data). Cirrhosis observed 2 times more often in men over 40 years of age compared to the general population.

Etiology

The most common causes of liver cirrhosis are the following diseases and conditions. ■ Viral hepatitis - (B, C, D). ■ Almost always, the development of alcoholic cirrhosis is preceded by constant alcohol consumption for more than 10 years. The risk of liver damage significantly increases with consumption of more than 40–80 g of pure ethanol per day for at least 5 years. ■ Immune liver diseases: autoimmune hepatitis, graft-versus-host disease. ■ Diseases of the biliary tract: extra- and intrahepatic obstruction of the biliary tract caused by various causes, cholangiopathies in children. ■ Metabolic diseases: hemochromatosis, α1-antitrypsin deficiency, Wilson–Konovalov disease, cystic fibrosis (cystic fibrosis), galactosemia, glycogenosis, hereditary tyrosinemia, hereditary fructose intolerance, abetalipoproteinemia, porphyria. ■ Impaired venous outflow from the liver: Budd–Chiari syndrome, veno-occlusive disease, severe right ventricular heart failure. ■ Use of hepatotoxic drugs (methotrexate B, amiodarone C), toxins, chemicals. ■ Other infections: schistosomiasis, brucellosis, syphilis, sarcoidosis. ■ Other causes: non-alcoholic steatohepatitis, hypervitaminosis A. The time required for the development of liver fibrosis largely depends on the etiological factor. The most commonly observed forms of fibrosis and cirrhosis develop slowly: alcoholic cirrhosis of the liver develops over 10–12 years of alcohol abuse, viral cirrhosis of the liver develops 20–25 years after infection. The fastest rates of development of liver cirrhosis (several months) were observed in patients with biliary obstruction of tumor etiology and in newborns with bile duct atresia.

Prevention

Prevention of liver cirrhosis includes timely identification of conditions that can lead to its development and adequate correction of detected disorders. ■ Hemochromatosis. Several studies have demonstrated the cost-effectiveness of population-based screening for hereditary hemochromatosis. During screening, iron in the blood serum, total and free iron-binding capacity of the serum are determined. If these indicators are elevated, they are determined again and if there is a significant increase, the patient is examined for hemochromatosis. ■ Screening for alcohol abuse: limiting alcohol consumption significantly reduces the likelihood of developing liver cirrhosisB. It is possible to use the CAGE test (Cut - cut, Angry - angry, Guilty - guilt, Empty - empty), which includes four questions. 1. Have you ever felt that you should cut down on your drinking? 2. Have you ever felt irritated if someone around you (friends, relatives) told you about the need to reduce your drinking? 3. Have you ever felt guilty about drinking alcohol? 4. Have you ever had the urge to drink alcohol the morning after an episode of drinking? Sensitivity and specificity are approximately 70%, the main advantage is the ability to test while collecting anamnesis. A positive answer to more than two questions allows one to suspect alcohol dependence, accompanied by changes in behavior and personality. Among laboratory signs, markers of alcohol abuse may include a predominant increase in AST activity compared to ALT, increase in GGTP, Ig A, increase in average erythrocyte volume. All of these signs have high specificity with relatively low sensitivity, with the exception of GGTP activity, the increase of which is considered a highly specific sign of both alcohol abuse and alcohol dependence A. ■ Screening for hepatitis B and C viruses: for more details, see the article “Acute and chronic viral hepatitis.” Individuals with risk factors for chronic hepatitis should be tested for hepatitis B and C viruses. Survival of patients with chronic hepatitis, both in the presence of cirrhosis and without it, is significantly higher with timely interferon therapy B. ■ Screening for the use of hepatotoxic drugs, primarily methotrexate B and amiodarone C, by determining the activity of ALT and AST every 1–3 months. These drugs, when used for a long time, can lead to cirrhosis of the liver. ■ Screening among relatives of patients with chronic liver damage. First-degree relatives are examined: the degree of transferrin saturation and serum ferritin concentration (detection of congenital hemochromatosis B), serum concentration of ceruloplasmin (diagnosis of Wilson-Konovalov disease B), and detection of α1-antitrypsin deficiency are determined. ■ Screening for non-alcoholic fatty liver disease. Risk factors - type 2 diabetes mellitus, obesity, hyperlipidemia, AST/ALT activity ratio above 1.0; The risk increases especially significantly in patients over 45 years of age. All patients at risk should undergo liver ultrasound to detect steatosis. Patients should be informed about the possibility of developing cirrhosis of the liver.

Screening

Screening to directly detect liver cirrhosis is not carried out. Screening activities are carried out in order to identify diseases and conditions that can lead to liver cirrhosis (see the “Prevention” section above).

Classification

Liver cirrhosis is divided according to etiology (see the “Etiology” section above) and severity, for which the Child–Pugh A classification is used (Table 4-10). Table 4-10. Determination of the severity of liver cirrhosis according to Child-Pugh

Indicator
Encephalopathy
		Soft, easy to treat	Tense, difficult to treat
Serum bilirubin concentration, µmol/l (mg%)	Less than 34 (<2,0)	34–51 (2,0–3,0)	More than 51 (>3.0)
Serum albumin level, g
Prothrombin time (s), or prothrombin index (%)			More than 6 (<40)

Each of the indicators is assessed in points (1, 2 or 3 points, respectively). Interpretation is carried out according to the following criteria. ■ Class A (compensated) - 5–6 points. ■ Class B (subcompensated) - 7–9 points. ■ Class C (decompensated) - 10–15 points.

Diagnostics

Survey plan

The diagnosis of liver cirrhosis can be assumed by clinical and anamnestic data (symptoms are very diverse, see section “Anamnesis and physical examination”), confirmed by the results of laboratory and instrumental examination. It is necessary to establish the etiology of the disease, since in some cases etiotropic therapy can slow down the progression of the disease and reduce mortality. The most common causes are viral hepatitis and alcohol abuse; less common causes are listed in the Etiology section. In some cases, the cause of cirrhosis cannot be detected, in which case a diagnosis of cryptogenic cirrhosis is made. When making a diagnosis, it is necessary to additionally evaluate the following parameters. ■ State of the main functions of the liver: the presence of cytolysis syndromes, cholestasis, the state of the blood coagulation system (cirrhosis is characterized by hemorrhagic syndrome), protein-synthetic function of the liver. ■ Detection of hypersplenism syndrome (primarily by platelet count). ■ Identification and assessment of the degree of portal hypertension (dangerous primarily due to bleeding from varicose veins of the esophagus and stomach - FEGDS). ■ Detection of possible ascites. ■ Assessment of mental status for timely diagnosis of hepatic encephalopathy. The severity of liver cirrhosis is determined by the Child–Pugh classification of hepatic cellular function in liver cirrhosis (see section “Classification”).

History and physical examination The following symptoms and syndromes are characteristic. ■ General symptoms: drowsiness, weakness, increased fatigue and itchy skin. With severe drowsiness, as well as with irritability and aggressive behavior, it is necessary to exclude hepatic encephalopathy. ■ Changes in the liver and spleen: the liver is compacted and enlarged, but can sometimes be small in size. In most patients, a moderately enlarged spleen is palpable (manifestations of portal hypertension). ■ Jaundice: the initial signs of jaundice are invisible to the patient and are characterized by icterus of the sclera and mucous membranes, frenulum of the tongue, and slight darkening of the urine, which patients usually do not attach due importance to. ■ Breathing difficulties (shallow, rapid breathing) can be caused by: ascites with increased intra-abdominal pressure and limited mobility of the diaphragm, chronic heart failure, hydrothorax against the background of edematous-ascitic syndrome. ■ Hemorrhagic syndrome (due to impaired synthesis of blood clotting factors in the liver): bleeding gums and nosebleeds are characteristic. Patients notice that bruises and bruises form even with minor mechanical stress. ■ Portal hypertension: ascites, varicose veins of the esophagus and stomach, dilatation of the veins of the anterior abdominal wall in the form of the “head of Medusa”, splenomegaly, hepatic encephalopathy. ■ Ascites (manifestation of portal hypertension): an increase in the abdomen in volume due to accumulated fluid (more than 10–15 liters of fluid can accumulate, a “frog belly” is typical); with a large amount of it, a picture of “tense ascites” is created, bulging of the navel, sometimes with its ruptures, percussion signs of fluid in the abdominal cavity, positive symptom of fluctuation. ■ Other signs characteristic of liver cirrhosis: ✧ telangiectasia on the upper half of the body and face; ✧ palmar erythema; ✧ gynecomastia; ✧ testicular atrophy/amenorrhea; ✧ swelling of the legs (with ascites); ✧ Cruvelier-Baumgarten noise - venous noise over the abdomen associated with the functioning of venous collaterals; ✧ Dupuytren's contracture, more typical of liver cirrhosis of alcoholic etiology; ✧ changes in the terminal phalanges of the fingers like drumsticks; ✧ atrophy of skeletal muscles, lack of hair growth in the armpit; ✧ enlargement of the parotid salivary glands (typical for patients suffering from alcoholism); ✧ hepatic odor occurs during decompensation of liver functions, precedes and accompanies the development of hepatic coma; ✧ flapping tremor is also characteristic of decompensation of liver functions. Particular attention should be paid to signs of developed complications: ■ symptoms of gastrointestinal bleeding: hematemesis, melena, systolic blood pressure less than 100 mm Hg. with a decrease of 20 mm Hg. when moving to a vertical position, heart rate is more than 100 per minute; ■ signs of spontaneous bacterial peritonitis - diffuse pain of varying intensity in the abdominal cavity, fever, vomiting, diarrhea, signs of intestinal paresis; ■ confusion, reflecting the development of hepatic encephalopathy; ■ a decrease in daily diuresis - a likely sign of the development of renal failure.

Chronic hepatitis is an inflammation of the liver tissue that is widespread (diffuse) and lasts more than six months.
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Causes of chronic hepatitis

Chronic hepatitis, like cirrhosis of the liver, often has a fairly blurred clinical picture, up to an asymptomatic course until the terminal stage. For the timely detection of disturbances in vital processes, timely and instrumental examination methods are necessary, among which the following are mandatory for this pathology. You can go through the entire range of necessary diagnostic measures in. You can find out the general list and them by following the links to the relevant sections.

According to etiological factors, the most common forms are:

• Viral
• Alcoholic
• Toxic
• Drug-induced hepatitis;

According to the clinical course:

• Chronic active hepatitis
• Persistent
• Reactive
• Secondary biliary hepatitis due to impaired bile outflow - cholestasis.

Distinctive features of liver cirrhosis

Liver cirrhosis is characterized by diffuse proliferation of connective tissue, causing disruption of the liver structure (architectonics of the organ), disruption of trophism with subsequent degeneration and necrosis of liver cells - hepatocytes. As the processes of cirrhotic changes progress, portal hypertension develops and liver failure increases. Liver cirrhosis is usually accompanied by an enlarged spleen – hypersplenism; other organs are also involved in the pathological process.

Main clinical syndromes in chronic processes in the liver

In the clinic of chronic pathologies of the liver, the following syndromes are distinguished:

• Asthenovegetative
• Dyspeptic
• Disturbances in the outflow of bile – cholestasis
• Phenomena of liver failure
• Portal hypertension
• Enlarged spleen – hypersplenomegaly;

Clinical manifestations of chronic hepatitis

The clinical picture of chronic hepatitis is characterized by the following symptoms: liver enlargement, severe pain localized mainly in the right hypochondrium, dyspepsia; in some cases, jaundice and an enlarged spleen may occur. There are benign (persistent) chronic hepatitis and active hepatitis, which is characterized by a more aggressive course. Persistent hepatitis often occurs without pronounced clinical symptoms and patient complaints; the presence of the disease in this case is confirmed only by laboratory diagnostics. With active hepatitis, all the patient's symptoms and complaints are more pronounced and are clearly confirmed by the results of laboratory tests and instrumental diagnostic methods. Active hepatitis is often accompanied by signs of autoimmune damage: polyarthralgia, glomerulonephritis, myocarditis, skin rashes.

Differences in the manifestations of changes in the liver during cirrhosis and hepatitis

With cirrhosis, the liver is denser, it can be either enlarged or reduced in size (in later stages). Cirrhosis is characterized by a dense, pointed edge of the liver upon palpation; sometimes its granular, heterogeneous surface is determined. Quite often, with cirrhosis, there is an enlarged spleen and the presence of “liver signs”: spider veins - telagioectasia, a bright red hepatic tongue, hepatic palms. Signs of portal hypertension (increased pressure in the portal vein system of the liver) are revealed: varicose veins of the esophagus, ascites and others.

Diagnosis of chronic liver diseases

During laboratory diagnostics, the following studies are performed:

• All forms of bilirubin
• Blood enzymes (ALAT, AST, alkaline phosphatase)
• Prothrombin
• Blood clotting indicators
• Cholesterol
• Blood glucose
• Total protein and protein fractions, especially albumin - as an indicator of the protein-synthetic function of the liver
• Immunoglobulins
• Australian antigen;

Instrumental examination methods for chronic liver diseases

These may include the following activities:

• Ultrasound examination of the liver and other abdominal organs
• Esophagogastroduodenoscopy (FGS or FGDS)
• Colonoscopy
• Liver biopsy
• Scintigraphy
• Computed tomography and NMR
• Laparoscopic diagnosis;

Basic principles of treatment of chronic liver pathologies

• A patient with an established diagnosis of chronic hepatitis or cirrhosis of the liver is recommended to strictly adhere to the diet and diet (small meals, with the exception of fatty, fried and spicy foods and spices, the absolute exclusion of alcoholic beverages and soda, canned food);
• It is necessary to stop the patient's contact with any hepatotoxic agents and poisons;
• Stop taking medications that can have a hepatotoxic effect and simply medications that you can do without
• It is necessary to lead a moderate and correct lifestyle, with reasonable limitation of physical activity

Basics of treatment of chronic hepatitis

If viral chronic hepatitis occurs in persistent form, no special treatment is required. For alcoholic hepatitis, it is recommended (in addition to completely avoiding alcohol intake) a course of hepatoprotectors (Essentiale, Karsil). In the case of an aggressive form of hepatitis (chronic active - CAH) with a pronounced immunological reaction, low doses of corticosteroids are used in treatment: prednisolone, sometimes azothiaprine, followed by a reduction in dosage to maintenance doses.

Basics of treatment of liver cirrhosis

If liver cirrhosis is accompanied by severe symptoms of portal hypertension and ascites, diuretics (diuretics) are added to treatment: veroshpiron, furosemide, hypothiazide. This requires monitoring of daily diuresis: if it is above 3 liters, this can be dangerous due to the occurrence of electrolyte disturbances. In the presence of varicose veins of the esophagus, prevention of bleeding from them is necessary (mechanically and thermally gentle food, taking antacids, beta blockers).

Herbal treatment for liver cirrhosis and chronic hepatitis

The following herbal medicine is indicated for patients with these diseases:

• Immortelle flowers – 2 parts;
• Yarrow herb – 2 parts;
• Nettle leaves – 2 parts;
• Fennel – 1 part;
• Corn silk – 2 parts;
• Chamomile flowers – 1 part;
• Knotweed – 2 parts.

The infusion is prepared by infusing 5 g of herbal mixture in 350 ml of boiling water for 30 minutes. Take 100 ml three times a day before meals, for a month.

The invention relates to the field of biochemical diagnostics and can be used for differential diagnosis of chronic hepatitis and cirrhosis of the liver. The essence of the method is that an enzyme-linked immunosorbent determination of the content of thyroglobulin in the blood serum is carried out and when the level of thyroglobulin increases by 2 times or more compared to the norm, chronic hepatitis is diagnosed, and when the level of thyroglobulin decreases by 1.5-2.5 times compared to the norm is cirrhosis of the liver. The technical result is to increase the accuracy of differential diagnosis and reduce trauma.

The invention relates to the field of medicine and can be used in the differential diagnosis of chronic hepatitis and cirrhosis of the liver.

There is a known method for the differential diagnosis of chronic hepatitis and cirrhosis of the liver by ultrasound echography, adopted as an analogue (1).

There is a known method for the differential diagnosis of chronic hepatitis and cirrhosis of the liver by ultrasound echography and morphological examination of liver biopsy (2), adopted as a prototype.

However, the accuracy of the differential diagnosis of chronic hepatitis and cirrhosis of the liver, according to the prototype method, is relatively limited, and it is traumatic.

The purpose of the present invention is to improve the accuracy of differential diagnosis of chronic hepatitis and cirrhosis of the liver while reducing morbidity.

The technical result is achieved by additionally carrying out an enzyme-linked immunosorbent determination of the content of thyroglobulin in the blood serum and when the level of thyroglobulin increases by 2 times or more compared to the norm, chronic hepatitis is diagnosed, and when the level of thyroglobulin decreases by 1.5-2.5 times compared to the norm is cirrhosis of the liver.

The method is carried out as follows.

The patient complains of weakness, especially in the morning, fatigue, a feeling of heaviness and pain in the epigastric region and the area of ​​the right hypochondrium, dyspepsia - loss of appetite, intolerance to fatty foods, bloating, nausea. With severe exacerbation during chronic hepatitis, weight loss and periodic increases in body temperature are noted. The liver is enlarged and painful on palpation, its surface is smooth. Less common is an enlarged spleen and sometimes the phenomenon of “spider veins” and “liver palms”. The activity of the process is determined by hyperenzymemia (AST, ALT, gamma-glutamyl transpeptidase, warming of alkaline phosphatase levels), hypergammaglobulinemia and an increase in the content of immunoglobulins. In chronic viral hepatitis, HBV DNA and HCV RNA are detected in the blood serum.

Echohepatogram for chronic hepatitis: liver tissue is compacted, intensively reflects the echo signal. In most cases, echoes do not reach their maximum amplitude.

Laparoscopy reveals a large white or large variegated liver with damage to both lobes or only one.

In liver cirrhosis, as a result of chronic hepatitis, the clinical picture consists of hepatocellular failure, portal hypertension (varicose veins of the esophagus, stomach and, less commonly, hemorrhoidal veins), damage to the reticuloendothelial system, hemodynamic disorders, fever, changes in the nervous and endocrine systems. Typical with liver cirrhosis are sleep disturbances - insomnia at night and drowsiness during the day. Insomnia can be aggravated by itching of the skin, which develops in the case of cholestasis; in some cases, paresthesia in the arms and legs (a feeling of numbness, crawling “goosebumps”) is observed.

With subcompensated cirrhosis, patients complain of weakness and fatigue, irritability and decreased appetite, belching, dull pain in the right hypochondrium radiating to the right scapula. An increase in temperature is noted. The skin is dry, yellowish-gray in color. On palpation, the liver is enlarged, painful, its consistency is dense, the surface of the liver is uneven.

The echohepatogram in liver cirrhosis is characterized by the presence of a large number of reflected signals from sclerotic intrahepatic structures, and the amplitude of the reflected signals reaches a significant value.

Determination of the content of thyroid hormones in the blood of patients with chronic liver diseases was carried out using the enzyme immunoassay method in the blood serum and when the level of thyroglobulin increases by 2 times or more compared to the norm, chronic hepatitis is diagnosed, and when the level of thyroglobulin decreases by 1.5-2.5 times compared with the norm - liver cirrhosis.

Confirmation of the correctness of what was done. The basis of the proposed method of conclusions are the results of a morphological study of liver biopsies. Liver biopsies from chronic hepatitis show stepwise and, sometimes, bridging necrosis; lymphoid and histiocytic infiltration of lobules and portal tracts. Specific markers include frosted glassy hepatocytes with the presence of HBsAg and hepatocytes with sandy nuclei, which contain HBs Ag.

A morphological study of liver biopsy in cirrhosis reveals necrosis and regeneration of the liver parenchyma, which is accompanied by the formation of false lobules, diffuse proliferation of connective tissue, structural changes and deformation of the organ. Initial necrosis of hepatocytes is accompanied by hyperplasia of the remaining liver parenchyma with the formation of regeneration nodes (false lobules). In areas of massive necrosis, stromal collapse and inflammation, fibrous septa are formed, in which arteriovenous anastomoses are formed.

The method is confirmed by the following examples.

Patient E-v, 44 years old, upon admission complains of fatigue, a feeling of heaviness in the epigastric region, decreased appetite and bloating. The patient has lost 2 kg and notes periodic increases in body temperature. The liver is enlarged and painful on palpation. There is an enlargement of the spleen.

In the biochemical blood test: Ac AT - 45 units/l, Al AT - 48 units/l; alkaline phosphatase - 195 units/l, gamma-glutamyl transpeptidase - 59 units/l, bilirubin - 41.0 µm/l. The content of immunoglobulins in the blood serum was: IgM - 155 mg% (normal 105), IgG-1890 mg% (normal 1080), IgA-345 mg% (normal 155).

In this patient, HBV DNA and HCV RNA are detected in the blood serum.

Ultrasound examination: liver tissue is compacted and intensively reflects the echo signal. Echoes do not reach maximum amplitude.

Determination of thyroglobulin content in blood serum showed an increase in its level by 2.1 times compared to the norm (32±3.5 ng/ml). It was concluded that the patient had chronic hepatitis of B-C viral etiology.

A morphological study of liver biopsy specimens confirmed the correctness of the diagnosis. Liver biopsy specimens revealed stepwise necrosis and lymphoid infiltration of the lobules and portal tracts.

Patient G-ko, 38 years old, upon admission complains of weakness, especially in the morning, pain in the epigastric region and right hypochondrium, bloating, and nausea. On palpation, the liver is enlarged and painful, its surface is smooth. Splenomegaly is noted and spider veins are detected.

In the biochemical blood test: Ac AT - 50 units/l, Al AT - 54 units/l; alkaline phosphatase - 214 units/l, gamma-glutamyl transpeptidase - 67 units/l, bilirubin - 46 µm/l. The content of immunoglobulins in the blood serum was: IgM - 170 mg%, IgG - 1940 mg%, IgA - 387 mg%. In this patient, HBV DNA and HCV RNA are detected in the blood serum.

An echohepatogram showed compaction of the liver tissue and the presence of high-amplitude echo signals.

Thyroglobulin level is 96 ng/ml. Based on the study, the patient was diagnosed with DS: Chronic hepatitis of B- and C-viral etiology.

Morphological examination of liver biopsies showed the presence of bridging necrosis, lymphoid-histiocytic infiltration of lobules and portal tracts. Frosted glassy hepatocytes with the presence of HBsAg and hepatocytes with sandy nuclei containing HBs Ag were revealed.

The patient received a course of treatment. Subsequent outpatient follow-up for 1.5 years confirmed the correctness of the diagnosis and improvement in the parameters of biochemical tests.

Patient M-va, 65 years old, complains of weakness, irritability and dull pain in the right hypochondrium; the skin is yellowish-gray. Hyperthermia is noted. The patient is somewhat inhibited.

On palpation, the liver is enlarged and painful, its consistency is dense, its surface is uneven, the spleen is enlarged, and the phenomena of “spider veins” and “liver palms” are noted.

The echohepatogram is characterized by the presence of a large number of reflected signals from sclerotic intrahepatic structures, the amplitude of the reflected signals reaches its maximum value.

Determination of the thyroglobulin content in the patient’s blood showed that its level was 22 ng/ml, which allows us to make a diagnosis of liver cirrhosis.

Confirmation of the correctness of the conclusions made on the basis of the proposed method are the results of a morphological study of liver biopsies: necrosis and regeneration of the liver parenchyma with the formation of false lobules, diffuse proliferation of connective tissue. In areas of massive necrosis, stromal collapse and inflammation, fibrous septa are formed, in which arteriovenous anastomoses are formed.

The patient was treated. Her condition has stabilized. Follow-up observation for 15 months did not reveal progression of liver cirrhosis, which confirms the correctness of the diagnosis.

Patient Gr-n, 54 years old, complains of fatigue, decreased appetite, pain in the right hypochondrium. The skin is dry, yellowish-gray in color. An increase in temperature is noted.

Palpation of the liver is painful, its consistency is dense, upon palpation the liver is enlarged, its surface is uneven, splenomegaly, the phenomena of “spider veins” and “liver palms” are noted.

Ultrasound examination reveals the presence of a large number of reflected signals from intrahepatic structures, the amplitude of the reflected signals is maximum.

There is slight hyperfermentemia and hypergammaglobulinemia in the blood.

Determination of the thyroglobulin content in the patient’s blood showed that its level was 12.5 ng/ml, which allows us to make a diagnosis of liver cirrhosis.

Confirmation of the correctness of the conclusions made on the basis of the proposed method are the results of a morphological study of liver biopsies. A morphological examination of a liver biopsy reveals necrosis and regeneration of the liver parenchyma with the formation of false lobules, diffuse proliferation of connective tissue, structural changes and deformation of the organ. Initial necrosis of hepatocytes is accompanied by hyperplasia of the remaining liver parenchyma with the formation of regeneration nodes. In areas of massive necrosis, stromal collapse and inflammation, fibrous septa are formed, in which arteriovenous anastomoses are formed.

The patient was treated. He was discharged in satisfactory condition. Follow-up observation for 19 months confirmed the correctness of the diagnosis.

According to the claimed method, 53 patients were diagnosed and found to have: 24 patients with chronic hepatitis and 29 patients with cirrhosis of the liver. For 94% of these patients, subsequent follow-up confirmed the correctness of the diagnosis.

Literature

1. Diseases of the digestive system in children./Ed. A.V. Mazurina. - M., 1984, 630 p.

A method for the differential diagnosis of chronic hepatitis and cirrhosis of the liver by ultrasound examination of the liver, characterized in that an enzyme-linked immunosorbent determination of the content of thyroglobulin in the blood serum is additionally carried out and when the level of thyroglobulin increases by 2 or more times compared to the norm, chronic hepatitis is diagnosed, and when the level of thyroglobulin decreases in 1.5-2.5 times compared to the norm - liver cirrhosis.

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