ANATOMY OF LIVER

Macroscopic structure

The liver is the largest gland of the body, weighing 1200 -1600 g, it is wedge-shaped, and covered by a network of connective tissue (Glisson's capsule).

Situated in the upper right portion of the abdominal cavity, the liver is divided by fissures (fossae) into four lobes: the right (the largest lobe), left, quadrate and caudate lobes.

It is connected to the diaphragm and abdominal walls by five ligaments: the membranous falciform (also separates the right and left lobes), coronary, right and left triangular ligaments, and the fibrous round ligament (which is derived from the embryonic umbilical vein).

The liver is the only human organ that has the remarkable property of self-regeneration. If a part of the liver is removed, the remaining parts can grow back to its original size and shape.

Blood flow

Venous blood from the entire gastrointestinal tract (containing nutrients from the intestines) is brought to the liver by the hepatic portal vein. Branches of this vein pass in between the lobules and terminate in the sinusoids. Oxygenated blood is supplied in the hepatic artery. The blood leaves the liver via a central vein in each lobule, which drains in the hepatic vein.

Hepatic vein - one of several short veins originating within the lobes of the liver as small branches, which unite to form the hepatic veins. These lead directly to the inferior vena cava, draining blood from the liver.
Inferior vena cava - formed by the union of the right and left common iliac veins, collects blood from parts of the body below the diaphragm and conveys it to the right atrium of the heart.
Hepatic artery - a blood vessel which supplies the liver with oxygenated blood. It supplies 20% of the liver's blood.
Hepatic portal vein - a blood vessel which drains venous blood into the liver from the entire gastrointestinal tract. It supplies the remaining 80% of the liver's blood.

Microscopic structure

Lobules - hexagonally shaped functional units of the liver, made up of liver cells arranged in one-cell-thick plate like layers that radiate from the central vein to the edge of the lobule.

Hepatocytes - the liver cells.
Sinusoids - small blood vessels between the radiating rows of hepatocytes. They receive oxygen-rich blood from the hepatic artery and nutrients from the intestines via the portal vein. Oxygen and nutrients diffuse through the capillary walls into the liver cells.
Portal area - situated at the corner of each lobule, it is a complex composed of branches of the hepatic portal vein, hepatic artery, bile duct, and nerve.
Bile ducts - any of the ducts that convey bile from the liver. Bile is drained from the liver cells by many small ducts that unite to form the main bile duct of the liver, the hepatic duct. This joins the cystic duct, which leads from the gallbladder, to form the common bile duct, which drains into the duodenum.
Central vein - a blood vessel in the middle of each lobule which receives blood from the hepatic portal vein and hepatic artery via the sinusoids and drains the blood into the hepatic vein.

PHYSIOLOGY OF LIVER

The Important liver functions are:

· Removing and excreting body wastes and hormones as well as drugs and other foreign substances These substances have entered the blood supply either through production by metabolism within the body or from the outside in the form of drugs or other foreign compounds. Enzymes in the liver alter some toxins so they can be more easily excreted in urine.

· Synthesizing plasma proteins, including those necessary for blood clotting Most of the 12 clotting factors are plasma proteins produced by the liver. If the liver is damaged or diseased, it can take longer for the body to form clots. Other plasma proteins produced by the liver include albumin which binds many water-insoluble substances and contributes to osmotic pressure, fibrogen which is key to the clotting process, and certain globulins which transport substances such as cholesterol and iron.

· Producing immune factors and removing bacteria, helping the body fight infection The phagocytes in the liver produce acute-phase proteins in response to microbes. These proteins are associated with the inflammation process, tissue repair, and immune cell activities.

Other important but less immediate functions include:

· Producing bile to aid in digestion Bile salts aid in fat digestion and absorption. Bile is continuously secreted by the liver and stored in the gallbladder until a meal, when bile enters the beginning of the small intestine. Bile production ranges from 250 mL to 1 L per day depending of amount of food eaten.

· Excretion of bilirubin Bilirubin is one of the few waste products excreted in bile. Macrophages in the liver remove worn out red blood cells from the blood. Bilirubin then results from the breakdown of the hemoglobin in the red blood cells and is excreted into bile by hepatocytes. Jaundice results when bilirubin cannot be removed from the blood quickly enough due to gallstones, liver disease, or the excessive breakdown of red blood cells.

· Storing certain vitamins, minerals, and sugars The liver stores enough glucose in the form of glycogen to provide about a day's worth of energy. The liver also stores fats, iron, copper, and many vitamins including vitamins A, D, K, and B12.

· Processing nutrients absorbed from digestive tract The liver convert’s glucose into glycogen, its storage form. This glycogen can then be transformed back into glucose if the body needs energy. The fatty acids produced by the digestion of lipids are used to synthesize cholesterol and other substances. The liver also has the ability to convert certain amino acids into others.

Despite the wide variety of functions performed by the liver, there is very little specialization among hepatocytes (liver cells). Aside from the macrophages called Kupffer cells in the liver, hepatocytes all seem to be able to perform the same wide variety of tasks.

One of the liver's most interesting abilities is self-repair and the regeneration of damaged tissues. In clearing the body of toxins, the liver is damaged by exposure to harmful substances, demonstrating why this capability is important. It also gives hope that if a failing liver can be supported for a certain period of time, it might regenerate and allows the patient to survive and regain a normal life.

Hemostasis	glucose
	proteins
	fat and cholesterol
	hormones
	vitamins, in particular fat-soluble ones (A, D, E, K)
Synthesis	proteins including the clotting factors (~50g/day)
	bile acids (important in fat digestion)
	heparin (anti-coagulant)
	somatomedins (hormones that promote growth in bone, soft tissues)
	estrogen
	angiotensinogen
	cholesterol
	acute phase proteins
Storage	vitamins
	glycogen
	cholesterol
	iron, copper
	fats
Excretion	cholesterol, bile acids, phospholipids
	bilirubin
	drugs
	poisons including heavy metals
	hormones
Filtering	poisons
	nutrients including amino acids, sugars, and fats
	bilirubin, bile acids
	IgA
	drugs
	dead or damaged cells in circulatory system
Immune	excretes IgA into digestive tract
	Kupffer cells (macrophages) filter out antigens

Metabolic Functions of the Liver

Hepatocytes are metabolic super-achievers in the body. They play critical roles in synthesizing molecules that are utilized elsewhere to support homeostasis, in converting molecules of one type to another, and in regulating energy balances.

Carbohydrate Metabolism

It is critical for all animals to maintain concentrations of glucose in blood within a narrow, normal range. Maintenance of normal blood glucose levels over both short (hours) and long (days to weeks) periods of time is one particularly important function of the liver.

Hepatocytes house many different metabolic pathways and employ dozens of enzymes that are alternatively turned on or off depending on whether blood levels of glucose are rising or falling out of the normal range. Two important examples of these abilities are:

· Excess glucose entering the blood after a meal is rapidly taken up by the liver and sequestered as the large polymer, glycogen (a process called glycogenesis).

Later, when blood concentrations of glucose begin to decline, the liver activates other pathways which lead to depolymerization of glycogen (glycogenolysis) and export of glucose back into the blood for transport to all other tissues.

· When hepatic glycogen reserves become exhausted, as occurs when an animal has not eaten for several hours, do the hepatocytes give up? No! They recognize the problem and activate additional groups of enzymes that begin synthesizing glucose out of such things as amino acids and non-hexose carbohydrates (gluconeogenesis).

The ability of the liver to synthesize this "new" glucose is of monumental importance to carnivores, which, at least in the wild, have diets virtually devoid of starch.

Fat Metabolism

Few aspects of lipid metabolism are unique to the liver, but many are carried out predominantly by the liver. Major examples of the role of the liver in fat metabolism include:

· The liver is extremely active in oxidizing triglycerides to produce energy. The liver breaks down many more fatty acids that the hepatocytes need, and exports large quantities of acetoacetate into blood where it can be picked up and readily metabolized by other tissues.

· A bulk of the lipoproteins is synthesized in the liver.

· The liver is the major site for converting excess carbohydrates and proteins into fatty acids and triglyceride, which are then exported and stored in adipose tissue.

· The liver synthesizes large quantities of cholesterol and phospholipids. Some of this is packaged with lipoproteins and made available to the rest of the body. The remainder is excreted in bile as cholesterol or after conversion to bile acids.

Protein Metabolism

The most critical aspects of protein metabolism that occur in the liver are:

· Deamination and transamination of amino acids, followed by conversion of the non-nitrogenous part of those molecules to glucose or lipids. Several of the enzymes used in these pathways (for example, alanine and aspartate aminotransferases) are commonly assayed in serum to assess liver damage.

· Removal of ammonia from the body by synthesis of urea. Ammonia is very toxic and if not rapidly and efficiently removed from the circulation, will result in central nervous system disease. A frequent cause of such hepatic encephalopathy in dogs and cats are malformations of the blood supply to the liver called port systemic shunts.

· Synthesis of non-essential amino acids.

· Hepatocytes are responsible for synthesis of most of the plasma proteins. Albumin, the major plasma protein, is synthesized almost exclusively by the liver. Also, the liver synthesizes many of the clotting factors necessary for blood coagulation.

PATHOLOGY OF LIVER

Cirrhosis leading to hepatocellular carcinoma (autopsy specimen).

Macroscopically, the liver is initially enlarged, but with progression of the disease, it becomes smaller. Its surface is irregular, the consistency is firm and the color is often yellow (if associatessteatosis). Depending on the size of the nodules there are three macroscopic types: micronodular, macronodular and mixed cirrhosis. In micronodular form (Laennec's cirrhosis or portal cirrhosis) regenerating nodules are less than 3 mm. In macronodular cirrhosis (post-necrotic cirrhosis), the nodules are larger than 3 mm. The mixed cirrhosis consists in a variety of nodules with different sizes.

However, cirrhosis is defined by its pathological features on microscopy: (1) the presence of regenerating nodules of hepatocytes and (2) the presence of fibrosis, or the deposition of connective tissue between these nodules. The pattern of fibrosis seen can depend upon the underlying insult that led to cirrhosis; fibrosis can also proliferate even if the underlying process that caused it has resolved or ceased. The fibrosis in cirrhosis can lead to destruction of other normal tissues in the liver: including the sinusoids, the space of Disse, and other vascular structures, which leads to altered resistance to blood flow in the liver and portal hypertension.

As cirrhosis can be caused by many different entities which injure the liver in different ways, different cause-specific patterns of cirrhosis, and other cause-specific abnormalities can be seen in cirrhosis. For example, in chronic hepatitis B, there is infiltration of the liver parenchyma with lymphocytes; in cardiac cirrhosis there are erythrocytes and a greater amount of fibrosis in the tissue surrounding the hepatic veins; in primary biliary cirrhosis, there is fibrosis around the bile duct, the presence of granulomas and pooling of bile; and in alcoholic cirrhosis, there is infiltration of the liver with neutrophils.

Grading:

The severity of cirrhosis is commonly classified with the Child-Pugh score. This score uses bilirubin, albumin, INR, presence and severity of ascites and encephalopathy to classify patients in class A, B or C; class A has a favorable prognosis, while class C is at high risk of death. It was devised in 1964 by Child and Turcotte and modified in 1973 by Pugh et al..

More modern scores, used in the allocation of liver transplants but also in other contexts, are the Model for End-Stage Liver Disease (MELD) score and its pediatric counterpart, the Pediatric End-Stage Liver Disease (PELD) score.

The hepatic venous pressure gradient, i.e., the difference in venous pressure between afferent and efferent blood to the liver, also determines severity of cirrhosis, although hard to measure. A value of 16 mm or more means a greatly increased risk of dying.

Liver Conditions

· Hepatitis: Inflammation of the liver, usually caused by viruses like hepatitis A, B, and C. Hepatitis can have non-infectious causes too, including heavy drinking, drugs, allergic reactions, or obesity.

· Cirrhosis: Long-term damage to the liver from any cause can lead to permanent scarring, called cirrhosis. The liver then becomes unable to function well.

· Liver cancer: The most common type of liver cancer, hepatocellular carcinoma, almost always occurs after cirrhosis is present.

· Liver failure: Liver failure has many causes including infection, genetic diseases, and excessive alcohol.

· Ascites: As cirrhosis results, the liver leaks fluid (ascites) into the belly, which becomes distended and heavy.

· Gallstones: If a gallstone becomes stuck in the bile duct draining the liver, hepatitis and bile duct infection (cholangitis) can result.

· Hemochromatosis: Hemochromatosis allows iron to deposit in the liver, damaging it. The iron also deposits throughout the body, causing multiple other health problems.

· Primary sclerosing cholangitis: A rare disease with unknown causes, primary sclerosing cholangitis causes inflammation and scarring in the bile ducts in the liver.

· Primary biliary cirrhosis: In this rare disorder, an unclear process slowly destroys the bile ducts in the liver. Permanent liver scarring (cirrhosis) eventually develops.

CIRRHOSIS OF LIVER:

Cirrhosis is "A chronic liver disease of highly various etiology characterized by inflammation, degeneration, and regeneration in differing proportions; pathologic hallmark is formation of microscopic or macroscopic nodules separated by bands of fibrous tissue; impairment of hepatocellular function and obstruction to portal circulation often lead to jaundice, ascites, and hepatic failure."

The signs and symptoms of cirrhosis:
Symptoms are not common during the early stages of cirrhosis. However, as scar tissue accumulates the liver's ability to function properly is undermined. The following signs and symptoms may occur:

· Blood capillaries become visible on the skin on the upper abdomen

· Fatigue

· Insomnia

· Itchy skin

· Loss of appetite

· Loss of bodyweight

· Nausea

· Pain or tenderness in the area where the liver is located

· Red or blotchy palms

· Weakness

The following signs and symptoms may appear as the disease progresses:

· Abdomen fills up with fluid, giving the patient a large tummy (ascites)

· Accelerated heartbeat

· Altered personality (as blood toxins build up and affect the brain)

· Bleeding gums

· Body and upper arms lose mass

· Body finds it harder to process alcohol

· Body finds it harder to process drugs

· Confusion

· Dizziness

· Fluid buildup on ankles, feet and legs (edema)

· Hair loss

· Higher susceptibility to bruising

· Jaundice (yellowing of the skin, whites of the eyes, and tongue)

· Loss of libido (sex drive)

· Memory problems

· More frequent fevers (susceptibility to infections)

· Muscle cramps

· Nosebleeds

· Pain on the right shoulder

· Panting (breathlessness)

· Stools become black and tarry, or very pale

· Urine becomes darker

· Vomiting blood

· Walking problems (staggering)

Causes of cirrhosis:

The most common causes of cirrhosis are:

Fatty liver disease,

Overconsumption of alcohol
Hepatitis B & C infection
Non-alcoholic steatohepatitis (NASH)
Autoimmune hepatitis
some genetic conditions:

· Hemochromatosis - iron accumulates in the liver and other parts of the body.

· Wilson's disease - copper accumulates in the liver and other parts of the body.

Blockage of bile ducts: Some conditions and diseases, such as cancer of the bile ducts, or cancer of the pancreas can block the bile ducts, increasing the risk of cirrhosis.

Budd-Chiari syndrome: There is thrombosis (blood clots) in the hepatic vein, the blood vessel that carries blood from the liver, leading to liver enlargement and the development of collateral vessels.

Some other diseases and conditions

· Cystic fibrosis

· Primary sclerosing cholangitis - hardening and scarring of the bile ducts

· Galactosemia - inability to process sugars in milk

· Schistosomiasis - a parasite commonly found in some developing countries

· Biliary atresia - badly formed bile ducts in babies

· Glycogen storage disease - problems in the storage and energy release vital for cell function

Diagnosis of cirrhosis

Cirrhosis in its early stages is often diagnosed when the patient is being tested for some other condition or disease because symptoms are not present.

Anybody who has the following symptoms should see their doctor immediately:

Fever with shivering
Panting (shortness of breath)
Vomiting blood
Dark stools, or tarry stools (as if covered with tar)
Episodes of drowsiness or confusion.

The following tests may also be ordered:
A blood test - to measure how well the liver is functioning and determine whether there is any damage. If levels of ALT (alanine transaminase) are high the patient may have hepatitis.

Imaging tests - this may involve an ultrasound, CT (computerized tomography), or MRI (magnetic resonance imaging) scan of the liver. Apart from seeing whether the liver is enlarged, the doctor will also be able to detect any scarring.

A biopsy - a small sample of liver cells are extracted and examined under a microscope. The doctor inserts a fine needle in between the ribs and into the liver. The patient will receive a local anesthetic. The biopsy not only confirms or rules out cirrhosis, but may also reveal its cause (if it is cirrhosis).

Endoscopy - an endoscope, a long, thin tube with a light and video camera at the end goes down the patient's windpipe (esophagus) and into their stomach. The doctor sees the inside of the stomach on a screen, and looks out for swollen blood vessels (varices); a hallmark sign of cirrhosis.

Complications of cirrhosis:

· Edema & Ascites (fluid buildup in the abdomen)

· Variceal hemorrhage (bleeding in the upper stomach and esophagus from ruptured blood vessels)

· Spontaneous bacterial peritonitis is a form of peritonitis (inflammation of the membrane that lines the abdomen).

· Hepatic encephalopathy (damage to the brain).

· Hepatorenal syndrome

· Hepato pulmonary syndrome

· Hypersplenism

· Liver cancer

· Other complications are:

a. Osteoporosis

b. Kidney failure

c. Insulin resistance and type 2 diabetes

d. Heart problems

Homoeopathy medicines for liver cirrhosis:

Arsenicum album:

§ Painful bloatedness in right hypochondrium, with burning pain.

§ Pain in hepatic region increased on pressure.

§ Stitches in right hypochondrium, extending to gastric region, ending as violent pressure over whole abdomen

§ Vomiting of black masses, black stools.

§ Perforation into the stomach or intestines.

Aurum metalicum:

§ Hepatic congestion consecutive to cardiac disease, with burning and cutting in right hypochondria, ending in cirrhosis and fatty degeneration with dropsy.

§ Jaundice with pain in liver and pit of stomach.

§ Greenish brown urine.

§ Foul breath and putrid taste, constipation or stools of a grayish or ashy white color.

Carbo vegetalis:

§ Hepatic region very sensitive and painful to touch.

§ Right lobe of liver painful, stitching, burning pains.

§ Great flatulency in stomach and abdomen

§ Feces escape with flatus.

Chelidonium majus:

§ Abdominal plethora from simple congestion to positive inflammation.

§ Soreness up to sharp stitching pains, shooting from liver down into the stomach or down into the back from posterior part of liver.

§ Marked pain under the angle of right scapula.

§ Pain in hepatic region, decreased by eating.

§ Diarrhea and constipation alternating, stools clay colored or yellowish, great weariness and anorexia.

§ Desire for milk or acids.

Iodum:

§ Pressure and stitches in hepatic region, painful to touch, loss of appetite, emaciation, excessive weakness, diarrhea.

§ Hard cirrhosis of liver can be felt as emaciation progresses.

§ Jaundice with much pain and tenderness in hepatic region.

Lachesis:

§ Enlarged liver of drunkards, going on to a low grade of symptoms with inflammation and abscess of liver.

§ Jaundice.

§ Tenderness on pressure all the time, intolerance of clothing, deep throbbing on right side.

§ Liver complaints at the climaxis, after ague, from syphilis.

§ Pain as if something had lodged in right side, with stinging pains.

§ Much flatulence, palpitations, pain when coughing as from an ulcerated spot.

§ Constant tormenting urging in anus, but no stool follows, or excessively offensive stools, increased in spring.

§ Gastric pains decreasing during eating and returning again after one or two hours.

§ Mental depression.

Leptandra:

§ Dull aching in right hypochondria in region of gall bladder and also in posterior portion of liver, accompanied by soreness.

§ Burning distress in and about liver, often spreading to stomach and abdomen.

§ Drowsiness and despondency.

§ Diarrhea stools black as pitch with burning, colicky pains at the navel.

§ Gripping continuing after stool.

§ Vomiting of bile with burning distress and occasionally clay colored stools.

§ Pain in left shoulder and arm.

Lycopodium:

§ Cirrhosis of liver with ascites, especially in drunkards.

§ Gin liver.

§ Tongue coated.

§ Sour, putrid taste in the morning on rising.

§ Hunger, but few mouthfuls of food fill him up to the throat, quickly followed by hunger again.

§ Distress in stomach immediately after eating.

§ Tension in hypochondria after a meal as from a cord, cannot stretch or stand upright.

§ Flatulence tends upwards rather downwards.

Magnesium muriaticum:

§ Enlarged liver of children, who are puny in their growth and rachitic.

§ Pressing pains in enlarged and hard liver when walking or touching it, increased when lying on right side.

§ Regurgitation when walking.

§ Knotty stools, like sheep dung or diarrhea.

§ Tongue large, coated yellow, takes imprint of teeth.

§ Dyspnoea and palpitation increased when quiet and decreased from moving about.

Mercurius:

§ Liver enlarged and often indurated.

§ Dirty, yellowish white coating of tongue, which takes imprint of teeth.

§ Gums ulcerate and become spongy.

§ Fetid breath.

§ Jaundiced hue of skin and conjunctiva.

§ Liver sore to touch.

§ Abdomen tympanitic and swollen.

§ Cannot lie on right side.

§ Stools clayey from absence of bile or yellowish green, bilious, passed with much tenesmous, and followed by a never-get-done feeling.

§ Mental depression and emaciation.

Natrum muriaticum:

§ Malarial cachexia.

§ Dull, heavy aching and distension about liver after eating, decreased as digestion advances.

§ Stitches and tension in liver, skin yellow, earthy.

§ Obstinate constipation.

Nux vomica:

§ Hepatic affection in good livers, in alcoholic excesses and after allopathic dosing.

§ Liver swollen, hard and sensitive to pressure of clothing.

§ Jaundice provoked by violent anger, abuse of quinine, with attacks of faintness, leaving him sick and weak, haemorrhoidal colic or from gastric and bilious derangements, with sudden, severe pain in right side.

§ Stitches in hepatic region, increased from contact or motion.

Phosphorous:

§ Hyperemia, at first enlargement, fatty degeneration and finally atrophy of the liver with jaundice and dropsy.

§ Waxy liver dependent upon long-lasting bone disease.

§ Fatty liver in consequences of cardiac troubles.

§ Acute yellow atrophy of liver.

§ Enlargement in right hypochondrium and marked soreness of liver.

§ Malignant jaundice from venous obstruction, often from alcoholism.

§ Gall bladder full of pale yellow, slimy fluid.

§ Loss of appétit, unquenchable thirst, aggravation after eating and drinking.

§ Abdomen flaccid, with chronic loose bowels.

Plumbem metallicum:

§ Continuing darting pain in region of liver.

§ Cirrhosis of liver first enlarged and then contracted.

§ Hepatic region sensitive to pressure without being enlarged, or somewhat hypertrophied.

§ Sensitive of heat, and burning in liver and spine.

§ Persistent sticking pain in hepatic region, first anteriorly, then posterior.

Selenium:

§ Enlarged liver with loss of appetite, aggravation in morning.

§ White coating of tongue, no thirst.

§ Sharp, stitching pains in hepatic region, aggravation by pressure and motion.

§ Peculiar fine rash over hepatic region, which is sensitive to touch.

Sepia officinalis:

§ Functional derangements of liver, often preceded by migraine or wandering articular affections with profuse sweats.

§ Constant aching pain in right side of abdomen.

§ Aching in right shoulder and scapula.

§ Cheeks flushed forehead and conjunctiva yellow, also around mouth, and yellow or red saddle over bridge of nose down cheeks.

§ Irregular yellow patches on face.

§ Tongue flabby and indented, no appetite or easily satisfied, aggravation from acids or fats.

§ Flatulence.

§ Stools bright-yellow or of an ash color.

§ Pain in hypochondria more tolerable when lying on painful side.

§ Stitches under right ribs.

Prevention of cirrhosis

Alcohol - do not exceed the recommended daily/weekly alcohol limit.

· Men: maximum of 21 units per week, or three/four units per day

· Women: maximum of 14 units per week, or two/three units per day

Individuals who have cirrhosis should abstain from alcohol completely. Alcohol accelerates the progression of the disease.

A CASE OF LIVER CIRRHOSIS:

Preliminary data:

Name- Mr. Govindan

Age-56years

Sex-male

Religion-Hindu

Occupation-retired teacher

Social economic status-middle

Marital status-married

Address-kodambakkam

Presenting complaints:

Bloatedness of abdomen since 1month

Pain in abdomen since 2weeks

History of presenting complaints:

Patient complaints of bloatedness of abdomen since 1month, abdominal distention is more immediately after eating. Sour eructation is present, a while after eating anything.

Pain in the right sided abdomen since 2 weeks, pain is of aching type, which radiates from right side to left side. Pain increase after eating and decrease in warm drinks.

Past history and treatment history:

Ø Diagnose with alcohol induced liver cirrhosis in June 2010.

Ø Jaundice- 1 year before.

Family history:

Nothing specific

Mental generals:

Ø Confusion state in the morning after waking up.

Ø Inability to concentrate on anything.

Ø Weak memory.

Ø Forgets easily

Ø Gets irritate for silly matters and used to shout

Physical generals:

Appetite-good, 3 times per day

Thirst-half to one liter per day, prefers warm water

Desire-chicken, mutton, hot food

Aversion-nothing specific

Intolerance-nothing specific

Urine-3-4 times in day, 1 time at night

Stool-regular, once a day

Sleep- sound

Dreams-nothing specific

Completed symptoms:

Location

GIT-right hypochondria

Sensation

Modalities

Concomitants

General physical examination:

Patient is conscious, disoriented, and afebrile

BP-130/70mmhg

Pulse- 80/minute

Respiratory rate- 18/minute

Pallor-absent

Clubbing-present

Cyanosis-absent

Lymphadynopathy-absent

Fetor hepaticas- present

Systemic examination:

Respiratory system- normal vesicular breath sound is heard

Cardio vascular system- s1 s2 normal

Gastro intestinal tract-abdominal distention, marked ascites present, unable to detect visceromegaly

Nervous system- apathetic, confused, disoriented, drowsy, slurred speech, flapping tremor present

Laboratory investigation:

Abdomen:

USG: margins are mildly nodular

Texture non- homogenous and course

No obvious focal lesion

Portal vein dilated 13.2mm

Features suggestive of cirrhosis

Final diagnosis:

Cirrhosis of liver

Analysis of symptoms:

Common

Pain in abdomen

Uncommon

Ø Abdominal distention

Ø < after eating

Ø Sour eructation

Ø Aching pain in the right hypochondria

Ø Pain radiates from right to left hypochondria

Ø Pain < after eating

Ø Pain > warm drinks

Evaluation of symptoms:

According to Kent:

Mental generals:

Ø Confusion after waking up in the morning

Ø Inability to concentrate

Ø Weak memory

Physical generals:

Ø Desire for meat

Ø Desire for hot food

Particulars:

Ø Abdominal distention < after eating

Ø Sour eructation

Ø Aching pain in right hypochondria

Ø Radiates from right- left hypochondria

Ø < after eating

Ø > warm drinks

Reportorial totality:

S no.	symptom	rubric	Pg. no.
1 2 3 4 5 6 7 8 9 10 11	Confusion after waking up in the morning Inability to concentrate Weak memory Desire- meat Desire- hot food Abdominal distention < after eating Sour eructation Pain in right hypochondria Pain radiates from right to left hypochondria Pain < after eating Pain> warm drinks	Mind-confusion-morning-waking on Mind-concentration-difficult Mind-weakness of Stomach-desire-meat Stomach-desire-warm food Abdomen-distention-eating after Stomach-eructation-sour Abdomen-pain-hypochondria Abdomen-pain-hypochondria-right-to left Abdomen-pain-eating-after Abdomen-pain-warm drinks-amel	14 13 64 485 486 545 496 563 563 558 561

Reportorial result:

As lycopodium has more markings it is selected for the prescription

Prescription:

Lycopodium 200/1 dose.

Homöopathie für Heilung

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Tuesday, April 09, 2013

Cirrhosis of the Liver - Dr. B. G. Narmadha