Liver Diseases – Liver Disorders, Symptoms, and Chronic Course

Globally, hepatitis infections (inflammation of the liver) are among the most widespread infectious diseases. They can lead to acute and/or chronic inflammation. Unlike liver tumors, hepatitis often affects not just a portion of the liver, but the entire organ.

Liver inflammation can be acute or chronic. Liver failure is a serious concern. It can occur

• develop as a result of severe acute liver inflammation (hepatitis) or
• as a result of less severe but persistent—and thus chronic—inflammatory activity

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The inflammation leads to the destruction of liver cells—that is, the death of the cells.

Ultimately, hepatitis is a manifestation of the liver’s uniform response to various causes of disease and pathogens. These can include viruses or bacteria, but autoimmune diseases (primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC), or autoimmune hepatitis (AIH)) affecting the liver and/or bile ducts can also lead to hepatitis.

Hepatitis is considered chronic when the disease lasts longer than six months.

Common causes of acute or chronic hepatitis include

• excessive alcohol consumption and
• obesity with associated impairment of fat and sugar metabolism.

In the latter cases, steatotic liver disease (SLD), also known as steatohepatitis, develops. It can

• be triggered by alcohol (metALD, metabolic and alcohol-related liver disease) or
• develop without alcohol consumption due to metabolic factors (including obesity) (MASLD, metabolic dysfunction-associated steatotic liver disease).

A distinction is made between inflammatory and neoplastic liver diseases. Liver diseases include: 

• Hepatitis
• Fatty liver
• Cirrhosis
• Hepatic coma
• Acute liver failure
• Echinococcosis (infections with fox or dog tapeworms).

The liver is connected to the gallbladder via the bile ducts. These transport bile from the liver to the duodenum. Therefore, in a broader sense, liver diseases also include inflammation of the bile ducts, also known as cholangitis.

A distinction is made between primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC). These conditions are classified as cholestatic liver diseases.

Liver tumors can be malignant or benign. Benign tumors are not life-threatening but can still cause symptoms. The size and type of the tumor are often decisive factors here.

Malignant tumors break through the structural boundaries of the organs and can form secondary tumors in other organs (metastasis).

Liver tumors can originate within the organ itself and are therefore referred to as primary tumors. These include, for example,

• hepatocellular carcinoma and
• bile duct cancer (cholangiocellular carcinoma).

In most cases, however, they are secondary tumors—that is, liver metastases. In this case, the cancer cells have spread to the liver from another tumor via the blood and lymphatic systems. Liver metastases often result from

• colorectal cancer,
• stomach cancer, or
• esophageal cancer.

In cases of liver metastases, the primary tumor must therefore also be treated.

Tumors of the liver are often not detected until distinct symptoms appear or they are discovered incidentally during screening exams, such as

• weight loss,
• general fatigue, and
• weakness in the patient.

The most common initial symptom is usually fatigue.

Another typical symptom that may indicate liver disease is itching, which is caused by a blockage in bile flow. Metabolic waste products then remain in the body and trigger this symptom, known in medical terms as pruritus.

Sometimes the itching is referred to as the “liver’s expression of pain.” The liver itself is only sensitive to pain in its connective-tissue capsule, but not within the organ itself.

The cardinal symptom of liver disease is yellowing (icterus) of the whites of the eyes and, in severe cases, of the skin as well. There is also a specific type of bad breath in patients with advanced liver disease. Medically, this bad breath is called foetor hepaticus. However, because it appears late in the course of the disease, it is not suitable for the early detection of liver disease.

Chronic liver inflammation can progress to the stage of liver scarring, known as cirrhosis. In this case, liver function can only partially recover. In cirrhosis, liver tissue is converted into connective tissue. These structural changes are sometimes so advanced that they cannot be reversed.

However, even with only a portion of the organ remaining, the liver can often continue to perform its vital functions.

Accompanying symptoms of liver cirrhosis include

• difficulty concentrating,
• tremors and muscle twitching,
• severe fatigue.

Illustration of cirrhosis of the liver in an advanced stage © SciePro | AdobeStock

If symptoms suggest liver disease, a thorough examination by a doctor is crucial. The patient’s medical history, all symptoms, and information about diet and lifestyle are recorded (medical history).

The doctor palpates the upper abdomen to detect possible swelling, enlargement, or hardening of the liver. 

An ultrasound examination (sonography) reveals the condition of the liver and bile ducts.

The bile ducts can also be examined endoscopically or radiologically. Abnormalities or gallstones can be detected and removed during these procedures (ERCP and cholangioscopy).

A blood test provides information about possible deviations from normal values. Elevated white blood cell counts and elevated C-reactive protein are common markers of inflammation. Signs of an immune response to a hepatitis virus infection can also be detected in the blood.

A liver biopsy (tissue sample) provides the doctor with information about the condition of the liver tissue. During the procedure, the organ is punctured through the abdominal skin and ribs using a hollow needle. The procedure takes only a few seconds and is performed under local anesthesia. 

If symptoms suggest liver disease, a thorough examination by a doctor is crucial. The patient’s individual medical history, all symptoms, and information about diet and lifestyle are recorded (medical history).

The doctor palpates the upper abdomen to detect any swelling, enlargement, or hardening of the liver. An ultrasound examination (sonography) reveals the condition of the liver and bile ducts.

The bile ducts can also be examined endoscopically or radiologically. Abnormalities or gallstones can be detected and removed during these procedures (ERCP and cholangioscopy).

A blood test provides information about possible deviations from normal values. Elevated white blood cell counts and elevated C-reactive protein are common markers of inflammation. Signs of an immune response to a hepatitis virus infection can also be detected in the blood.

A liver biopsy (tissue sample) provides the doctor with information about the condition of the liver tissue. During the procedure, the organ is punctured through the abdominal skin and ribs using a hollow needle. The procedure takes only a few seconds and is performed under local anesthesia. 

Treatment for liver disease depends on its specific causes. A liver that is only slightly damaged can certainly recover. However, liver damage caused by cirrhosis does not reverse; the changes are irreversible. Serious liver diseases, such as acute liver failure or hepatic coma, are medical emergencies that absolutely require hospital treatment.

Many infectious diseases can be prevented through appropriate preventive measures: for example, vaccination against the hepatitis B virus can prevent infection. Very effective medications against the hepatitis C virus have recently become available. Effective medications are also available for bacterial or parasitic infections of the liver.

However, even simple hygiene standards can help prevent the development of hepatitis. In many countries around the world, contaminated drinking water or food is a potential route of infection for some of these diseases.

For cases of hepatitis caused by alcohol consumption or obesity, only avoiding these triggers can lead to improvement. So far, only a few effective medications are available for these conditions, and the harmful factors almost always lead to a worsening of the disease. Liver damage caused by alcohol consumption can be halted through abstinence.

In advanced stages of chronic liver disease, a liver transplant may be the only chance for long-term survival. However, there are currently far fewer organs available than are needed.

The treatment of autoimmune hepatitis involves the administration of immunosuppressants. Corticosteroids and other immunomodulatory therapies are primarily used for this purpose. In most cases, complete resolution of inflammatory activity cannot be achieved, even over long periods of time.