Enlarged liver in heart failure. Liver cirrhosis as a consequence of heart failure

I found out last year that I have stagnation of bile. For many years I suffered from pain under my right ribs, suffered from heaviness in my stomach and didn’t even know what was wrong. When they appeared, I thought that the reason was the fatty and fried foods that were often present in my diet. I got rid of all this quite simply. I took it and ate it Activated carbon– this eliminated painful sensations in the liver area. And the reason, as it turned out later, was poor bile secretion. But this leads to the disruption of the entire digestion process. The liver and intestines suffer. Doctors advised me to stimulate bile production. After that, I began to study what could contribute to this process. In the literature I came across the following advice: in the morning on an empty stomach you need to drink a glass of hot water. Of course, you don’t need to drink boiling water, but the water should still be hot enough and boiled. Drinking a glass of water before breakfast will help you digestive system, which will make it easier to digest breakfast. Water ensures the awakening of the digestive and biliary systems after a night's sleep.
After that, I began to study foods that are useful to consume during bile stagnation. I limited my intake of sweets. They provoke a weakening of bile secretion. I started preparing vegetable dishes for myself vegetable oil, especially the vinaigrette, which has beneficial effect for digestion.
Among all the products that are good for me, I found my favorite. This is the zucchini that I first tried as a child. It turned out that it helps relieve the liver. And besides, it helps good digestion. It contains a large number of substances. The large amount of antioxidants that have a rejuvenating effect on the body contained in this vegetable pleased me most. But for the active manifestation of all these benefits that this vegetable has, I consumed it raw. I made salads from it. Sometimes I stewed it, but not for long. Quite simple in terms of preparation is my favorite dish, which I often prepare from zucchini.
To prepare it, you need to take a raw zucchini, wash it, and then cut it into strips. Then add the same amount of cucumber to the resulting mass. After this, the salad is dressed with sour cream. You can decorate it with an egg and pieces of tomatoes, which you need to take half as much as cucumbers. You can add a variety of greens.
I find this dish not only very healthy, but also delicious. Many grandchildren also eat this medicinal salad with great pleasure. When I feel heaviness in the liver area, I exclude the egg from this salad. And then my bile secretion comes into order, thanks to raw zucchini. In the summer months at the dacha, I consider this salad indispensable, because everyone at the dacha has zucchini, cucumbers, tomatoes and herbs.
At the personal premiere, I was convinced that the body begins to work better when you slightly adjust your diet. It's much better than swallowing pills.

In case of heart failure, not only the patient’s heart suffers, but also other organs, since they are closely interconnected in the functioning of the body. As pressure increases in the systemic circulation, the right parts of the heart muscle become overloaded. As a result, the liver is affected: painful sensations occur and an increase in size is observed. Congestive liver in heart failure is quite a rare event, but when such symptoms appear, the patient needs treatment.

Congestive liver - pathological condition, characterized by stretching of the organ due to stagnation of blood under the influence of high pressure in the veins.

One of the secondary causes of liver congestion is a cardiac sign. It means that primary factor The development of the pathology was not caused by a disease of the organ itself, but by dysfunction in the functioning of the heart. late stages Chronic heart failure is observed in cardiac cirrhosis of the liver.

Failure means the heart's inability to pump blood through the vessels at the required speed. This leads to its accumulation in the organs, pressure increases, and swelling of the liver occurs. Stagnant blood reduces oxygen saturation of tissues, causing oxygen starvation. This inevitably leads to necrosis of liver cells, causing ischemia. Dead hepatocytes are replaced by cells of fibrous tissue, and cirrhosis gradually develops.

Factors that provoke congestion in the liver include:

1. Pulmonary heart.
2. Compressive pericarditis.
3. Mitral valve stenosis.
4. Tricuspid valve insufficiency.
5. Cardiomyopathy.
6. Consequences of the Fontan operation.
7. Severe pulmonary hypertension.

The primary manifestations of a decompensated heart condition are shortness of breath and arrhythmia during physical activity. Gradually, shortness of breath occurs at rest, and tachycardia accompanies the patient everywhere. With left ventricular failure, there is an accumulation of blood in the pulmonary circle.

The following manifestations are characteristic:

• wheezing in the lungs;
• sputum interspersed with blood;
• blue tint of lips, fingers.

A cirrhotic liver is a manifestation of a disease on the right side of the heart. If a decrease in the performance of the right ventricle is not a primary phenomenon, blood stagnation secondarily accompanies the pathology of the left side of the heart muscle.

When opened, the internal organ is heavy and dense in composition. The color depends on the duration of stagnation, it varies from red to purple or bluish-brown. Sometimes yellowish spots are observed at the edges of the lobules due to fatty degeneration of the liver cells. In the center of the lobule, the vein cavity has a bluish-red color. This type of liver is called “nutmeg” liver. With a long stagnant process, the pattern of the liver lobules is erased. Fibrous tissue formed at the site of dead hepatocytes forms “false lobulation.” When stagnation suddenly occurs, many hemorrhages are recorded.

Anatomical changes and dysfunction of the liver appear when exposed to increased venous pressure and lack of oxygen at the same time.

Often, in people with heart failure, the symptoms of liver congestion are predetermined. This disease inevitably occurs when cardiac muscle dysfunction is diagnosed in the later stages.

Signs of stagnation during weak heart the same for all types of cirrhosis:

1. Increase in size (In the first stages, the organ grows in front and behind, is not palpable. With the progression of heart pathology, an enlargement of the liver is visible, it is determined at the bottom of the right rib. Pain is caused by stretching of the liver capsule).
2. Intense pain under the right rib with heaviness and pressure.
3. Swelling of the limbs.
4. Increase in body temperature.
5. Nausea, vomiting, loss of appetite.
6. Lethargy, weight loss, fatigue.
7. Aggressiveness, bad mood, sleep problems.
8. Increase in abdominal size.
9. Symptoms of jaundice.

These manifestations are a reflection of an abnormal process occurring in the liver itself. The patient may simultaneously experience pain associated with impaired functioning of the heart.

The cardiac cause of congestion is indicated by symptoms that occur with failure of the right ventricle of the heart: swelling of the arms and legs, shortness of breath at rest or during exercise.

In cardiac cirrhosis, ascites usually occurs, which is not treatable with drugs.

A stagnant internal organ is always an unfavorable phenomenon. Cirrhosis causes activation of the pathological chain and leads to further complications.

When a patient first contacts a doctor, general examination and the complaints of the sick person are clarified. Disease for a long time may be asymptomatic due to the high compensation of liver cells.

Doctors distinguish cardiac cirrhosis from other types of liver damage by the following symptoms:

1. At the beginning, the enlarged liver has a soft density. Then it hardens and decreases in volume.
2. Treatment of the heart, which is the main cause of congestive processes, leads to an improvement in the patient’s condition.
3. When you press on the liver, the veins in the neck swell.

To detect blood stagnation, comprehensive examination, including the following methods:

1. Blood biochemistry ( total protein, enzymes, bilirubin, alkaline phosphatase).
2. Analysis of the structure and volume of the liver using ultrasound.
3. Hemostasiogram (blood test for clotting).
4. Chest X-ray (examination of the lungs, determination of the size of the heart).
5. Electrocardiography, echocardiography (analysis of heart function).
6. Laparocentesis (sampling of fluid from abdominal cavity).
7. Study of the coronary vessels of the heart using angiography.
8. Liver puncture biopsy (for heart muscle transplantation).

To make a correct diagnosis, the presence of hepatitis, inflammation, the presence of toxic elements in the blood (from alcohol, hazardous industries) and other types of pathology should be excluded.

Advanced conditions with congestion in the liver are almost always asymptomatic. They are discovered only during clinical studies in laboratory conditions.

The only method of preventing congestive cirrhosis is a timely visit to a cardiologist. Success therapeutic methods depends entirely on the correct recognition of the main disease - cardiac dysfunction. Doctors are not able to completely cure a sick person, but they can prolong life and alleviate the condition.

The life expectancy of patients suffering from cardiac cirrhosis is 3-7 years. Usually leads to death internal bleeding or the onset of hepatic coma.

Shown moderate rhythm life, reduction of physical activity and an individually selected course of physical activity. Limited use table salt and liquids. It is useful to follow a diet, balanced diet. Products that burden the liver are strictly prohibited: spices, smoked meats, alcohol, fried and fatty foods.

With low efficiency general events medications are prescribed:

1. Cardiac glycosides (digoxin) for the treatment and normal functioning heart muscle.
2. Beta blockers (metoprolol) to normalize blood pressure and heart rhythms.

Liver enlargement- hepatomegaly - noted in cases where the size of this the most important body exceeds natural, anatomically determined parameters. As doctors emphasize, this pathology cannot be considered a separate liver disease, since it is a symptom characteristic of many diseases, including those affecting other human organs and systems.

The danger of liver enlargement lies in complications of liver failure and other pathological conditions that disrupt normal functioning of this body and create many serious health problems.

Therefore, it is worth talking about such a common pathology as liver enlargement in more detail.

Causes of liver enlargement

Perhaps the list below, including the causes of liver enlargement, is incomplete, but it should make one realize the true scale of its pathogenesis and get an answer to the question - is liver enlargement dangerous?

So, an enlarged liver in an adult can be a consequence of:

overuse alcohol; liver cirrhosis; reception large doses some medicines, vitamin complexes and dietary supplements; infectious diseases(malaria, tularemia, etc.); damage by hepatitis A, B, C viruses; infectious lesion enteroviruses, pathogens of intestinal infections, Leptospira, Epstein-Barr virus (mononucleosis); toxic damage to the parenchyma by industrial or plant poisons; fatty liver disease(fatty degeneration or steatosis of the liver); disorders of copper metabolism in the liver (hepatolenticular degeneration or Wilson's disease); disorders of iron metabolism in the liver (hemochromatosis); inflammation of the intrahepatic bile ducts (cholangitis); genetically determined systemic diseases (amyloidosis, hyperlipoproteinemia, glucosylceramide lipidosis, generalized glycogenosis, etc.); obliterating endarteritis of the liver veins; liver cancer (hepatocarcinoma, epithelioma or metastatic cancer); leukemia; diffuse non-Hodgkin's lymphoma; formation of multiple cysts (polycystic disease).

As a rule, there is an increase in the lobe of the liver, and an increase in the right lobe of the liver (which has a higher functional load in the functioning of the organ) is diagnosed more often than an enlargement of the left lobe of the liver. However, there is nothing good in this either, since left lobe is so close to the pancreas that it may be this gland that is causing the problem.

Simultaneous enlargement of the liver and pancreas is possible with inflammation of the pancreas (pancreatitis). Inflammation is accompanied by intoxication, and it removes toxins from the blood liver. If the course of pancreatitis takes especially severe forms, the liver may not cope with its task and increases in size.

Diffuse enlargement of the liver is a clearly non-localized change in the size of its lobules, consisting of hepatocytes (liver cells). For one of the above reasons, hepatocytes begin to die, and glandular tissue gives way to fibrous. The latter continues to grow, thereby enlarging (and deforming) individual areas of the organ, squeezing the hepatic veins and creating the preconditions for inflammation and swelling of the parenchyma.

Symptoms of liver enlargement

A person may not feel a slightly pronounced pathology - an enlargement of the liver by 1 cm or an enlargement of the liver by 2 cm. But the process of changing the natural size of the liver sooner or later begins to manifest itself with more obvious clinical symptoms.

Most typical symptoms liver enlargement: weakness and fatigue, which patients feel even in the absence intense loads; discomfort(heaviness and discomfort) in the abdominal cavity; attacks of nausea; weight loss. This may be followed by heartburn, halitosis (constant bad breath), itchy skin and dyspepsia.

An enlarged liver due to hepatitis is accompanied not only by general malaise, but also by yellowness skin and sclera, fever, aching in all joints, nagging pain in the area of ​​the right hypochondrium.

Liver enlargement in cirrhosis occurs against the background of the same set of symptoms, which are accompanied by such signs of this disease: abdominal pain and increase in its size, a quickly onset feeling of fullness when eating, increased drowsiness during the day and insomnia at night, nosebleeds and bleeding gums, weight loss, hair loss, decreased ability to remember information. In addition to the enlargement of the liver with cirrhosis (first of both lobes, and then more of the left), the size of the spleen in half of the patients also increases, and doctors determine that they have hepatosplenomegaly - an enlargement of the liver and spleen.

In the clinical manifestation of damage to the body by the human immunodeficiency virus, liver enlargement in HIV is diagnosed at stage 2B - in acute HIV infection without secondary diseases. In addition to the enlargement of the liver and spleen, at this stage there is a fever, skin swelling and rashes on the mucous membranes of the mouth and pharynx, enlarged lymph nodes, as well as dyspepsia.

Fatty hepatosis with liver enlargement

Fatty hepatosis (or steatosis), according to the latest WHO data, affects 25% of European adults and up to 10% of children and adolescents. In Europe, “fatty liver” develops in 90% of alcohol abusers and 94% of obese people. Regardless of the underlying cause of the pathology, fatty hepatosis with liver enlargement progresses to cirrhosis within eight years in 10-12% of patients. And with concomitant inflammation of the liver tissue - into hepatocellular carcinoma.

Except alcohol intoxication liver and obesity, this disease is associated with impaired glucose tolerance in type II diabetes mellitus and pathology of the metabolism of cholesterol and other fats (dyslipidemia). From a pathophysiological point of view, fatty liver disease with or without liver enlargement develops due to damage to fatty acid metabolism, which may be caused by an imbalance between energy intake and energy expenditure. As a result, an abnormal accumulation of lipids, in particular triglycerides, occurs in the liver tissue.

Under the pressure of accumulated fat and the resulting fatty infiltrates, parenchyma cells lose viability, the size of the liver grows, and normal operation the organ is disrupted.

On early stages fatty hepatosis may not have obvious symptoms, but over time, patient complaints of nausea and increased gas formation in the intestines, as well as heaviness or pain in the hypochondrium on the right.

Liver enlargement in heart failure

The functional interaction of all body systems is so close that liver enlargement in heart failure is an indicator of a decrease in blood output from the right ventricle of the heart and a consequence of circulatory disorders.

At the same time, blood circulation in the liver vessels slows down, venous stagnation forms (hemodynamic dysfunction), and the liver swells, increasing in size. Since heart failure is most often chronic, prolonged oxygen deficiency inevitably leads to the death of some liver cells. In their place, connective tissue cells grow, forming entire areas that disrupt the functioning of the liver. These zones enlarge and thicken, and at the same time the liver (most often its left lobe) enlarges.

In clinical hepatology, this is called hepatocellular necrosis and is diagnosed as cardiac cirrhosis or cardiac fibrosis. And cardiologists in such cases make a diagnosis of cardiogenic ischemic hepatitis, which, in essence, is an enlargement of the liver in heart failure.

Enlarged liver in a child

There are many reasons for an enlarged liver in a child. So, it could be syphilis or tuberculosis, generalized cytomegaly or toxoplasmosis, congenital hepatitis or bile duct abnormalities.

With this pathogenesis, not only a moderate enlargement of the liver, but also a strong enlargement of the liver with significant compaction of the parenchyma can be established by the end of the first year of the child’s life.

Enlargement of the liver and spleen in infants - the so-called hepatolienal syndrome or hepatosplenomegaly - is the result of congenital higher level levels of immunoglobulins in the blood (hypergammaglobulinemia). This pathology, in addition to the enlargement of these organs, manifests itself in a delay general development child, poor appetite and very pale skin. Enlargement of the liver and spleen (with icteric symptoms) occurs in newborns with congenital aplastic anemia, which occurs due to the destruction of red blood cells, as well as due to extramedullary hematopoiesis - when red blood cells are not formed in bone marrow, but directly in the liver and spleen.

Fatty hepatosis with liver enlargement in children develops in almost half of cases due to a significant excess age standards body weight. Although this pathology can occur with some chronic diseases Gastrointestinal tract, after long-term use non-steroidal anti-inflammatory drugs, antibacterial or hormonal therapy.

Diagnosis of liver enlargement

Diagnosis of liver enlargement begins with a physical examination of the patient and palpation internal organs abdominal cavity to the right of the midline of the abdomen - in the epigastric region.

During a medical examination, the doctor may detect severe enlargement of the liver. What does it mean? This means that the liver protrudes from under the edge of the costal arch much more than expected by the anatomical norm (in an adult of average height this is no more than 1.5 cm), and can be felt significantly below the edge of the ribs. Then it is stated that the liver is enlarged by 3 cm, the liver is enlarged by 5 cm, or the liver is enlarged by 6 cm. But the final “verdict” is made only after a comprehensive examination of the patient, primarily using ultrasound.

An enlarged liver on ultrasound confirms that there is, for example, “an enlarged liver of a homogeneous hyperechoic structure with a displacement towards the stomach, the contours are unclear” or that “diffuse hyperechogenicity of the liver and unclear vascular pattern and borders of the liver have been identified.” By the way, in an adult, a healthy liver has the following parameters (on ultrasound): the anteroposterior size of the right lobe is up to 12.5 cm, the left lobe is up to 7 cm.

In addition to ultrasound examination, the following is used in the diagnosis of liver enlargement:

blood test for viral hepatitis (serum virus markers); biochemical analysis blood (for amylase and liver enzymes, bilirubin, prothrombin time, etc.); urine test for bilirubin; laboratory research functional reserves of the liver (using biochemical and immunological tests); radiography; hepatoscintigraphy (radioisotope liver scan); CT or MRI of the abdominal cavity; precision puncture biopsy (if necessary, obtain a sample of liver tissue to check for oncology).

Enlarged liver lymph nodes during ultrasound examination are noted by hepatologists in all types of liver cirrhosis, viral hepatitis, tuberculosis lymph nodes, lymphogranulomatosis, sarcoidosis, Gaucher disease, drug-induced lymphadenopathy, HIV infection, pancreatic cancer.

Treatment of liver enlargement

Treatment of liver enlargement is treatment of the symptom, but, by and large, it is necessary complex therapy a specific disease that led to a pathological change in a given organ.

Drug therapy for hypertrophied liver must be maintained proper nutrition with diet and vitamin intake. According to experts, in some diseases accompanied by liver enlargement, damaged parenchyma and normal sizes the organ can be restored.

For the regeneration of liver cells, their normal functioning and protection from negative impact hepatoprotective drugs are used - special medications for liver enlargement.

The drug Gepabene is a hepatoprotector plant origin(synonyms - Karsil, Levasil, Legalon, Silegon, Silebor, Simepar, Geparsil, Hepatofalk-Planta). Active substances The preparations are obtained from extracts of fumaria officinalis (protipin) and milk thistle fruits (silymarin and silibinin). They stimulate the synthesis of proteins and phospholipids in damaged liver cells, inhibit the formation of fibrous tissue and accelerate the process of parenchyma restoration.

This medicine is prescribed for toxic hepatitis, chronic inflammatory diseases of the liver, disorders of its metabolism and functions with liver enlargement of various etiologies. It is recommended to take one capsule three times a day (with meals). The minimum course of treatment is three months. Among the contraindications of this drug are: sharp forms inflammation of the liver and bile ducts, age up to 18 years. For hemorrhoids and varicose veins, Gepabene is used with caution. During pregnancy and lactation, the drug is used only as prescribed by a doctor and under his supervision. Possible side effects include laxative and diuretic effects, as well as the appearance of a skin rash. Taking Gepabene is incompatible with drinking alcohol.

The therapeutic effect of the drug Essentiale (Essentiale Forte) is based on the action of phospholipids (complex fat-containing compounds), which are similar in structure to the natural phospholipids that make up human tissue cells, ensuring their division and restoration in case of damage. Phospholipids block the growth of fibrous tissue cells, due to which this drug the risk of developing liver cirrhosis is reduced. Essentiale is prescribed for liver steatosis, hepatitis, liver cirrhosis and its toxic lesions. The standard dose is 1-2 capsules three times a day (with meals). Side effects (in the form of diarrhea) are rare.

The drug Essliver differs from Essentiale in the presence in its composition - along with phospholipids - of vitamins B1, B2, B5, B6 and B12. And the combined hepatoprotective medicine Phosphogliv (in capsules), in addition to phospholipids, contains glycyrrhizic acid, which has anti-inflammatory and antioxidant properties. It helps reduce damage to hepatocyte membranes during inflammation and liver enlargement, as well as normalize metabolic processes. The method of administration and dosage of the last two drugs are similar to Essentiale.

Medicines for liver enlargement include a drug based on the artichoke sativum plant - Artichol (synonyms - Hofitol, Cynarix, Artichoke extract). Given medicine helps improve the condition of liver cells and normalize their functioning. Doctors recommend taking this drug 1-2 tablets three times a day (before meals). The course of treatment lasts from two weeks to a month, depending on the severity of the disease. As side effects Heartburn, diarrhea, and stomach pain may occur. And contraindications to its use are obstruction urinary tract and bile ducts, gallstones, as well as severe forms of renal and liver failure.

Besides that medicinal plants are the basis of many hepatoprotective drugs; herbs for liver enlargement are widely used in the form of infusions and decoctions prepared at home. For this pathology, herbalists advise using dandelion, corn silk, calendula, sandy immortelle, yarrow, peppermint. Standard recipe water infusion: for 200-250 ml of boiling water, take a tablespoon of dry herbs or flowers, brew with boiling water, infuse until cool, strain and take 50 ml 3-4 times a day (25-30 minutes before meals).

Diet for liver enlargement

A strictly followed diet for liver enlargement is the key to successful treatment. With a hypertrophied liver, you need to completely avoid eating fatty, fried, smoked and spicy foods, since such foods overload the liver and the entire digestive system.

In addition, the diet for liver enlargement is incompatible with foods such as legumes, radishes, radishes, spinach and sorrel; sausage and spicy cheeses; margarine and spreads; White bread and baked goods; vinegar, mustard and pepper; confectionery with cream, chocolate and ice cream; carbonated drinks and alcohol.

Everything else (especially vegetables and fruits) can be eaten, at least five times a day, but little by little. It is not recommended to eat after 7 p.m. healthy liver, and especially if the liver is enlarged, it is strictly forbidden. Here's a glass of water with a spoon natural honey possible and necessary.

IN daily diet should be 100 g of animal proteins, about the same vegetable proteins and 50 g vegetable fats. The volume of carbohydrate food is 450-500 g, while sugar consumption should be reduced to 50-60 g per day, and salt to 10-12 g. The daily volume of liquid (excluding liquid food) is at least 1.5 liters.

Prevention of liver enlargement

The best prevention of liver enlargement caused by excess weight or addiction to strong drinks, you know what it is. Nothing will work out here without following the principles of a healthy lifestyle...

Unfortunately, it is impossible to predict how the liver will behave and how much it may enlarge, for example, with hepatitis, mononucleosis, Wilson's disease, hemochromatosis or cholangitis. But even in such cases, a balanced diet, consumption of vitamins, physical activity, hardening and giving up bad habits will help the liver cope with cleansing the blood of toxins, producing bile and enzymes, regulating protein, carbohydrate and fat metabolism in organism. Also, to help the liver when there is a threat of hepatomegaly, B vitamins, vitamin E, zinc (to restore liver tissue) and selenium (to increase overall immunity and reduce the risk of inflammatory liver diseases) are especially needed.

Forecast for liver enlargement

The prognosis for liver enlargement is quite alarming. Because the pronounced signs This pathology does not appear immediately; treatment in a third of cases begins when the process reaches the “point of no return.” And most likely consequences liver enlargement – ​​partial or complete loss of its functionality.

Liver in congestive heart failure

Morphological changes

In those who die from heart failure, the process of autolysis in the liver occurs especially quickly. Thus, the material obtained during autopsy does not make it possible to reliably assess intravital changes in the liver in heart failure.

Macroscopic picture. The liver, as a rule, is enlarged, with a rounded edge, its color is purple, the lobular structure is preserved. Sometimes nodular accumulations of hepatocytes (nodular regenerative hyperplasia) can be detected. The section reveals dilatation of the hepatic veins, their walls may be thickened. The liver is full of blood. Zone 3 of the hepatic lobule is clearly defined with alternating yellow (fatty changes) and red (hemorrhage) areas.

Microscopic picture. As a rule, the venules are dilated, the sinusoids flowing into them are full-blooded in areas of varying length - from the center to the periphery. In severe cases, severe hemorrhages and focal necrosis of hepatocytes are determined. Various degenerative changes are found in them. In the area of ​​the portal tracts, hepatocytes are relatively preserved. The number of unchanged hepatocytes is inversely related to the degree of atrophy of zone 3. During biopsy, pronounced fatty infiltration is detected in a third of cases, which does not correspond to the usual picture at autopsy. Cellular infiltration is insignificant.

The brown pigment lipofuscin is often found in the cytoplasm of degenerative zone 3 cells. When hepatocytes are destroyed, it can be located outside the cells. In patients with severe jaundice, bile thrombi are detected in zone 1. In zone 3, hyaline bodies resistant to diastase are detected using the PHIK reaction.

The reticular fibers in zone 3 are compacted. The amount of collagen is increased, sclerosis of the central vein is determined. Eccentric thickening of the venous wall or occlusion of zone 3 veins and perivenular sclerosis extend deep into the hepatic lobule. In long-term or recurrent heart failure, the formation of “bridges” between the central veins leads to the formation of a ring of fibrosis around the unchanged area of ​​the portal tract (“reverse lobular structure”). Subsequently, as it spreads pathological process develops into the portal zone mixed cirrhosis. True cardiac cirrhosis of the liver is extremely rare.

Pathogenesis

Hypoxia causes degeneration of zone 3 hepatocytes, dilation of sinusoids and slower bile secretion. Endotoxins entering the portal vein system through intestinal wall, may exacerbate these changes. The absorption of oxygen from the blood of the sinusoids increases compensatoryly. A slight impairment of oxygen diffusion may result from sclerosis of the space of Disse.

Decline blood pressure with low cardiac output leads to necrosis of hepatocytes. The increase in pressure in the hepatic veins and the associated stagnation in zone 3 are determined by the level of central venous pressure.

Thrombosis occurring in the sinusoids can spread to hepatic veins with the development of secondary local portal vein thrombosis and ischemia, loss of parenchymal tissue and fibrosis.

Clinical manifestations

Patients are usually slightly icteric. Severe jaundice is rare and is found in patients with chronic congestive insufficiency due to ischemic heart disease or mitral stenosis. In hospitalized patients, the most common cause An increase in the concentration of bilirubin in the serum is caused by diseases of the heart and lungs. Long-term or recurrent heart failure leads to increased jaundice. In edematous areas, jaundice is not observed, since bilirubin is bound to proteins and does not enter the edematous fluid with low content squirrel.

Jaundice is partly hepatic in origin, and the greater the extent of zone 3 necrosis, the greater the severity of the jaundice.

Hyperbilirubinemia due to pulmonary infarction or stagnation of blood in the lungs creates an increased functional load on the liver under hypoxic conditions. In a patient with heart failure, the appearance of jaundice in combination with minimal signs of liver damage is characteristic of a pulmonary infarction. An increase in the level of unconjugated bilirubin is detected in the blood.

The patient may complain of pain in the right abdomen, most likely caused by stretching of the capsule of the enlarged liver. The edge of the liver is dense, smooth, painful, and can be detected at the level of the navel.

Increased pressure in the right atrium is transmitted to the hepatic veins, especially with tricuspid valve insufficiency. When using invasive methods, the curves of pressure changes in the hepatic veins in such patients resemble the pressure curves in the right atrium. Palpable expansion of the liver during systole can also be explained by pressure transmission. In patients with tricuspid stenosis, presystolic pulsation of the liver is detected. Liver swelling is detected by bimanual palpation. In this case, one hand is placed in the projection of the liver in front, and the second - on the area of ​​​​the posterior segments of the right lower ribs. Increasing the size will make it possible to distinguish liver pulsation from pulsation in epigastric region, transmitted from the aorta or hypertrophied right ventricle. It is important to establish the connection between pulsation and the phase of the cardiac cycle.

In patients with heart failure, pressure on the liver area leads to increased venous return. Disturbed functionality the right ventricle is not allowed to cope with the increased preload, which causes an increase in pressure in the jugular veins. Hepatojugular reflux is used to detect the pulse in the jugular veins, as well as to determine the patency of the venous vessels connecting the hepatic and jugular veins. In patients with occlusion or block of the hepatic, jugular or main veins of the mediastinum, reflux is absent. It is used in the diagnosis of tricuspid regurgitation.

Pressure in the right atrium is transmitted to the vessels up to the portal system. Using pulse duplex Doppler study increased pulsation of the portal vein can be determined; in this case, the amplitude of the pulsation is determined by the severity of heart failure. However, phase fluctuations in blood flow are not found in all patients with high pressure in the right atrium.

A connection has been established between ascites and significantly increased venous pressure, low cardiac output and severe necrosis of zone 3 hepatocytes. This combination is found in patients with mitral stenosis, tricuspid valve insufficiency or constrictive pericarditis. In this case, the severity of ascites may not correspond to the severity of edema and clinical manifestations congestive heart failure. The high protein content in ascitic fluid (up to 2.5 g%) corresponds to that in Budd-Chiari syndrome.

Brain hypoxia leads to drowsiness and stupor. Sometimes a detailed picture of hepatic coma is observed. Splenomegaly is common. Other signs of portal hypertension are usually absent, except in patients with severe cardiac cirrhosis in combination with constrictive pericarditis. At the same time, in 6.7% of 74 patients with congestive heart failure, autopsy revealed esophageal varices, of which only one patient had an episode of bleeding.

On CT immediately after intravenous administration of a contrast agent, retrograde filling of the hepatic veins is noted, and in the vascular phase there is a diffuse uneven distribution of the contrast agent.

In patients with constrictive pericarditis or long-term decompensated mitral disease heart with the formation of tricuspid insufficiency, one should assume the development cardiac cirrhosis liver. With the introduction of surgical methods for treating these diseases, the incidence of cardiac cirrhosis of the liver has decreased significantly.

Changes in biochemical parameters

Biochemical changes are usually moderate and are determined by the severity of heart failure.

The serum bilirubin concentration in patients with congestive heart failure usually exceeds 17.1 µmol/L (1 mg%), and in a third of cases it is more than 34.2 µmol/L (2 mg%). Jaundice may be severe, with bilirubin levels greater than 5 mg% (up to 26.9 mg%). Bilirubin concentration depends on the severity of heart failure. In patients with advanced mitral heart disease normal level serum bilirubin during its normal uptake by the liver is explained by the organ’s reduced ability to excrete conjugated bilirubin due to a decrease in hepatic blood flow. The latter is one of the factors in the development of jaundice after surgery.

Alkaline phosphatase activity may be slightly elevated or normal. Maybe slight decrease Serum albumin concentrations, which are facilitated by intestinal protein loss.

Forecast

The prognosis is determined by the underlying heart disease. Jaundice, especially severe, is always an unfavorable sign in heart disease.

Cardiac cirrhosis in itself is not a bad prognostic sign. At effective treatment heart failure can be compensated for cirrhosis.

Liver dysfunction and cardiovascular abnormalities in childhood

In children with heart failure and “blue” heart defects, liver dysfunction is detected. Hypoxemia, venous congestion, and decreased cardiac output lead to increased prothrombin time, increased bilirubin levels, and increased serum transaminase activity. The most pronounced changes are found with reduced cardiac output. Liver function is closely related to the condition of the cardiovascular system.

Liver with constrictive pericarditis

In patients with constrictive pericarditis, clinical and morphological characteristics Budd-Chiari syndrome.

Due to significant compaction, the liver capsule resembles icing sugar (“ glazed liver » — « Zuckergussleber"). Microscopic examination reveals a picture of cardiac cirrhosis.

There is no jaundice. The liver is enlarged, compacted, and sometimes its pulsation is detected. There is pronounced ascites.

It is necessary to exclude liver cirrhosis and hepatic vein obstruction as a cause of ascites. Diagnosis is facilitated by the presence of paradoxical pulsus, venous pulsation, pericardial calcifications, and characteristic changes in the patient during echocardiography, electrocardiography, and cardiac catheterization.

Treatment is aimed at eliminating cardiac pathology. Patients who have undergone pericardiectomy have a favorable prognosis, but recovery of liver function is slow. Within 6 months after successful operation there is a gradual improvement functional indicators and reduction in liver size. A complete reversal of cardiac cirrhosis cannot be expected, but fibrous septa in the liver become thinner and become avascular.

Cardiac cirrhosis of the liver

Cardiac, or cardiac cirrhosis of the liver develops as a consequence of chronic heart failure.

This type of cirrhosis is classified as secondary, because It is not caused by liver pathology, but by a disease of another organ.

What is chronic heart failure?

Chronic heart failure is a chronic pathological condition that is caused by a decrease in contractility myocardium.

This condition can be caused by many factors, including high blood pressure, heart defects, alcohol abuse, diabetes, inflammatory heart diseases, coronary heart disease, etc.

There are left and right ventricular heart failure. It is chronic failure of the right ventricle that late stages and leads to cardiac cirrhosis of the liver.

Chronic heart failure develops under the influence of pathological factors which lead to the following:

• Organic or functional disorders of the heart muscle, heart valves (heart defects)
• Excessive heart work (alcoholism, diabetes, blood pressure, etc.)
• Combination of the first two factors

For these reasons, symptoms of chronic right ventricular heart failure develop:

• Shortness of breath, first during exercise, then at rest
• Decreased performance
• Edema of the upper and lower extremities
• Liver damage

Causes of development of cardiac cirrhosis of the liver

Right ventricular failure means that the heart does not fully perform its function as a blood pump. The speed of blood flow decreases big circle blood circulation, which includes the liver.

Blood stagnation begins, both in the liver and in other organs. Due to high blood pressure, the liquid part of the blood passes into the liver tissue, causing swelling.

• Hypoxia of hepatocytes
• Reduction and necrosis of hepatocytes
• Development of portal hypertension
• Collagen formation, fibrosis
• With increased blood stagnation, the proliferation of connective tissue and the destruction of the liver structure intensify

Symptoms of cardiac cirrhosis of the liver

Liver cirrhosis associated with cardiac pathology is characterized by all the symptoms of other types of disease:

• Fatigue, loss of appetite, weight loss
• Gastrointestinal disorders (flatulence, vomiting, nausea)
• Phlebeurysm
• Abdominal enlargement, ascites
• Edema of the lower extremities
• Bleeding from the esophagus, stomach, etc.
• Jaundice
• Increased body temperature
• Signs of hepatic encephalopathy (changes in the rhythm of sleep and wakefulness, difficulty performing usual activities, changes in behavior, etc., up to impairment of consciousness)
• Pain in the right hypochondrium
• Enlarged liver, spleen
• Jellyfish head - dilation of veins on the skin of the abdomen

There are also signs that are typical for congestive liver:

• Disappearance or reduction of symptoms of cardiac cirrhosis after treatment of heart failure, bringing positive results
• On initial stages during the process, the liver is enlarged, soft to the touch, later the liver becomes of a typical dense consistency
• With palpation and pressure on the liver area, the veins of the neck swell

However, when further development process, treatment of heart failure does not affect liver pathology. This means that cardiac cirrhosis of the liver has fully developed.

Also, cardiological cirrhosis of the liver is characterized by changes in blood tests (anemia, leukocytosis), urine (erythrocytes, protein), feces (acholia - decreased stercobilin), blood biochemistry (increased transaminases, alkaline phosphatase, gamma-GGT, fructose-1-phosphate aldolase, arginase, prothrombin time, bilirubin, globulin, decreased albumin, cholesterol, fibrinogen, prothrombin.

Ultrasound reveals an enlarged liver with uniformly increased echogenicity and an enlarged spleen. Liver biopsy gives a characteristic picture of cirrhosis if possible.

Cardiac cirrhosis of the liver: treatment

First of all, a diet is prescribed with a limit on fatty, fried, smoked foods, salt and spices are limited. Required complete failure from bad habits.

The following drugs are used to correct chronic heart failure:

1. Cardiac glycosides (digoxin, dobutamine) are used to strengthen and protect the myocardium
2. Beta-blockers (atenolol, bisoprolol, metoprolol, propronalol, bopindolol, timolol) are necessary to normalize blood pressure
3. Diuretics (hypothiazide, spironolactone, furosemide) reduce swelling, they also help in the treatment of ascites

For the treatment of cardiac cirrhosis of the liver are used various groups drugs, depending on the degree of activity and stage of compensation:

1. Vitamin therapy (vitamins of groups B, C are prescribed)
2. Hepatoprotectors – drugs that protect the liver from damage (Essentiale, Heptral)
3. If complications occur, they are treated

Cardiac cirrhosis of the liver: prognosis

The prognosis, as in the case of other types of cirrhosis, depends on the stage of compensation. Compensated cirrhosis allows you to live quite a long time, often more than 10 years.

Decompensated cardiac cirrhosis of the liver has a much worse prognosis: most often the life expectancy is no more than 3 years. If bleeding develops, the prognosis is poor: mortality is about 40%.

Ascites also affects life expectancy for the worse. The 3-year survival rate is only 25%.

Please rate this material!

(3 ratings. average rating: 5,00 out of 5)

Heart failure (HF) is in most cases associated with dysfunction of the heart muscle. With heart failure, the level of supply of the body with metabolic needs decreases.

Heart failure can be divided into:

1. Systolic;
2. Diastolic.

Systolic heart failure is characterized by impaired contractility of the heart. And diastolic is characterized by a failure of the relaxation ability of the heart muscle and an imbalance in the filling of the ventricles.

1. Organic disorders;
2. Functional disorders;
3. Birth defects;
4. Acquired diseases, etc.

Symptoms of HF

Physically, HF manifests itself in a decrease in work capacity and exercise tolerance. This is demonstrated by the appearance of shortness of breath in heart failure and rapid fatigue. All these symptoms are associated with a quantitative decrease cardiac output or fluid retention in the body.

As a rule, right ventricular heart failure is characterized by a whole list of liver disorders. Severe congestion in the liver is almost always asymptomatic and is detected only during laboratory and clinical studies. The main pathologies of the development of liver dysfunction include:

1. Passive venous stasis (due to increased pressure due to filling);
2. Impaired blood circulation and decreased cardiac output.

Complications of HF

With an increase in CVP (central venous pressure), as a result, the level of liver enzymes and direct and indirect serum bilirubin may increase.

Deterioration in perfusion resulting sharp decline cardiac output, can result in hepatocellular necrosis with an increased serum aminotransferase index. “Shock liver” or cardiogenic ischemic hepatitis is the result of pronounced hypotension in patients suffering from heart failure.

Cardiac cirrhosis or fibrosis can result from long-term hemodynamic dysfunction, which is fraught functional disorder liver, accompanied by coagulation problems, as well as deterioration in the digestibility of certain cardiovascular drugs and make them undesirably toxic, reducing albumin production.

Unfortunately, it is difficult to determine the exact dosage of these drugs.

If we consider this problem from the perspective of pathophysiology and histology, we will see that liver problems associated with venous stagnation are typical for patients with the right-sided type of heart failure adjacent to high blood pressure in the right ventricle. and it doesn’t matter what causes right-sided heart failure. Any case can be the starting point of hepatic stagnation.

Factors causing congestion in the liver

These reasons include:

1. Constrictive pericarditis;
2. Severe pulmonary hypertension;
3. Mitral valve stenosis;
4. Tricuspid valve insufficiency;
5. Pulmonary heart;
6. Cardiomyopathy;
7. Consequences of the Fontan operation for pulmonary atresia and hypoplastic left heart syndrome;
8. Tricuspid regurgitation (in 100% of cases). It occurs due to right ventricular pressure on the veins and sinusoids of the liver.

With a close study of the structure of the congestive liver, its general increase is observed. The color of such a liver takes on a purple or reddish tint. At the same time, it is equipped with full-blooded hepatic veins. The section clearly shows areas of necrosis and hemorrhage in the 3rd zone and intact or occasionally steatotic areas in the 1st and 2nd zones.

Microscopic examination of the venous hepatic hypertension shows us full-blooded central veins with sinusoidal congestion and hemorrhages. Indifference and inaction in this matter leads to cardiac fibrosis and liver cirrhosis of the cardiac type.

Profound systemic hypotension in myocardial infarction, worsening heart failure, and pulmonary embolism often become good reasons for the development of acute ischemic hepatitis. Conditions such as: obstructive sleep apnea syndrome, respiratory failure, increased metabolic demand are a signal of ischemic hepatitis.

Hepatitis and HF

The use of the term “hepatitis” in this case is not entirely correct, since the inflammatory conditions that give infectious hepatitis, we don't observe.

development chronic hypoxia in the liver is accompanied by specific protective processes. This process is characterized by an increase in oxygen production by liver cells from blood flowing through the liver. But there are conditions under which this defense mechanism It does not work. These are persistent inadequate perfusion of target organs, tissue hypoxia and acute hypoxia. In case of damage to hepatocytes, sharp increase: ALT, AST, LDH, prothrombin time in blood serum. The onset of functional renal failure is also possible.

The temporary development of cardiogenic ischemic hepatitis varies from 1 day to 3 days. Normalization of the disease occurs from the fifth to the tenth day from the moment of the first episode of the disease.

Clinical manifestations in patients with left-sided HF are:

1. Shortness of breath;
2. Orthopnea;
3. Paroxysmal nocturnal dyspnea;
4. Cough;
5. Rapid onset of fatigue.

Right-sided heart failure is characterized by:

1. Peripheral edema;
2. Ascites;
3. Hepatomegaly;
4. Dull stretching pain in the upper right quadrant of the abdomen (rare).

Hepatomegaly is characteristic of right-sided chronic heart failure. But it happens that hepatomegaly also develops in acute heart failure.

For ascites, only 25% of the total number sick people As for jaundice, it is mostly absent. There is presystolic pulsation of the liver

Ischemic hepatitis, in the majority of cases, proceeds benignly.

Diagnostics

Diagnosed inadvertently when an enzymatic increase is detected after systemic hypotension. But systemic hypotension does not only lead to elevated liver enzymes. Also, after such episodes, createnine increases, nausea, vomiting, eating disorders may appear, pain symptoms in the right upper abdominal quadrant, oliguria, jaundice, tremor, hepatic encephalopathy.

Congestive liver is observed in chronic heart failure, which is a common complication all organic heart diseases (defects, hypertension and coronary disease, constrictive pericarditis, myocarditis, infective endocarditis, fibroelastosis, myxoma, etc.), a number chronic diseases internal organs (lungs, liver, kidneys) and endocrine diseases(diabetes mellitus, thyrotoxicosis, myxedema, obesity).

The appearance of the first signs of heart failure depends on a number of reasons, including a combination of several diseases, the patient’s lifestyle, and the addition of intercurrent diseases. In some patients, from the moment organic disease decades pass before the first signs of heart failure appear, and sometimes it develops quite quickly after organic damage hearts.

Clinical picture

The first signs of chronic heart failure are palpitations and shortness of breath during exercise. Over time, tachycardia becomes constant, and shortness of breath occurs at rest, and cyanosis appears. IN lower parts Moist rales are heard from the lungs. The liver enlarges, swelling appears in the legs, then fluid accumulates in the subcutaneous tissue and on the body, in the serous cavities, anasarca develops.

In the first stages of heart failure, the liver enlarges in the anteroposterior direction and is not palpable. An enlarged liver can be detected using instrumental studies(rheohepatography, ultrasound). With the increase of heart failure, the liver noticeably enlarges, and it is palpated in the form of a painful edge protruding from the hypochondrium. Liver pain on palpation is associated with stretching of its capsule. The severity and pressing pain in the right hypochondrium, bloating. The liver is noticeably enlarged, sensitive or painful, its surface is smooth, its edge is sharp. Jaundice is often observed. Liver function tests were moderately altered. These changes are in most cases reversible.

At histological examination Liver biopsies reveal dilation of the central veins and sinusoids, thickening of their walls, atrophy of hepatocytes, and the development of centrilobular fibrosis (congestive liver fibrosis). Over time, fibrosis spreads to the entire lobule (septal congestive cirrhosis of the liver develops).

Diagnostics

Identify a disease that may be causing heart failure. Correct assessment of tachycardia and detection of signs plays an important role venous stagnation. Of no small importance is the favorable dynamics of symptoms during treatment with cardiac glycosides and diuretics.

Treatment

Treatment is successful if the underlying disease that led to heart failure is correctly recognized and appropriate causal therapy is carried out. Patients are limited in physical activity, fluid intake and table salt.

If general measures are insufficiently effective, cardiac glycosides are used internally, long-term or permanently (digoxin, digitoxin, isolanide, celanide, acetyldigitoxin, Adonis infusion), thiazides (furosemide, brinaldix, hypothiazide, Yurinex, Burinex, Uregit, etc.) and potassium-sparing diuretics (triamterene , triampur, amiloride, moduretic, veroshpiron). The choice of a diuretic drug and the method of its use are determined by the degree of edema syndrome, the stage of heart failure and tolerability.