A CURA DEL DOTT. GUARDO S. RAUL delle donne... · 2010-12-17 · and distribute them to other...

A CURA DEL DOTT. GUARDO S. RAUL

ONLUS (D.Lgs. 460/97)

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1

THE LIVER IN WOMEN Dr. Raul Guardo Salinas

The liver is the most voluminous organ of the human body and its weight is around 1.5

kilograms. It is a gland located in the right abdomen, which plays a key role in metabolism and

allows you to:

Convert of the products of digestion of the elements necessary for life and growth, so as

to determine the metabolism of carbohydrates and sugars needed to produce energy;

The metabolism and removal from the blood of drugs, alcohol and all the toxins that can

be harmful to the body;

The production of bile, which is essential to dissolve and absorb fats and vitamins in the

intestine;




2 The metabolism of proteins, namely the splitting of proteins into simpler molecules, to

produce other proteins and other molecules necessary for blood clotting;

The maintenance of normal hormone balance.

From all this we can deduce the importance of the liver to the body: on the one hand, it has the

crucial role of detoxifying the body from harmful substances with which we come into contact

and, secondly, to capture the nutrients contained in the blood resulting from diets to metabolize

and distribute them to other organs.

As a result, diseases that affect the liver have an impact on the health and welfare of the whole

organism, since it affects the normal functionality.

What are the most common liver disease

The liver, in part because of the many essential functions it carries out, is the target of many

different diseases. Hepatic abnormalities, however, do usually cause clinical symptoms,

regardless of their origin.

The liver disease can have different causes:

Inflammatory

Vascular

Metabolic

Cancer

Inflammatory diseases (hepatitis)

The literal meaning of hepatitis is inflammation of the liver parenchyma (tissue type of the

liver). This condition has many causes and usually results in lesions of hepatocytes (liver cells).

Hepatitis is often caused by infection, toxic, immunologic diseases.

Infections. Infections are the main cause of hepatitis. Borne viral infection of the liver

parenchyma is relatively common. The three most common etiologic agents that cause

viral hepatitis in Europe are the hepatitis A virus (HAV), B (HBV) and C (HCV) currently

there are also other isolated strains that can cause liver disease. The virus strains differ

with regard to the mode of transmission and how they cause damage to liver

parenchyma. Even bacteria, fungi and protozoa can infect the liver. The liver parenchyma

is also almost always involved, even indirectly, in all hematological infections.

Materials to toxic. Toxic substances such as alcohol, drugs or poisons can cause

hepatitis directly (by damaging the liver tissue) or indirectly (by reducing the immune

system or causing an autoimmune response), although the exact pathogenesis of liver

injury is not always clear. The extent of damage to the liver parenchyma does not




3 necessarily depend on the amount of toxic substance introduced and can vary from a

mild asymptomatic inflammation to a part of fulminate hepatic failure or fibrosis, which

can progress to cirrhosis. Alcohol, however, is metabolized by the liver and its

metabolites are indeed a cause of liver damage. As for many drugs are those that can

damage the liver, with injuries ranging from moderate and asymptomatic biochemical

damage to lethal hepatic failure. There are drugs such as phenytoin (an anticonvulsant)

and isoniazide (an anti-tuberculosis agent) that can cause hepatitis "virus-like" (similar to

those caused by viruses).

Immunological diseases. Normally the immune system is able to recognize antigens "foreign" or

"non-self" (proteins that do not belong to your body), such as those brought or produced by

viruses and bacteria, and eliminate them through the intervention of antibodies (proteins with

high specificity that bind selectively to antigens), but sometimes it may happen that you develop

a condition called autoimmunity, in which the immune system reacts against antigens

uncontrollably "self" (one's own cells). And 'what happens in autoimmune hepatitis and primary

biliary cirrhosis, diseases characterized by the attack by the immune system to portions of the

liver parenchyma. If left unchecked, chronic inflammation can lead to a framework of cirrhosis

Vascular disease (portal hypertension)

The liver receives blood from the intestines and spleen through the portal vein. If the resistance

of the liver increases, as in fibrosis or cirrhosis, there is also an increase in intravenous pressure

in the portal vein (portal hypertension). Since in this situation is difficult for blood to pass through

the liver, it tries to flow toward the heart along alternative routes, usually with the development

of new collateral vessels called veins, which connects the portal vein with the blood

stream systemic. Portal hypertension has three major consequences:




4

1) porto-systemic shunt and relative hepatic encephalopathy, with the first you miss the

important role of "filter" of the liver and the latter can also have serious effects on the brain;

2) varicose veins (vascular dilation with potentially serious internal bleeding);

3) ascites: it is a deposit and accumulation of serous fluid containing protein (ascites) in the

abdominal cavity, which can cause loss of appetite or anorexia, dyspnea, shortness of breath.




5

Metabolic diseases

Alterations in hepatic metabolism may be congenital (present at birth) or acquired. Some of

these diseases, such as Wilson disease, alpha-1 antitrypsin deficiency and the

hemochromatosis, may present with symptoms similar to hepatitis or cirrhosis, it is necessary to

make a correct differential diagnosis in order to set the appropriate treatment.

Neoplastic diseases (cancer)

Benign liver tumors. They are usually asymptomatic, the most common is the

hemangioma, characterized by a tangle of vessels taking shape "a ball" is more common

in women and is present in 5% of the population.

Malignant liver tumors. The main primary liver cancer is hepatocellular carcinoma or

HCC, it most commonly affects patients with cirrhosis secondary to viral infection, to

alcoholism, to hemochromatosis, a deficiency of alpha1-antitrypsin. The male sex is more

affected than the female and the prognosis is severe, with a median survival of

approximately six months after the onset of symptoms.

Metastasizing tumors in the liver. Some cancers, like breast cancer and lung cancer can

metastasize (spread "small pieces of tumor elsewhere in the body that are transported

through the circulation, with implantation and growth in other tissues).Because of its

action "filter" the liver is one of the most common sites of metastasis of malignant tumors

(secondary liver).

Involvement of the liver in extrahepatic disease

Given its key role in the production of many proteins, including "inflammatory proteins”, the liver

may be involved or be affected by several extrahepatic diseases, particularly autoimmune

diseases (disorders where the immune system attacks normal body tissues). Some examples

include rheumatic diseases (such as systemic lupus erythematosus and rheumatoid arthritis)

and inflammatory bowel disease (such as ulcerative colitis and rectal Crohn's

disease). Systemic infections such as tuberculosis, candidiasis, and toxoplasmosis, can cause

liver damage. In addition, heart failure can lead to hepatic congestion, fibrosis and the

appearance of ascites, due to blood stasis in the liver, caused by a deficiency of the heart

pump.

What are the differences between the sexes Between the sexes there are structural differences, but in life, the liver can undergo functional

changes. It is known that in particular during pregnancy estrogens have multiple and different

effects on hepatic metabolism, the ability of synthesis of plasma proteins and secretory




6 function. You may well find some modifications of the laboratory tests that return to normal after

pregnancy.

The most common liver disease in women The female liver is more vulnerable to situations of autoimmunity, namely those alterations of

the immune response, leading to the formation of antibodies that can attack the liver cells.

For this reason there are two typical diseases covered in this chapter: autoimmune hepatitis,

chronic liver inflammation that is now easily diagnosed and treatable, and primary biliary

cirrhosis, which selectively targets the cells of the bile duct blocking the secretion bile. Typically

the latter disease affects almost exclusively women (a ratio of 9:1) and the onset occurs

predominantly in perimenopausal period (around the menopause). This has therefore think the

interference of hormonal factors, as well as immunological, to explain the pathogenesis. Today

it is known that female hormones, especially oestrogen, may play a role in promoting the

damage, immune-mediated liver cells.

Environmental factors, dietary and behavioral liver disease

Do not forget that more women than men are consumers of drugs. The liver is the organ

that metabolizes drugs and toxic substances, and for this reason it can suffer damage

from drugs is not always clinically evident. In fact, the mechanism of damage from drugs

is only in exceptional cases due to an overdose (dose dependent), and in most cases the

mechanism of the damage from drugs is of type immune-allergic. This means that even a

single administration of drug to determine liver damage.

Among the most toxic known we mention that alcohol is one of the most important factors

of liver injury. The women relative to men has less ability to detoxify alcohol, so the

woman has a lower tolerance to ethanol (alcohol). The distribution of ethanol in tissues is

also influenced by their water content. The woman who has a different body of water

content, has an increased duration of circulating ethanol. In addition, during pregnancy,

alcohol spreads easily through the placenta and the foetus has very limited capacity

enzyme. Hence the recommendation to abstain from alcohol during pregnancy,

particularly in the first quarter.




7 Finally, we must not forget about the overwork of the liver secondary to poor nutrition or

genetic disorders of the metabolism of sugar or fat. Overweight, obesity,

hypercholesterolemia, hypertriglyceridemia, diabetes may have an impact at the level of

various organs and systems. The liver can become ill with the accumulation of fat within

its cells, a condition that goes by the name of fatty liver. This is a condition for the most

part benign and reversible, if they are correct the main factors, but also may experience a

progressive worsening up to determine the presence of cirrhosis.

Acute hepatitis A virus (HAV)

Hepatitis A is a highly contagious disease that affects the liver, is responsible for a small RNA virus called HAV (or hepatitis A), which is transmitted through consumption of contaminated food and beverages or by direct contact with infected people. Fortunately, the A is not as dangerous as other forms of hepatitis, but, albeit rarely, fulminate hepatitis may be complicated in the dreaded, and for this reason, one should not underestimate it, and take all necessary rules to prevent it, first of all the vaccination of people at risk. The symptoms are often absent and usually mild, characterized by fever and general malaise and sometimes jaundice is present. The hepatitis A virus replicates in the liver and is eliminated via the faeces out. For this reason, the prevention of hepatitis A is based on the adoption of the basic rules of hygiene such as washing hands, cleaning food generously and cook before eating. For people most at risk, such as those who go on holiday in countries at risk, it is recommended that active or passive immunization. In the presence of mild infection, the disease resolves spontaneously even without treatment. Unlike hepatitis B and C, the liver inflammation has a sustained course of acute HAV, not chronic, do not facilitate the onset of cirrhosis and liver cancer in the long run and leaves the chronic carrier state.

Chronic hepatitis B virus (HBV) Over the past 20 years the epidemiology of HBV infection has changed dramatically in

Italy. Currently, the prevalence of carriers is less than 1%, with a higher prevalence in males.

This reduction is due to infection prevention measures and educational campaigns: disposable

injection equipment, cleaning and disinfection of instruments, screening of family members of

chronic carriers, monitoring and measures taken in areas at risk, to a lesser extent also to

introduction of compulsory vaccination in our country.

Infection with HBV is transmitted parenterally, that is, through transfusion of infected blood or

blood products (this mode is now non-existent in our country since the donations are highly

controlled), hemodialysis, exchange of syringes and / or contaminated needles with infected

blood, micro-lesions of the skin and mucous membranes, caused by instruments or objects

contaminated with infected blood (toothbrushes, scissors, manicure and pedicure items, combs,

needles, pins, knives, etc.). by sexual or by prenatal (from mother to child).




8

Chronic hepatitis C virus (HCV)

The epidemiology of HCV is completely different from that of HBV. In recent years, several

epidemiological studies have been made on the general population, which show that the rate of

carriers of anti-HCV in Italy is an average of 3.5%, but increases gradually in old age, so that, in

subjects with over 65 years, there is a prevalence of infections by 25-35%. In this age there is a

higher prevalence of hepatitis in women than in men.

Currently, HCV is the leading cause of chronic liver disease. The chronicity of acute infection is

very high (> 80%), but the severity of the disease depends on various causes (genetic risk co-

factors such as infection with other hepatitis viruses, alcohol intake, metabolic disorders,

etc.). Hepatitis C is contracted by direct contact, or ignored obvious, with blood from a carrier of

the virus. The risk of infection is much lower than that of hepatitis B for many reasons: because

blood donations are very controlled, because sexual transmission is rare and so the vertical

transmission (mother-child).

The problems of the liver in pregnancy

In pregnancy, the liver can get sick of some very specific conditions that affect only this

particular period: hyperemesis gravidarum, acute fatty liver of pregnancy, intrahepatic

cholestasis of pregnancy, HELLP syndrome.

Hyperemesis gravidarum: is characterized by intractable vomiting, which begins early in

pregnancy and the cause is unknown. Occurs with an incidence ranging between 1 of

100 and 3 in 1.000 pregnancies.

The hyperemesis may be associated with metabolic disorders such as obesity, such as

hyperthyroidism or hormonal. Liver involvement is usually modest and is configured in a

transient increase of some laboratory tests of liver function. The noise is very annoying,




9 you may need to administer intravenous fluids, but it is safe for either the mother or the

foetus.

Acute Fatty of pregnancy: is outstanding in Italy, and is due to a particular metabolic

disorder to genetic transmission. In some cases it may be very serious and manifest

signs of hepatic coma. Can be exacerbated by the use of antibiotics or malnutrition, as in

certain areas of the Third World.

Cholestasis of pregnancy:is a condition variable incidence (from us is estimated at 1:

3000-5000 pregnancies), characterized by itching, which appears in the third trimester

and resolves spontaneously with the birth. He has run in families because it can be in

other female members of the same family, so that no evidence of transmission of genetic,

although the mode of transmission has not been definitively clarified. As occurs in

genetically susceptible individuals, tends to recur in subsequent pregnancies. The

prognosis is good for the mother, because symptoms resolve rapidly after birth, and there

is a rapid normalization of biochemical tests (clinical). It is, however, reported an

increased risk of gallbladder stones after pregnancy.

The incidence of obstetric complications, on the contrary, are quite high. Globally there is

a risk of foetal distress, foetal mortality and prematurity 5 times higher than normal

pregnancies. Preventing these complications is in a close monitoring of mother and

possibly anticipating the birth with caesarean section.

The prevention of liver disease

Primary prevention consists in removing or neutralizing the causes of the disease. An example

is vaccination against hepatitis B. Persons who respond develop antibodies, which have a

virtually unlimited life. It is also recommended that vaccination against hepatitis A for people

who travel for pleasure or for work in endemic areas.

Some eating habits are in primary prevention. The only food "toxic” to the liver if taken in

inappropriate quantities is alcohol. The threshold of "security" is considered 40 grams of ethanol

per day for males and 20 grams for females. This corresponds in a simplified form for the

woman to two glasses of wine a day or a glass of whiskey a day. Of course, if the liver is

already ill for any reason, you should abstain from alcohol completely, because the liver is

forced to overwork.




10

With regard to nutrition, primary prevention of metabolic diseases is to maintain a balanced diet,

and avoiding excess weight. Subjects with hypercholesterolemia, hypertriglyceridemia and

diabetes with proper diet must correct the metabolic abnormalities and eventually, if diet alone is

not sufficient, must follow a treatment program.

Finally part of primary prevention to prevent inappropriate behaviour or lifestyles that promote

the transmission of hepatitis viruses: drug abuse, tattooing, piercing, unprotected sex with

people at risk.

Secondary prevention is early diagnosis of the disease and especially in liver function, where

there is a need for medication and hormones that may pose problems for the liver.

Since the drugs may fall under the causes of liver injury, the general rule is to assume any treatment under close medical prescription.

Child-bearing age, in the case of hormone therapy prescribed by gynaecologists, should be assessed before treatment and after 1-2 months of starting treatment, the liver function tests. If during routine examination one discovers a change, you should consult your doctor and possibly to a specialist for further diagnosis on the floor cause liver damage.

In menopausal age, in case of Hormone Replacement Therapy (HRT), it should be noted

that the hormone treatment should be undertaken with caution for women who have a

healthy liver, but may be a problem if there is liver damage of any kind. In these cases it

is wise not to submit to overwork the liver.

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A CURA DEL DOTT. GUARDO S. RAUL delle donne... · 2010-12-17 · and distribute them to other...

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