Multaq Liver Failure : Although seemingly obvious on the surface, the distinction between acute and chronic liver disease is not always straightforward. A patient with a chronic liver disease that has not been diagnosed at an earlier stage may come to the doctor with worsening, or newly apparent, symptoms or laboratory abnormalities. Examples could be Wilson disease, autoimmune hepatitis, or hemochromatosis. In other instances, patients with cirrhosis can have acute worsening of liver function if, for example, they develop an infectious illness. Such a case can be considered an acute exacerbation, or acute presentation, of a chronic disease.
Patients with acute liver diseases can often be misdiagnosed as having chronic liver diseases. Patients with severe, acute alcoholic or viral hepatitis, for example, sometimes have the same signs and symptoms as patients with end-stage cirrhosis and can be misdiagnosed as having cirrhosis. In these cases, the illness and symptoms can resolve completely. An acute liver disease can also occur superimposed on a chronic liver disease. In these cases, individuals with cirrhosis—a chronic disease—can develop acute hepatitis on top of the existing cirrhosis. A classic example is the alcoholic with cirrhosis whose condition suddenly worsens when developing acute alcoholic hepatitis from binge drinking. The doctor must keep all of these possibilities in mind when approaching a patient with a liver disease, especially one seeking medical treatment for the first time.
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Drug and alcohol use, in particular, must be carefully evaluated in a patient with liver disease. Alcohol abuse is the leading cause of acquired liver disease in the United States and most Western countries. Patients should not hide information from or lie to their doctors about the amount of alcohol they drink (nonetheless, virtually all individuals with alcohol abuse or dependence disorders significantly underreport alcohol consumption). The quantity of alcohol that individuals must consume to acquire liver disease varies tremendously; the reasons for these differences are unknown. Some individuals can drink half a gallon of alcohol a day and never develop liver disease (they will likely develop several other medical problems!) while others may develop liver disease from drinking as little as three drinks per day over many years. In general, alcohol should always be considered as a possible contributing factor to liver disease in individuals who regularly consume more than two drinks per day.
Both prescription and over-the-counter drugs can cause liver disease. It is essential for an examining doctor to obtain a thorough drug history from individuals with suspected liver disease and for patients to discuss all drug use in detail with their doctors. Even if drugs are not the cause of liver disease, drugs may be metabolized differently in patients with liver disease and can contribute to an underlying problem. Toxins and even unusual food products, such as Jamaican bush tea or Amanita phalloides mushrooms, also can cause liver disease.
Viruses that cause acute and chronic hepatitis are spread by various routes, and information about possible exposure is of vital importance to any medical history. Hepatitis B, C, and D viruses are spread by blood and blood products, and important patient information includes knowledge of past blood transfusions and past or present intravenous drug use. Even someone who used intravenous drugs just once in the remote past could be infected with the hepatitis B or C virus; thus, patients should openly discuss any prior drug use with their doctors. Questions about sex can be embarrassing, but a careful history of sexual practices is also important as hepatitis viruses, especially hepatitis B virus, can be transmitted by homosexual and heterosexual relations.
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Hepatitis A is generally transmitted by contaminated foods—usually seafood—or unsanitary conditions of waste disposal. If a patient comes to the doctor with acute liver disease, it is important to rule out this virus as a cause and obtain a careful history of food consumption. A travel history is also important to detect travel to countries where hepatitis A is common or to parts of the world where infection due to hepatitis E virus occurs. Similarly, a history of living in certain countries in Asia, or parts of Africa where hepatitis B infection is endemic, should be ascertained. Past or present occupational exposure to blood products, such as employment or volunteer work in the health care field, also should be investigated.
Several liver diseases are inherited. For this reason, it is important to ask a patient with suspected liver disease about family history. A family history may also be relevant to liver diseases that are not inherited. For example, a careful family history may identify a household contact with viral hepatitis that could prove contagious.
Many individuals with liver disease will have no symptoms or only nonspecific complaints such as fatigue or depression; other symptoms, however, are very suggestive of liver disease. A history of current or past jaundice (yellow skin and eyes) would be suggestive of liver disease. Itching, generally all over the body, could also be suggestive of liver dysfunction. Swelling in the abdomen and/or legs caused by fluid retention could be from cirrhosis, hi addition, mental confusion, from mild to severe, can occur due to cirrhosis or acute liver failure. Bruis- mg easily and bleeding upon even slight contact with objects also may indicate abnormal liver function. A doctor should question any patient with suspected liver disease about such symptoms.
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