History: If an acetaminophen overdosage has occurred, the doctor will attempt to determine the time and amount of acetaminophen taken. It is important for the doctor to know what medications the individual has ingested and how much. Having access to all medication bottles that the person may have taken will help the doctor to determine the maximum amount taken. A sexual history will also be taken.
Physical: The doctor will look for signs and symptoms of liver toxicity. These signs may include jaundice (yellow skin), abdominal pain, vomiting, and ascites (fluid in the abdomen). On physical examination, a doctor looks for liver tenderness and enlargement using palpation. Palpation is a method of examination in which the examiner feels the body to determine its size, shape, firmness, or location.
Albumin: Serum albumin levels measures the main protein made by the liver and tells how well the liver is making this protein. Low levels of albumin may indicate liver damage.
Ammonia: An ammonia test measures the amount of ammonia in the blood. Most ammonia in the body forms when protein is broken down by bacteria in the intestines. The liver normally converts ammonia into urea, which is then eliminated in urine. Ammonia levels in the blood rise when the liver is not able to convert ammonia to urea. This may be caused by cirrhosis or severe hepatitis.
Alpha-fetoprotein (AFP) test: Alpha-fetoprotein (AFP) is a type of protein produced in the developing embryo and fetus. In humans, AFP levels decrease gradually after birth, reaching adult levels by 8-12 months. If an individual has high levels of alpha-fetoprotein in the blood, it may be a sign of liver cancer. Healthy adult males and non-pregnant females typically have less than 40 micrograms of alpha-fetoprotein per liter of blood.
Bilirubin: Bilirubin is a waste product made from old blood cells; it is a yellow compound that causes jaundice and dark urine when present in increased amounts. Tests for bilirubin levels help determine if the liver is functioning appropriately.
INR: International normalized ratio (INR) is a blood-clotting test. It is used to measure how quickly blood forms a clot, compared with normal clotting time. The liver produces certain proteins (clotting factors) that help in blood clotting. If there is liver disease and cirrhosis, the liver may not produce the normal amount of proteins and then the blood is not able to clot normally. When a doctor is evaluating the function of the liver, a high INR usually means that the liver is not working as well as it could because it is not making the blood clot normally.
Liver biopsy: A liver biopsy may be performed to determine the extent of liver damage and to determine the best treatment option for the patient. During the procedure, a needle is inserted into the liver and a small tissue sample is removed. The tissue is then analyzed under a microscope in a laboratory.
Liver enzymes: Another blood test may be performed to check for elevated levels of liver enzymes, such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST). These enzymes leak into the bloodstream when liver cells are injured. Also, alkaline phosphatase (ALP) levels may be checked. ALP is an enzyme related to the bile ducts. ALP levels are often increased when they are blocked. Liver enzymes help catalyze or start chemical reactions in the liver cells. These enzymes are released into the bloodstream when the liver is damaged.
Transferrin saturation test: The transferrin saturation test reveals how much iron is bound to the protein that carries iron in the blood. Transferrin saturation tests are used in determining if hemochromatosis exists. Transferrin saturation values higher than 45% are considered too high. The total iron binding capacity test measures how well the blood can transport iron, and the serum ferritin test shows the level of iron in the liver. If either of these tests shows higher than normal levels of iron in the body, THEN doctors can order a special blood test to detect the genetic mutation for hemochromatosis, which will confirm the diagnosis. If the mutation is not present, hereditary hemochromatosis is not the reason for the iron buildup and the doctor will look for other causes.
In diagnosing liver toxicity, the doctor may use images of the liver obtained by an ultrasound test, a computerized tomography (CT) scan, or a magnetic resonance imaging (MRI) scan. These diagnostic tests can determine if the presence of liver damage exists. Evidence of fatty liver or liver damage can be viewed by the doctor as dark spots or abnormal images.
A liver scan is a diagnostic procedure to evaluate the liver for suspected disease. A harmless amount of a radioactive substance that concentrates in the liver is injected intravenously (IV or into the veins) and the image of its distribution in the liver is analyzed to diagnose abnormalities. Women who are pregnant or breastfeeding should not have this test.
signs and symptoms
Jaundice is the yellowish staining of the skin and sclerae (the whites of the eyes) that is caused by high levels of the chemical bilirubin in the blood. Bilirubin is a brownish yellow substance found in bile. It is produced when the liver breaks down old red blood cells. Bilirubin is removed from the body through the stool (feces) and gives stool its normal brown color. The color of the skin and sclerae vary depending on the level of bilirubin. Excessive hemolysis or breakdown of red blood cells causes the formation of higher than normal amounts of bilirubin. When bilirubin levels increase, the liver may not be able to process the excess amounts. Jaundice then occurs. When the bilirubin level is mildly elevated, they are yellowish. When the bilirubin level is high, they tend to be brown. Icterus is the term for yellowing of the sclerae.
Other signs and symptoms of liver toxicity include: abdominal pain and swelling; chronic itchy skin; dark urine color; pale stool color; joint pain; bloody or tar-colored stool; chronic fatigue; nausea; and loss of appetite.
Edema and ascites: Fluid accumulation in the legs (edema) and in the abdomen (ascites) may occur when the liver loses its ability to make the protein albumin. Albumin, produced only in the liver, is the major plasma protein that circulates in the bloodstream.
Bruising and bleeding: Bruising and bleeding may occur when the liver slows or stops production of the proteins needed for blood clotting. The palms of the hands may be reddish and blotchy.
Itching: Bile products deposited in the skin may cause intense itching.
Gallstones: Gallstones are solid deposits of cholesterol or calcium salts that form in the gallbladder or nearby bile ducts. They often cause no symptoms and require no treatment. But some people with gallstones have a gallbladder attack (that can cause symptoms, such as nausea and an intense, steady ache in their upper middle or upper right abdomen). Gallbladder attacks include pain or tenderness under the rib cage on the right side, pain between shoulder blades, light or chalky colored stools, indigestion after eating, especially fatty or greasy foods, nausea, bloating, gas, burping or belching, and diarrhea or constipation. In some cases, the pain can be severe and intermittent. If cirrhosis blocks the tubes from the liver to the gallbladder and prevents bile from reaching the gallbladder, gallstones may develop.
Toxins in the blood or brain: A damaged liver cannot remove toxins from the blood, causing them to accumulate in the blood and eventually the brain. There, toxins can dull mental functioning and cause personality changes, coma, and even death. Signs of the buildup of toxins in the brain include neglect of personal appearance, unresponsiveness, forgetfulness, trouble concentrating, or changes in sleep habits.
Sensitivity to medication: Cirrhosis slows the liver's ability to filter medications from the blood. After a drug is taken, it is metabolized in the body. Metabolism is the enzymatic conversion of one chemical compound into another. Most drug metabolism occurs in the liver, although some processes occur in the gut wall, lungs, and blood plasma. Because the liver does not remove drugs from the blood at the usual rate when hepatitis is present, they act longer than expected and build up in the body. This causes a person to be more sensitive to medications and their side effects.
Portal hypertension: Normally, blood from the intestines and spleen is carried to the liver through the portal vein. But cirrhosis slows the normal flow of blood through the portal vein, which increases the pressure inside it. This condition is called portal hypertension. The portal vein may become weakened and damaged and hemorrhage (bleeding) may occur.
Varices: When blood flow through the portal vein slows, blood from the intestines and spleen backs up into blood vessels in the stomach and esophagus. These blood vessels may become enlarged because they are not meant to carry this much blood. The enlarged blood vessels, called varices, have thin walls and carry high pressure, and thus are more likely to burst. If they do burst, the result is a serious bleeding problem in the upper stomach or esophagus that requires immediate medical attention. Hemorrhages, or bleeding, may occur in damaged vessels.
Insulin resistance and type 2 diabetes: Cirrhosis causes resistance to insulin. Insulin is a hormone produced by the pancreas. Insulin enables blood glucose to be used as energy by the cells of the body. If an individual has insulin resistance, their muscle, fat, and liver cells do not use insulin properly. The pancreas tries to keep up with the demand for insulin by producing more. Eventually, the pancreas cannot keep up with the body's need for insulin, and type 2 diabetes develops as excess glucose builds up in the bloodstream.
Liver cancer: According to the National Cancer Institute (NCI), cancer of the liver is a rare malignancy in the United States, but in parts of Asia and Africa, it is one of the most common malignancies. In the United States, the average age of onset is 60-70 years, and the condition occurs more frequently in males than females by a ratio of 2:1. There is a strong association between chronic hepatitis B and C viral infections and the development of hepatocellular (liver cell) carcinoma, which account for about two-thirds of all liver cancers. People with cirrhosis also have an increased risk of liver cancer. Other possible hepatocarcinogens include aflatoxin, nitrosamines, oral estrogen compounds, and numerous other chemicals.
Ascites: Ascites is the accumulation of protein-containing (ascitic) fluid in the abdominal cavity. Ascites tends to occur in chronic (long-term) rather than in acute (short-lived) disorders. It occurs most commonly in cirrhosis (severe scarring of the liver), especially in cirrhosis caused by alcoholism or viral hepatitis. It may occur in other liver disorders, such as severe alcoholic hepatitis without cirrhosis and chronic hepatitis. Ascites can also occur in disorders unrelated to the liver, such as cancer, heart failure, kidney failure, pancreatitis (inflammation of the pancreas), and tuberculosis (a bacterial infection in the lungs) affecting the lining of the abdominal cavity. In people with a liver disorder, ascitic fluid leaks from the surface of the liver and intestine. A combination of factors is responsible. They include portal hypertension, decreased ability of the blood vessels to retain fluid, fluid retention by the kidneys, and alterations in various hormones and chemicals that regulate bodily fluids.
Problems in other organs: Cirrhosis can cause immune system dysfunction, leading to infection. Fluid in the abdomen (ascites) may become infected with bacteria normally present in the intestines. Cirrhosis can also lead to impotence, kidney dysfunction and failure, and osteoporosis.