What is the liver?
The liver is a large organ located in the upper right quadrant of the abdomen, just below the diaphragm.
The liver is a vital organ, responsible for numerous functions in our body. Among the roles the liver plays are the production of digestive enzymes, proteins, clotting factors, cholesterol, glucose, and various other substances.
The liver is also responsible for metabolizing all nutrients absorbed from the intestines, as well as for cleaning circulating toxins.
Because it performs so many functions in the body, liver diseases can present a wide variety of symptoms. In the following, we will discuss the 12 most typical signs and symptoms of liver problems and briefly explain why they arise.
What is the portal vein?
Before we continue, it is important to explain what the hepatic portal vein is, since a large part of the symptoms of liver disease are caused by an obstruction of this vein.
The portal vein, or hepatic portal system, is a large vein located at the entrance to the liver, responsible for draining blood coming from the gastrointestinal system. All blood from the stomach, spleen, pancreas, and intestines passes through the portal vein and liver before returning to the heart. Thus, every substance ingested and absorbed in the gastrointestinal tract must first pass through the liver before it reaches the rest of the body.
In cases of severe liver disease, especially cirrhosis, the liver undergoes a process of fibrosis (scarring and stiffening of liver tissue) that can cause obstruction of the portal vein, making it difficult for blood to reach this large vessel. Blood coming from the digestive organs needs to pass through the portal vein and the liver before it continues on its way to the heart.
If the portal vein is blocked, there will be a large congestion of blood and an increase in pressure, not only in the portal vein, but also in all the veins of the gastrointestinal tract. This is called portal hypertension, and is responsible for many of the signs and symptoms that will be explained below.
Signs and Symptoms of a Diseased Liver
Next, we’ll look at the 12 most common signs and symptoms that patients with liver problems commonly experience. Are they:
- General and nonspecific symptoms.
- Collateral circulation.
- Digestive bleeding.
- Purple spots on the skin.
- Palmar erythema.
- Abdominal pain.
Patients with liver damage often present with a variety of general and nonspecific symptoms, which include nausea, loss of appetite, discouragement, and weight loss. In cases of acute hepatitis, the patient may also have fever, which further contributes to the appearance of this malaise.
A bitter taste in the mouth is a symptom popularly attributed to liver problems, but it is a very non-specific complaint, which can be triggered by several other causes, such as reflux, gastritis, teeth damage, gum lesions, infections in the pharynx or tonsils, dehydration, prolonged fasting, medications, smoking… If the patient does not have any other symptoms, it is unlikely that the feeling of a bitter mouth is a sign of a relevant liver problem.
A common symptom in any type of liver disease is fatigue or easy tiredness. This lack of energy affects patients with hepatitis, cirrhosis and even hepatic steatosis. The more advanced the liver damage, the more inappetence the patient feels.
Ascites is the name given to the accumulation of fluid within the abdominal cavity, popularly known as the water belly. Ascites is a typical symptom of liver cirrhosis and often occurs when the patient has portal hypertension.
In addition to cirrhosis, schistosomiasis is another disease that usually affects the liver and causes portal hypertension and ascites .
Ascites arises because trapped blood and high pressure within the veins of the gastrointestinal tract cause a translocation of water out of the blood vessels, leading to the accumulation of fluid within the abdominal cavity. It’s as if the blood vessels start to suck out water.
Ascites is a typical manifestation of liver disease, but it can also occur in diseases of other organs, such as decompensated heart failure and nephrotic syndrome .
When there is an obstruction to the passage of blood through the portal vein, the body must find another way for this blood to return to the heart. If the natural path is closed, a detour must be arranged; that’s what the organism does. Blood starts to return in large amounts through collateral veins, which in healthy people only drain small volumes of blood.
The diversion of large amounts of blood to the collateral veins causes them to dilate, becoming very apparent on examination of the abdomen. In the photo on the right, there is an example of a patient with ascites and exuberant collateral circulation, two typical signs of portal hypertension.
Obstruction of the portal vein causes an increase in pressure throughout the venous system of the digestive system, including the veins in the stomach and esophagus. This increased pressure causes varicose veins in these organs, facilitating the occurrence of bleeding.
Digestive bleeding from bleeding from esophageal varices is a typical manifestation of advanced liver cirrhosis. The patient suddenly presents with hemorrhagic vomiting, and may lose a large amount of blood in these episodes.
Increased pressure in the digestive system also affects the veins of the intestines and rectum, causing an increased incidence of hemorrhoids .
Encephalopathy is the name given to a dysfunction of basic brain functions. Hepatic encephalopathy, as the name implies, is the change in brain functions that occurs in patients with liver failure.
One of the goals of the hepatic portal system is to ensure that every substance that is digested and absorbed in the digestive tract must pass through the liver before moving on to the rest of the bloodstream. Some substances we ingest, especially animal proteins, are toxic and need to be metabolized by the liver before they can be used by the body. In cases of portal hypertension, blood follows its path through collateral veins and several toxic substances end up not being metabolized by the liver before they spread through the body.
In addition to portal hypertension, acute liver failure, as in severe hepatitis, can cause an acute failure of liver functions, causing it to lose its ability to neutralize toxic substances.
Hepatic encephalopathy is the result of the action of these toxins on the brain. Depending on the degree of liver failure or portal hypertension, the patient may present from mild conditions, with lethargy, irritability and difficulty concentrating, to severe encephalopathy, with reduced level of consciousness and coma.
Jaundice is the name given to the yellowish coloration of the skin, eyes, and mucous membranes that appears due to the accumulation of bilirubin in the blood.
Bilirubin is a substance produced in the spleen from the destruction of old red blood cells. One of the liver’s roles is to take this bilirubin from the blood, metabolize it, and excrete it into the bile ducts and intestines and eliminate it in the stool.
When the liver is sick, it loses the ability to metabolize and/or eliminate the bilirubin that is constantly produced by the spleen. In this situation, bilirubin accumulates in the blood and the excess is deposited on the skin, causing it to appear yellowish. Jaundice is often associated with itching, because the bilirubin deposited on the skin causes irritation of the nerve endings.
Two other signs usually occur together with jaundice: pale stools (fecal acholia) and very dark urine. Bilirubin is responsible for the brown coloration of the stool. If for some reason bilirubin is not being excreted into the intestines, the stool will no longer have its usual coloring, becoming much lighter in color. Dark urine, the color of Coca-Cola or Mate, occurs due to the filtration of the excess bilirubin circulating in the blood by the kidneys, which ends up being excreted in the urine.
Several liver diseases can cause jaundice, the most common being hepatitis and cirrhosis. Jaundice can also occur in diseases of the bile ducts, in infections such as malaria or leptospirosis, in cases of hemolysis (massive destruction of red blood cells) or by adverse reaction to some drugs.
Therefore, jaundice is a typical sign of liver disease, but it is not an exclusive sign of liver problems. To learn more about jaundice, read: ICTERÍCIA | Neonatal and Adult.
Purple spots on the skin
The patient with liver disease may have an easier time developing ecchymoses (purple spots on the skin) and bleeding after minor trauma. This is because the liver is responsible for the production of proteins that participate in the blood clotting system. Patients with liver disease may have a clotting deficiency, and thus bleed more easily.
Besides the deficiency of clotting factors, which can occur in any situation of liver malfunction, patients with cirrhosis and portal hypertension often also have a low number of platelets, which is another factor that contributes to a greater difficulty in clotting the blood.
Gynecomastia is the name given to the development of breasts in men. Male patients with cirrhosis often have gynecomastia. The causes are not yet well elucidated, but it is believed to be due to the increased concentration of estrogen in the blood, which occurs both by increased production and reduced metabolization of this female hormone by the liver.
Another important factor for the appearance of gynecomastia is the habitual use of the diuretic spironolactone, indicated in the treatment of ascites in patients with cirrhosis. One of the most common side effects of spironolactone is gynecomastia, which can occur even when used in patients without liver disease.
Teleangiectasias, also called vascular spiders, are vascular lesions composed of a central arteriole surrounded by many small vessels. Teleangiectasias are most often found on the trunk, face, and arms.
The origin of vascular spider veins is not completely unraveled, but it is believed that these lesions result from changes in the metabolism of sex hormones, especially estrogen.
Teleangiectasias are very common in cirrhosis, but can also be seen during pregnancy or in healthy people. In these two cases the lesions are usually small and fewer than three in number. In cirrhosis, the more advanced the disease, the greater the size and number of the vascular spiders present.
Erythema palmaris is the name given to a very reddened palm, especially in the tenar and hypothenar regions (muscles of the palm), usually sparing the central parts of the palm. Erythema palmaris is not a specific sign of liver disease, but can also be seen in patients with rheumatoid arthritis, hyperthyroidism, and in pregnant women.
Abdominal pain, located in the right upper quadrant, is a common symptom of liver disease, especially acute hepatitis. It usually occurs due to an increase in the size of the liver, which causes tearing of the hepatic capsule, a kind of cap that covers the entire liver.
It should be noted that pain in the liver region can also be caused by a variety of other conditions, including problems with the gallbladder, biliary tract, base of the right lung, and even injuries to the ribs or abdominal muscles.