Diseases of the liver and other digestive organs in UC and Crohn's disease

How does the disease manifest? Signs of liver problems

• External manifestations
• Internal manifestations

The liver is the largest gland in the human body, so its diseases have a serious impact on overall health. At the same time, it is very sensitive and extremely susceptible to various disorders. Doctors often hear the complaint “I have pain in the liver area.” But can the liver itself hurt and what sensations does a person experience when various diseases appear?

How does the disease manifest itself?

This organ is located in the abdominal cavity under the diaphragm, in the right upper quadrant of the abdomen. Many people who suspect they have certain diseases are interested in three questions: “How does the liver hurt and where?”, “What does pain and discomfort in the right hypochondrium indicate?” It should be noted here that there are no nerve endings in the organ itself, so the sensation of pain in the liver is impossible. However, there are a lot of nerve endings in the outer shell (capsule) of the liver. Therefore, if the liver enlarges and begins to put pressure on the capsule, the person experiences discomfort. There is never any acute pain. As a rule, she is stupid and persistent, and does not let go for a long time. As problems increase, the pain intensifies, becomes constant, and is especially evident when moving. In some cases, discomfort occurs in the right shoulder blade and back. If the pain is severe and cramping, then, as a rule, it speaks not of diseases of the liver, but of the gallbladder and biliary tract.

1.What does an enlarged liver mean?

An enlarged liver means that its size becomes larger than it should normally be. In medicine, an enlarged liver is called hepatomegaly.

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As a rule, hepatomegaly of the liver is not a disease, but a symptom of some kind of liver problem.
There are many possible causes of liver enlargement, including hepatitis.

Sometimes an enlarged liver can lead to liver failure

. This occurs in some diseases when a large part of the liver is damaged and cannot cope with its function.

The human liver is located on the right side of the abdominal cavity. This is a vital organ that helps the body get rid of toxins and produces substances necessary for life and various biological processes. For example, for blood clotting. Therefore, when the liver is enlarged, it is very important to find out the causes of this phenomenon and cope with the problem.

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Signs of liver problems

We have found out where a person’s liver is located and how it hurts; now we should talk about the symptoms. Liver diseases manifest themselves in different ways. There are external and internal symptoms of liver disease. Let's take a closer look at each group.

External manifestations

• The appearance of spider veins
  . Spider veins are a pronounced capillary network of dilated small vessels located in the superficial layers of the skin. This symptom is characteristic of serious liver dysfunction associated with intoxication, viral and alcoholic hepatitis, and cirrhosis. Spider veins most often appear on the lower torso, but sometimes appear on the cheeks and back.
• Changes in pigmentation of the skin and mucous membranes
  . With liver diseases, regardless of the cause, a person experiences jaundice syndrome. For example, in the acute form of hepatitis, the skin acquires a yellowish tint already 2–3 days after the onset of the disease. The color of the mucous membranes may change even earlier. This occurs due to the fact that the concentration of liver pigment fractions (bilirubin) greatly increases in the blood of an infected person.
• Change in color of palms and soles
  . A symptom of liver disease is also pronounced pigmentation in places of physiological folds. As a rule, it has a bronze or smoky tint.
• Hair loss
  . Accelerated hair loss is often observed with liver disease. The liver processes almost all nutrients that enter the body. If liver function suffers, then the body’s supply of “building materials” for growing tissues also suffers. For example, wounds heal more slowly or hair may fall out faster.
• The appearance of a rash
  . Along with changes in skin color, rashes appear in liver diseases. They can be of a very different nature. Pustular elements (folliculitis and furunculosis) are caused by an immune imbalance due to a decrease in the liver’s ability to synthesize immunoglobulin. An allergic rash (papules and spots) occurs due to a violation of the detoxification function of the liver. This reaction is triggered even to familiar environmental conditions. Hemorrhagic rash (small hemorrhages on the surface of the skin) appears when the synthetic function of the liver decreases. Patients have an increased tendency to form hematomas (“bruises”) even with minor injuries.

Internal manifestations

• Asthenia
  . It is characterized by general weakness and lethargy, drowsiness, fatigue, and decreased performance. These symptoms are usually the first to appear when the liver is damaged. Their occurrence is due to the inability of the organ to completely neutralize the products of nitrogen metabolism, which affect the functioning of the brain.
• Dyspepsia
  . In case of liver diseases, dyspeptic manifestations may be observed in the form of belching, nausea and vomiting, diarrhea or constipation, a feeling of heaviness after eating, and bloating due to increased flatulence. Due to impaired digestion and absorption of fats, qualitative changes in stool occur. Steatorrhea (“fatty stools”) is observed. Any liver disease is usually accompanied by changes in peristalsis (motor activity of the intestines) and the secretion of intestinal glands.
• Cytolysis.
  The first sign of liver damage is cytolysis—the destruction of hepatocytes. When liver cells (hepatocytes) are destroyed, the level of enzymes such as ALT and AST increases in the blood. If these enzymes are elevated in a biochemical blood test, this indicates an inflammatory process in the liver tissue.
• Increased body temperature
  . Often, people with constant pain in the liver area experience a slight rise in temperature (up to 37.8 °C). With cirrhosis, thermometer readings can reach 38 °C. In some cases, fluctuations are observed throughout the day, but most often appear in the evening. A higher temperature (from 39 °C) is a symptom of purulent processes in the gallbladder or bile ducts and is not associated with liver disease. Accordingly, treatment is prescribed for another organ.

To learn more about the causes of pain in the liver area and what to do when it occurs, you should consult a specialist. He will conduct an examination, based on which a diagnosis will be made and treatment will be prescribed. In most cases, the main minimum recommendation from doctors is to avoid drinking alcohol and junk food.

Main symptoms of liver diseases

A variety of symptoms, many of which have a rather characteristic manifestation, will help the doctor to promptly identify the problem and prescribe treatment. However, there remains a danger that some diseases in the early stages are practically asymptomatic. To eliminate the risk of developing the disease and diagnose the liver in a timely manner, gastroenterologists and hepatologists recommend paying attention to some points.

Liver dysfunction can manifest as one symptom or a combination of them, which depends on the specific disease and the presence of associated complications.

Pain and discomfort

Painful sensations are usually concentrated in the right hypochondrium. In some cases, they can radiate to the area between the shoulder blades, separately to the right shoulder blade. Pathology can be assessed based on the type and intensity of pain. For example, minor discomfort with aching pain, which complements the feeling of heaviness, may indicate the presence of an inflammatory process, including that caused by toxins. It is very difficult for the patient to clearly show the place where the pain is concentrated.

Intense and severe pain in the hypochondrium is characteristic of severe inflammation, including purulent inflammation. It is present in cases of stones in the bile ducts, liver injuries. Painful sensations are also typical for hepatic colic, which is caused by the movement of stones in the bile ducts.

There are pathologies that do not manifest themselves as unpleasant sensations. These are indolent processes, such as hepatitis C or cirrhosis of the liver. The patient does not notice them for a long time, which is why liver diagnosis and treatment may be delayed. Often these diseases are detected already in the later stages of development.

Vomiting and nausea

Feelings of nausea and vomiting are quite common with gastrointestinal diseases. If the problem affects the liver, these symptoms will be much more severe.

With the appearance of nausea, problems with appetite begin - it becomes dull or disappears completely. There is an aversion to specific foods, usually high in fat. In some cases, an attack of nausea ends with vomiting, after which relief occurs for a while. An admixture of bile in vomit indicates liver problems.

Manifestation of symptoms in the oral cavity

A characteristic symptom is the appearance of a yellow coating on the tongue. The intensity and color depend on the disease. For example, slight jaundice closer to the tip of the tongue may indicate an early stage of hepatitis. The appearance of a yellow-green coating is characteristic of serious pathologies of the gastrointestinal tract, biliary tract or liver. Stagnation of bile manifests itself in the form of a rich yellow coating. At these stages, tests may be prescribed to check the gastrointestinal tract.

An unpleasant bitterness may also be present. It occurs when bile enters the esophagus. The presence of a pronounced taste may be a symptom of viral hepatitis, liver tumor or cirrhosis, gastrointestinal tract disease or gall bladder. Sometimes bitterness is caused by severe stress and taking certain medications. To accurately determine the disease, doctors prescribe a comprehensive diagnosis of the patient’s body.

In addition to bitterness, a sweetish or “fishy” aroma may appear in the mouth, which is accompanied by constipation or diarrhea, bloating, and vomiting. This symptom indicates problems with the digestive system caused by liver problems.

Increased body temperature

A symptom indicates the presence of a pathogenic agent that the body is fighting. When the temperature rises to 38°C and fluctuates between 37-37.5°C, liver cirrhosis and hepatitis can occur.

In diseases of the biliary tract, the temperature remains at 39°C and above. In this case, the patient experiences twitching of facial and skeletal muscles.

Change in color of urine and stool

Due to the increased volume of bilirubin, characteristic of hepatitis or cirrhosis, the urine acquires a dark tint. When shaken, a rich yellow foam appears in it.

Some diseases are characterized by discoloration of stool, which is accompanied by fever and discomfort in the right hypochondrium. Vomiting may be present.

Changes in skin and mucous membrane color

Due to the accumulation of bile pigments in the tissues, the color of the mucous membranes and skin changes. This may indicate the presence of cirrhosis or hepatitis, especially if there is dark urine and light-colored stool. Yellowness of the skin is present in cholelithiasis. To clarify the diagnosis, the doctor may prescribe additional laboratory tests.

Problems with bile secretion sometimes appear as brown pigment spots with varying degrees of intensity. They usually occur in the groin, armpits or palms of the hands.

Other skin manifestations

An additional symptom that is observed in liver pathologies are spider veins. They usually appear on the back or cheeks. They are caused by metabolic problems and increased fragility of capillary walls. At an advanced stage, the patient immediately develops bruises with slight pressure on the skin.

Autoimmune diseases and hepatitis caused by infection are accompanied by allergic rashes and inflammation. At the next stage, atopic dermatitis and psoriasis may appear.

A characteristic symptom is “liver palms,” in which red spots appear on the feet and palms. They become paler when pressed. When the pressure stops, their color turns red again.

Hormonal changes

Chronic liver diseases cause hormonal imbalance. In this case, patients experience hair loss on the pubis and armpits. Men suffer from testicular atrophy and enlarged mammary glands - this is caused by an excess of female hormones. In women, the volume of estrogen increases, which is why a rash appears throughout the body, PMS becomes very pronounced, and the menstrual cycle is irregular.

Intoxication of the body

Since the liver is responsible for filtering and eliminating toxins from the body, liver damage interferes with these functions. Severe intoxication and accompanying symptoms occur. These include discomfort in muscles and joints, problems with appetite, fatigue and weight loss.

Help the liver with Phosphogliv*

If liver problems are detected, the patient is prescribed diet and exercise; if this is not enough, therapy is supplemented with medications. It often includes the use of hepatoprotectors - drugs for treating the liver. One such drug is Phosphogliv*. Phosphogliv* is used as a means of pathogenetic therapy. This product contains 2 active ingredients: glycyrrhizic acid and essential phospholipids.

Glycyrrhizic acid has anti-inflammatory, antioxidant and antifibrotic effects, which allows the drug to be used both at the stage of treating inflammation and for preventing its development, and essential phospholipids restore damaged liver cell membranes. The use of the drug Phosphogliv* ensures normalization of the patient’s general condition, relief of the inflammatory process in the liver - a decrease in ALT and AST enzymes, and also helps prevent the development of fibrosis and cirrhosis.

Treatment of liver diseases

Only high-quality diagnostics can identify the cause of the disease. It will allow you to prescribe treatment that is highly effective. The doctors of our medical center for family health "Nadezhda" will be able to make the correct diagnosis, they will identify the true causes of your illness. The center is equipped with the most modern equipment.

The liver, the disease and treatment of which is difficult, should be entrusted to the supervision of an experienced specialist. We employ only qualified specialists. They have extensive knowledge in this field, as well as extensive practice.

The recovery course requires the patient's patience. Don't expect quick results. The sick person should consult a doctor promptly. An advanced disease only complicates the course of treatment. Often the patient resorts to self-medication. This has a very detrimental effect on his health.

That is why treatment is recommended to be carried out under the guidance of only an experienced doctor. Our specialists will be able to select the appropriate drug therapy for your case. Diet and moderate exercise will also be taken into account.

Signs and symptoms of liver enlargement

If the liver is only slightly enlarged, in most cases it will not cause any symptoms at all. But with severe hepatomegaly of the liver, the following may appear:

• Feeling of fullness in the liver area;
• Abdominal discomfort;
• Depending on the specific cause of liver enlargement, symptoms of primary diseases. These may be jaundice, fatigue and weakness, nausea, weight loss.

During a medical examination, the doctor may notice an enlarged liver on the right side of the abdomen. To accurately determine the cause of liver hepatomegaly, a variety of tests, studies and tests can be performed:

• Blood tests to check for liver enzymes and other abnormalities associated with liver disease;
• Computed tomography, MRI or ultrasound to visually assess the condition of the liver;
• ERCP - examination to detect problems with the bile ducts;
• Liver biopsy is the removal of a small sample of liver tissue to be examined under a microscope to check for cancer or fatty liver disease.

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3.Causes of the disease

The causes of liver enlargement can be very different.

Inflammation or fatty liver can cause hepatomegaly, and it occurs as a result of factors such as:

• Infections due to a virus or abscess;
• Some medications;
• Toxins;
• Some types of hepatitis, including alcoholic hepatitis;
• Autoimmune diseases;
• Metabolic syndrome;
• Genetic disorders.

Liver enlargement can occur due to the growth of abnormal formations, including:

• Cysts;
• Tumors that begin to grow or spread into the liver.

Problems with blood flow are another possible cause of liver enlargement.

Various conditions can lead to this, including:

• Chronic heart failure, in which the heart cannot pump blood as well as it should;
• Vein thrombosis in the liver, blockage of veins in the liver;
• Veno-occlusive endarteritis, blockage of small veins in the liver.

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Introduction

In December 2022, in the city of Wuhan, Hubei Province, People's Republic of China (PRC), an outbreak of a new coronavirus infection caused by a new strain of coronavirus, which was named SARS-CoV-2 (Severe acute respiratory syndrome-related coronavirus 2) on February 11, 2020, was noted. . In 2022, the infection became a pandemic and was recognized as such by the World Health Organization (WHO) on March 11, 2022; it is given the name COVID-19 (Coronavirus disease 2019). At the end of January 2022, more than 97 million cases of COVID-19 infection were recorded (more than 3.6 million in the Russian Federation) with a death toll of over 2 million. A typical manifestation of the new infection is the rapid development of bilateral pneumonia with characteristic clinical and radiological symptoms, in some cases (up to 4%), accompanied by the development of acute respiratory distress syndrome (ARDS) [1, 2]. However, along with respiratory symptoms, a large number of patients with COVID-19 exhibited symptoms of gastrointestinal (GIT) damage, which often occurred at the onset of the disease [1, 3, 4]. Their appearance is due to the pathogenetic features of the impact of the SARS-CoV-2 virus on the human body and has important clinical and prognostic significance [2].

Gastrointestinal tract damage due to COVID-19

SARS-CoV-2 is a single-stranded RNA virus of the Coronaviridae family, possibly a recombinant between a bat coronavirus and a virus of unknown origin. The genetic structure of SARS-CoV-2 is close to the SARS-CoV coronavirus, the causative agent of SARS, the outbreak of which was recorded in November-December 2002 in South China; up to 73% of patients had symptoms associated with the gastrointestinal tract, most often diarrhea [5]. The SARS-CoV-2 virus is classified as pathogenicity group II; differs from other viruses of the family in its higher contagiousness. The main mechanism of transmission of the virus is airborne, but contact and fecal-oral transmission are not excluded. The initial stage of virus penetration into the human body is interaction with angiotensin-converting enzyme type 2 (ACE2) receptors, which are found not only in the alveolar cells of the lungs (which explains the rapid development of pneumonia), but also in a number of other cells, including in the cells of the gastrointestinal tract — esophagus, ileum, large intestine [1, 2, 6]. The nucleocapsid protein of the virus was detected in the epithelial cells of the salivary glands, stomach, duodenum and rectum (Fig. 1) [7].

Rice. 1. Histological and immunofluorescent staining of tissues of various parts of the gastrointestinal tract of a patient with COVID-19 [7].

The main pathogenetic mechanisms of gastrointestinal damage in patients with COVID-19 are considered to be the direct effect of the virus on epithelial cells, an indirect neurotropic effect on the mechanisms of intestinal neuroregulation, and a cytokine “storm” [4]. Two other coronaviruses related to SARS-CoV-2 - SARS-CoV and MERS-CoV - also had a clear affinity for the gastrointestinal tract (clinical symptoms were present in 20 and 32% of cases, respectively).

In addition, a study by T. Zuo et al., conducted in China and including 15 patients with a new coronavirus infection, revealed persistent disturbances in the fecal microbiome with an enrichment of opportunistic microorganisms (Coprobacillus, Clostridium ramosum and Clostridium hathewayi) and depletion of beneficial commensals; changes persisted after elimination of the virus and resolution of respiratory symptoms [8].

The presence of a fecal-oral route of transmission of the virus is considered probable by many authors based on the detection by polymerase chain reaction (PCR) in the feces of high levels of the pathogen, including live strains of the virus, in a significant number (about 50%) of patients [3, 4]. Cases of negative pharyngeal smear tests have been described in patients with typical clinical respiratory symptoms (shortness of breath, dry cough) and a positive stool test for SARS-CoV-2. However, detection of the virus in stool does not always correlate with the presence and severity of gastrointestinal symptoms, as well as with the severity of respiratory symptoms [5]. At the same time, the persistence and duration of detection of ribonucleic acid (RNA) of the virus in feces was noted. In a study of 73 patients with COVID-19, 53.4% ​​had a positive stool test and remained so for 1-12 days, with 23.3% of patients having a negative stool test. A similar picture is observed in children - in 8 out of 10 children who took part in the study, a rectal smear for SARS-CoV-2 was positive even with negative nasopharyngeal smears [6]. This suggests that virus shedding from the gastrointestinal tract may be profuse and persist after clinical symptoms resolve.

Dyspeptic syndrome and other gastroenterological symptoms, according to publications by Chinese researchers, were present in 2-40% of cases [4]. As a rule, gastrointestinal symptoms were somewhat delayed compared to respiratory symptoms, appearing on average 7.3 days before hospitalization (respiratory symptoms - 9 days). There is also evidence that these patients have more pronounced clinical manifestations of non-gastroenterological symptoms of the disease [9]. The leading symptom (not counting the nonspecific symptom of anorexia) was diarrhea - in 15% of patients, according to a study that included 1012 patients with mild forms of COVID-19, it was often the first manifestation of the infection. Another Chinese study analyzing the structure of complaints in 204 patients with COVID-19 from 3 hospitals in Hubei Province showed the presence of gastrointestinal complaints in 48.5% of them. 83.8% had anorexia, 29.3% had diarrhea, 8.1% had vomiting, 4% had abdominal pain; a combination of several symptoms was often encountered [10]. According to another large study conducted on the basis of an analysis of 1141 medical records from one of the hospitals in Wuhan with a 7-week observation period of patients, gastroenterological complaints with COVID-19 were noted in 16% (n=183) of patients and had the following detection frequency: nausea and vomiting - in approximately 60% of patients, diarrhea - in 37%, abdominal pain - in 25% of patients. In 7 examined patients, dyspeptic syndrome was the only manifestation of the disease without signs of damage to the bronchopulmonary system. The presence of gastroenterological symptoms that are not quite typical for COVID-19 was the reason for a later diagnosis in most patients. According to Chinese authors, the presence of symptoms of gastrointestinal tract damage is associated with more severe variants of the course of coronavirus infection [5]. A case of hematochesis was described as a casuistic case of the debut symptom of COVID-19 [11].

According to another study conducted in China, which summarized data on 1099 patients from 552 hospitals, diarrhea was detected in 3.8% of patients, nausea or vomiting in 5% of patients [6]. The comparative frequency of gastrointestinal complaints, according to several Chinese researchers, is presented in table. 1 [7, 12—22]. Anorexia was deliberately excluded from the symptoms, as, in our opinion, it is not a specific sign of gastrointestinal damage.

Table 1. Structure of gastrointestinal complaints in patients with COVID-19 according to Chinese studies [7, 12—22]

Researcher	Number of patients, n	Diarrhea, %	Nausea, %	Vomit, %	Abdominal pain, %
N. Chen et al. [12]	99	2	1	1	No data
W. Guan et al. [13]	1099	3,8	5	5	No data
C. Huang et al. [14]	38	2,6	No data	No data	No data
K. Liu et al. [15]	137	8	No data	No data	No data
H. Shi et al. [16]	81	3,7	No data	4,9	No data
D. Wang et al. [17]	138	10,1	10,1	3,6	2,2
F. Xiao et al. [7]	73	35,6	No data	No data	No data
X. Xu et al. [18]	62	4,8	No data	No data	No data
X. Yang et al. [19]	52	No data	No data	3,8	No data
J. Zhang. et al. [20]	139	12,9	17,3	5	5,8
F. Zhou et al. [21]	141	4,7	3,7	3,7	No data
X. Lu et al. [22]	171	8,8	No data	6,4	No data

Several studies from the United States completely lack information on the presence of gastrointestinal complaints in patients with COVID-19. However, the first patient with coronavirus infection in the United States had a two-day history of nausea and vomiting before hospitalization, diarrhea, and abdominal discomfort during the first days of hospitalization; Coronavirus RNA was detected in his stool using PCR on the 7th day of hospital treatment.

According to a study by A. Hormati et al., in a number of patients of different ages (19-83 years), hospitalized in the gastroenterological clinic of the province of Qom (Iran) and having a variety of symptoms of dyspepsia resistant to drug therapy, the SARS virus was detected during an extended examination. CoV-2 in pharyngeal smears and varying degrees of lung damage according to computed tomography (CT); respiratory symptoms were absent and did not appear during further observation; all cases ended in recovery [23].

When assessing gastrointestinal symptoms in children with a new coronavirus infection, a similar situation was revealed: in a cohort study that included 171 children, diarrhea was noted in 8.8%, vomiting in 6.4% of patients. Despite the generally milder clinical course of the disease with low severity of respiratory symptoms, gastrointestinal complaints in children in structure and frequency appear to be similar to those in the adult population [22].

Given the duration of detection of SARS-CoV-2 in feces and its possible asymptomatic shedding even after a negative result of pharyngeal smears, effective infection control is necessary with careful adherence to preventive measures - hand hygiene, social distancing; contact persons should be warned about the potential risk of contracting COVID-19 [1, 9].

The treatment of gastrointestinal manifestations of COVID-19 infection has been poorly studied. In clinical observations from the People's Republic of China, antiemetic drugs were used symptomatically to control nausea and vomiting. In the presence of diarrhea, before prescribing therapy, it was recommended to examine stool for Clostridioides difficile toxins and exclude other bacterial infections of the intestinal group; Antibiotic therapy was used only in cases of bacterial co-infection [9].

Experts from WHO and the British Dietetic Association have formulated a number of basic positions on nutrition correction in patients with coronavirus infection COVID-19 [2, 24, 25]. It is recommended to avoid alcohol, limit fat consumption to 30% of the daily requirement from saturated fats of animal origin, and it is advisable to increase the consumption of milk and lactic acid products, including those containing probiotics, in order to improve the quality of the intestinal microbiota and possibly limit the attachment of SARS-CoV-2 to cell membrane. It is shown to expand the diet with vegetables, fruits and whole grains, increase the consumption of vitamin D in conditions of self-isolation or hospital, and limit the consumption of granulated sugar and salt to 5 g per day of each of these products.