Enlargement of the liver in heart failure. Cirrhosis of the liver as a consequence of heart failure

Last year I found out that I have bile stasis. For many years I suffered from pain under my right ribs, suffered from heaviness in my stomach and did not even know what was the matter. 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 and ate Activated carbon- this eliminated pain in the liver. And the reason, as it turned out later, was in poor bile secretion. But this leads to the fact that the whole process of digestion is disturbed. The liver and intestines suffer. The doctors advised me to stimulate the production of bile. After that, I began to study what can 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 do not need to drink boiling water, but still the water should be hot enough and boiled. Drinking a glass of water before breakfast will digestive system which will make breakfast easier to digest. Water ensures the awakening of the digestive and biliary systems after a night's sleep.
After that, I began to study products that are useful for stagnation of bile. I have limited sweets. They provoke a weakening of bile secretion. I started cooking vegetable dishes for myself. vegetable oil, especially the vinaigrette, which has beneficial effect for digestion.
Among all the products that are useful for me, I found my favorite. This is a zucchini that I first tried when I was a child. It turned out that it helps to unload the liver. Yes, it also helps good digestion. In itself, it contains a large number of substances. A large number of antioxidants that have a rejuvenating effect on the body contained in this vegetable pleased me the most. But for the active manifestation of all this benefit that this vegetable has, I used it raw. I made salads out of it. Sometimes it was extinguished, but not for long. Quite simple in terms of preparation is my favorite dish, which I often cook 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 that, the salad is dressed with sour cream. You can decorate it with an egg and slices of tomatoes, which you need to take half as much as cucumbers. You can add a variety of greens.
I think this dish is not only very useful, but also delicious. This healing salad is eaten with great pleasure by many grandchildren. When I have heaviness in the liver area, I exclude the egg from this salad. And then my bile secretion comes in order, thanks to raw zucchini. In the summer months in the country, I consider this salad indispensable, because everyone has zucchini, cucumbers, tomatoes and herbs in the country.
At the personal premiere, I was convinced that the body starts to work better when you tweak your diet a little. It's much better than swallowing pills.

In heart failure, not only the patient's heart suffers, but also other organs, since they are closely related to each other in the process of functioning of the body. With an increase in pressure in the systemic circulation, an overload of the right sections of the heart muscle occurs. As a result, the liver is affected: pain occurs, an increase in size is observed. Congested liver in heart failure a rare event, but when such symptoms appear, the patient needs treatment.

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

One of the secondary causes of congestive liver conditions is a cardiac symptom. It means that primary factor the development of pathology was not a disease of the organ itself, but a dysfunction in the work of the heart. late stages chronic heart failure is observed in cardiac cirrhosis of the liver.

Insufficiency means the inability of the heart to disperse blood through the vessels at the required speed. This leads to its accumulation in the organs, pressure rises, liver edema occurs. Stagnant blood reduces tissue oxygen saturation, and oxygen starvation. This inevitably leads to necrosis of the liver cells, provoking ischemia. Dead hepatocytes are replaced by fibrous tissue cells, cirrhosis gradually develops.

Factors that cause congestion in the liver include:

Lung heart.
Compressive pericarditis.
Mitral valve stenosis.
Tricuspid valve insufficiency.
Cardiomyopathy.
Consequences of the Fontan operation.
Severe pulmonary hypertension.

The primary manifestations of a decompensated state of the heart are shortness of breath and arrhythmia with physical activity. Gradually, shortness of breath occurs at rest, tachycardia accompanies the patient everywhere. With insufficiency of the left ventricle, 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.

Cirrhosis of the liver is a manifestation of the disease of the right side of the heart. If the decrease in the efficiency of the right ventricle is not the primary phenomenon, blood stasis accompanies the pathology of the left side of the heart muscle for the second time.

At autopsy, the internal organ is heavy and dense in composition. The color depends on the duration of the 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 cavity of the vein has a bluish-red color. Such a liver is called "nutmeg". With a long stagnant process, the pattern of the hepatic lobules is erased. Fibrous tissue formed at the site of dead hepatocytes forms a "false lobularity". With a sudden onset of stagnation, a lot of hemorrhages are recorded.

Anatomical changes and impaired functioning 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 manifestation of symptoms of congestive liver is predetermined. This disease inevitably occurs when diagnosing dysfunctions of the heart muscle in the later stages.

Signs of congestion weak heart one for all types of cirrhosis:

Increase in size (At the first stages, the organ grows in front and behind, it is not palpable. With the progression of the pathology of the heart, an increase in the liver is seen, it is determined at the bottom of the right rib. Soreness is due to stretching of the liver capsule).
Intense pain under the right rib with a manifestation of heaviness and pressure.
Swelling of the limbs.
An increase in body temperature.
Nausea, vomiting, loss of appetite.
Lethargy, weight loss, fatigue.
Aggression, bad mood, sleep problems.
An increase in the size of the abdomen.
Symptoms of jaundice.

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

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

Cardiac cirrhosis usually results in ascites that does not respond to drug treatment.

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

When a patient first visits a doctor, general inspection and clarifies the complaints of a sick person. Disease for a long time may be asymptomatic due to high compensation of liver cells.

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

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

To detect blood clots, comprehensive examination, which includes the following methods:

Biochemistry of blood ( total protein, enzymes, bilirubin, alkaline phosphatase).
Analysis of the structure and volume of the liver using ultrasound.
Hemostasiogram (blood clotting test).
Chest x-ray (examination of the lungs, determination of the size of the heart).
Electrocardiography, echocardiography (analysis of the work of the heart).
Laparocentesis (fluid collection from abdominal cavity).
Examination of the coronary vessels of the heart by using angiography.
Puncture biopsy of the liver (with transplantation of the heart muscle).

For a correct diagnosis, the presence of hepatitis, inflammation, the presence of toxic elements in the blood (from alcohol, harmful production) and other types of pathology should be excluded.

Running conditions with stagnation in the liver are almost always asymptomatic. They are found only in clinical studies in the laboratory.

The only method of preventing congestive cirrhosis is a timely appeal to a cardiologist. success therapeutic methods depends entirely on the correct recognition of the main disease - disorders of the heart. Doctors are not able to completely cure a sick person, but they are able to achieve an extension of 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 motor loads and an individually selected course of physical activity. Limited use table salt and liquids. It is useful to follow a diet, balanced diet. Foods that load the liver are strictly prohibited: spices, smoked meats, alcohol, fried and fatty foods.

With low efficiency general events prescribe medications:

Cardiac glycosides (digoxin) for treatment and normal functioning heart muscle.
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 the natural, anatomically determined parameters. As physicians point out, this pathology cannot be considered a single liver disease, as it is a symptom characteristic of many diseases, including those affecting other human organs and systems.

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

Therefore, such a common pathology as an enlarged liver should be discussed in more detail.

Causes of liver enlargement

Perhaps the list below, which includes the causes of liver enlargement, is incomplete, but it should also make you realize the true extent of its pathogenesis and get an answer to the question - is liver enlargement dangerous?

So, an increase in the liver in an adult may be the result of:

As a rule, there is an increase in the share of the liver, moreover, an increase in the right lobe of the liver (which has a higher functional load in the work of the body) is diagnosed more often than an increase in the left lobe of the liver. However, this is also not good, because left lobe is located so close to the pancreas that it is probably this gland that creates the problem.

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

Diffuse enlargement of the liver is a clearly not 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 fibrosis. The latter continues to grow, thereby increasing (and deforming) certain parts of the organ, squeezing the hepatic veins and creating prerequisites for inflammation and swelling of the parenchyma.

Symptoms of an enlarged liver

A slightly pronounced pathology - an increase in the liver by 1 cm or an increase in the liver by 2 cm - a person may not feel. 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 that patients feel even in the absence of intensive loads; discomfort(heaviness and discomfort) in the abdominal cavity; bouts of nausea; weight loss. Further, heartburn, halitosis (permanent bad breath), itching of the skin and dyspepsia can join.

Enlargement of the liver in hepatitis is accompanied not only by general malaise, but also by yellowness. skin and sclera, fever, aching in all joints, pulling pain in the region of the right hypochondrium.

Enlargement of the liver with cirrhosis takes place against the background of the same complex of symptoms, to which such signs join this disease: abdominal pain and an increase in its size, a quickly occurring feeling of satiety 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 an increase in the liver with cirrhosis (first of both lobes, and then to a greater extent of the left), the size of the spleen in half of the patients also increases, and doctors determine they have hepatosplenomegaly - an increase in the liver and spleen.

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

Fatty liver with liver enlargement

Fatty hepatosis (or steatosis), according to the latest WHO data, affects 25% of adult Europeans and up to 10% of children and adolescents. In Europe, "fatty liver" develops in 90% of heavy drinkers and 94% of obese people. Regardless of the underlying cause of the pathology, fatty hepatosis with an increase in the liver for eight years in 10-12% of patients progresses to cirrhosis. And with concomitant inflammation of the liver tissues - in hepatocellular carcinoma.

Except alcohol intoxication liver and obesity, this disease is associated with impaired glucose tolerance in type II diabetes mellitus and the pathology of the metabolism of cholesterol and other fats (dyslipidemia). In terms of pathophysiology, fatty liver with or without liver enlargement develops due to damage to fatty acid metabolism, which can 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 tissues.

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

On early stages fatty liver may not have obvious symptoms, but over time, patients complain 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 an increase in the liver in heart failure is an indicator of a decrease in blood ejection by the right ventricle of the heart and a consequence of circulatory disorders.

At the same time, blood circulation in the vessels of the liver slows down, venous congestion (hemodynamic dysfunction) is formed, 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 whole areas that disrupt the functioning of the liver. These zones increase and thicken, and along with this there is an increase in the liver (most often its left lobe).

In clinical hepatology, this is referred to as hepatocellular necrosis and is diagnosed as cardiac cirrhosis or cardiac fibrosis. And cardiologists in such cases make a diagnosis - cardiogenic ischemic hepatitis, which, in fact, is an enlarged liver in heart failure.

Enlargement of the liver in a child

An enlarged liver in a child has enough reasons. So, it can be syphilis or tuberculosis, generalized cytomegaly or toxoplasmosis, congenital hepatitis or anomalies of the bile ducts.

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

Enlargement of the liver and spleen in infants - the so-called hepatolienal syndrome or hepatosplenomegaly - is the result of congenital advanced level blood levels of immunoglobulins (hypergammaglobulinemia). This pathology, in addition to an increase in 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 an enlarged liver in children in almost half of the cases develops due to a significant excess age norms body weight. Although this pathology can occur with some chronic diseases gastrointestinal tract, after long-term use non-steroidal anti-inflammatory drugs, antibiotic 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 physical examination, the doctor may find a 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 is assumed by the anatomical norm (in an adult of average height it is no more than 1.5 cm), and is palpated significantly below the edge of the ribs. Then an increase in the liver by 3 cm, an increase in the liver by 5 cm or an increase in the liver by 6 cm is stated. But the final "verdict" is made only after a comprehensive examination of the patient, primarily with the help of ultrasound.

The enlargement of the liver on ultrasound confirms that there is, for example, “an increase in the liver of a homogeneous hyperechoic structure with an offset to the stomach, the contours are fuzzy” or that “diffuse hyperechogenicity of the liver and fuzziness of the vascular pattern and borders of the liver are revealed.” By the way, in an adult, a healthy liver has the following parameters (on ultrasound): the anterior-posterior size of the right lobe is up to 12.5 cm, the left lobe is up to 7 cm.

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

biochemical analysis

laboratory research

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

Treatment for liver enlargement

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

Drug therapy for hypertrophied liver should be supported proper nutrition with diet and vitamins. According to experts, in some diseases accompanied by an increase in the liver, damaged parenchyma and normal sizes body can be restored.

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

The drug Gepabene is a hepatoprotector plant origin(synonyms - Karsil, Levasil, Legalon, Silegon, Silebor, Simepar, Geparsil, Hepatofalk-Planta). Active substances The drug was obtained from extracts of fume (protipin) and fruits of milk thistle (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 recovery.

This drug is prescribed for toxic hepatitis, chronic inflammatory diseases of the liver, disorders of its metabolism and functions with an increase in the liver 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. With 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 control. Possible side effects are laxative and diuretic effects, as well as the appearance of a skin rash. Reception Gepabene is incompatible with the use of alcohol.

The therapeutic effect of Essentiale (Essentiale Forte) is based on the action of phospholipids (complex fat-containing compounds), which are similar in structure to natural phospholipids that are part of human tissue cells, ensuring their division and recovery in case of damage. Phospholipids block the growth of fibrous tissue cells, due to which this drug reduces the risk of developing cirrhosis of the liver. Essentiale is prescribed for liver steatosis, hepatitis, cirrhosis of the liver 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 by the presence in its composition - along with phospholipids - of vitamins B1, B2, B5, B6 and B12. And the combined hepatoprotective drug Phosphogliv (in capsules), in addition to phospholipids, contains glycyrrhizic acid, which has anti-inflammatory and antioxidant properties. It helps to reduce damage to hepatocyte membranes during inflammation and enlargement of the liver, as well as normalize metabolic processes. The method of application and dosage of the last two drugs are similar to Essentiale.

Medicines for liver enlargement include a drug based on the artichoke plant - Artichol (synonyms - Hofitol, Cynarix, Artichoke extract). Given drug helps to 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, pain in the stomach can be observed. And contraindications to its use are obstruction urinary tract and bile ducts, gallstones, as well as severe forms of kidney and liver failure.

Besides that medicinal plants are the basis of many hepatoprotective drugs, herbs with an enlarged liver are widely used in the form of home-made infusions and decoctions. With this pathology, phytotherapists advise using dandelion, corn silk, calendula, sandy immortelle, yarrow, peppermint. Standard Recipe water infusion: for 200-250 ml of boiling water, a tablespoon of dry grass or flowers is taken, brewed with boiling water, infused until cool, filtered and taken 50 ml 3-4 times a day (25-30 minutes before meals).

Diet with an enlarged liver

A strictly observed diet with an enlarged liver is the key to successful treatment. With a hypertrophied liver, it is necessary to completely abandon the use of fatty, fried, smoked and spicy foods, since such food overloads the liver and the entire digestive system.

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

Everything else (especially vegetables and fruits) can be eaten, and at least five times a day, but little by little. After 7 p.m. eating is not recommended and healthy liver, and even with an increase in the liver - it is absolutely impossible. Here is 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 intake should be reduced to 50-60 g per day, and salt - up 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 yourself understand which one. Here, without following the principles of a healthy lifestyle, nothing will work ...

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

Liver enlargement prognosis

The prognosis for liver enlargement is rather 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 the most likely consequences liver enlargement - partial or complete loss of its functionality.

Liver in congestive heart failure

Morphological changes

In those who died from heart failure, the process of autolysis in the liver proceeds especially rapidly. 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 determined. On the cut, an expansion of the hepatic veins is found, their walls can be thickened. The liver is full-blooded. 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 various lengths - from the center to the periphery. In severe cases, pronounced hemorrhages and focal necrosis of hepatocytes are determined. They show various degenerative changes. In the area of the portal tracts, hepatocytes are relatively intact. 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 during autopsy. Cellular infiltration is insignificant.

In the cytoplasm of degeneratively altered cells of zone 3, the brown pigment lipofuscin is often found. With the destruction of hepatocytes, it can be located outside the cells. In patients with severe jaundice, biliary thrombi are determined in zone 1. In zone 3, diastasis-resistant hyaline bodies are detected using the PAS reaction.

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 zone 3 vein occlusion and perivenular sclerosis extends 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 zone of the portal tract ("reverse lobular structure"). Later, as it spread 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, expansion of the sinusoids, and slowing of bile secretion. Endotoxins enter the portal venous system through intestinal wall may exacerbate these changes. Compensatory increases the absorption of oxygen from the blood of the sinusoids. 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 arising in the sinusoids can spread to hepatic veins with the development of secondary local thrombosis of the portal vein 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 on the background of coronary artery disease or mitral stenosis. In hospitalized patients, the most common cause elevated serum bilirubin levels are associated with heart and lung diseases. Long-term or recurrent heart failure leads to increased jaundice. Jaundice is not observed in the edematous areas, 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 prevalence of zone 3 necrosis, the greater the severity of jaundice.

Hyperbilirubinemia due to pulmonary infarction or stagnation of blood in the lungs creates an increased functional load on the liver under conditions of hypoxia. In a patient with heart failure, the appearance of jaundice, combined with minimal signs of liver damage, is characteristic of 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 determined at the level of the navel.

An increase in pressure in the right atrium is transmitted to the hepatic veins, especially with tricuspid valve insufficiency. When using invasive methods, the pressure curves in the hepatic veins in such patients resemble the pressure curves in the right atrium. Palpable enlargement of the liver during systole may also be due to pressure transmission. Patients with tricuspid stenosis show presystolic pulsation of the liver. 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 region of the posterior segments of the right lower ribs. An increase in size will make it possible to distinguish the pulsation of the liver from the pulsation in epigastric region transmitted from the aorta or a hypertrophied right ventricle. It is important to establish a 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. Violated functionality the right ventricle is not allowed to cope with the increased preload, which leads to an increase in pressure in the jugular veins. Hepatojugular reflux is used to detect the pulse on 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.

The pressure in the right atrium is transmitted to the vessels up to the portal system. With pulse duplex Doppler study it is possible to determine the increase in the pulsation of the portal vein; while 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.

Ascites has been associated with 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 the ascitic fluid (up to 2.5 g%) corresponds to that in Budd-Chiari syndrome.

Hypoxia of the brain leads to drowsiness, stupor. Sometimes there is a detailed picture of hepatic coma. Splenomegaly is common. Other signs of portal hypertension are usually absent, with the exception of patients with severe cardiac cirrhosis in combination with constrictive pericarditis. At the same time, esophageal varices were found in 6.7% of 74 patients with congestive heart failure at autopsy, 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, a diffuse uneven distribution of the contrast agent is noted.

In patients with constrictive pericarditis or long-term decompensated mitral defect heart with the formation of tricuspid insufficiency should be assumed to develop cardiac cirrhosis liver. With the introduction of surgical methods for the treatment of these diseases, the incidence of cardiac cirrhosis of the liver has decreased significantly.

Changes in biochemical parameters

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

Serum bilirubin concentration in patients with congestive heart failure usually exceeds 17.1 µmol/l (1 mg%), and in a third of cases 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%). The concentration of bilirubin depends on the severity of heart failure. Patients with advanced mitral heart disease normal level serum bilirubin during its normal uptake by the liver is explained by the reduced ability of the organ to release conjugated bilirubin due to a decrease in hepatic blood flow. The latter is one of the factors in the development of jaundice after surgery.

ALP activity may be slightly elevated or normal. Maybe slight decrease serum albumin concentrations, aided by intestinal protein loss.

Forecast

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

By itself, cardiac cirrhosis is not a poor prognostic sign. At effective treatment heart failure can compensate for cirrhosis.

Impaired liver function and anomalies of the cardiovascular system in childhood

In children with heart failure and "blue" heart defects, abnormal liver function is detected. Hypoxemia, venous congestion and reduced cardiac output lead to an increase in prothrombin time, an increase in bilirubin levels and serum transaminase activity. The most pronounced changes are found with reduced cardiac output. Liver function is closely related to the state of the cardiovascular system.

Liver in constrictive pericarditis

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

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

Jaundice is absent. The liver is enlarged, compacted, sometimes its pulsation is determined. There is marked ascites.

Cirrhosis of the liver and obstruction of the hepatic veins should be excluded as a cause of ascites. Diagnosis is facilitated by the presence in the patient of a paradoxical pulse, pulsation of the veins, calcification of the pericardium, characteristic changes in echocardiography, electrocardiography and cardiac catheterization.

Treatment is aimed at eliminating cardiac pathology. Patients who have undergone pericardectomy have a good prognosis, but recovery of liver function is slow. Within 6 months after successful operation there is a gradual improvement functional indicators and shrinkage of the liver. Full regression of cardiac cirrhosis cannot be expected, but fibrous septa in the liver become thinner and become avascular.

Cardiac cirrhosis of the liver

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

This type of cirrhosis is classified as secondary, because. it is not the pathology of the liver that leads to it, but the 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.

Many causes can lead to this condition, including high blood pressure, heart defects, alcohol abuse, diabetes, inflammatory heart disease, coronary heart disease, etc.

Distinguish between left and right ventricular heart failure. It is chronic insufficiency of the right ventricle on final stages and leads to cardiological cirrhosis of the liver.

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

Organic or functional disorders of the heart muscle, heart valves (heart defects)
Excessive work of the heart (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 on exertion, then at rest
Decreased performance
Edema of the upper and lower extremities
Liver damage

Causes of development of cardiological cirrhosis of the liver

Right ventricular failure is expressed in the fact that the heart does not perform its function of a blood pump in full. Decreased blood flow velocity big circle circulation, including the liver.

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

Hypoxia of hepatocytes
Decrease and necrosis of hepatocytes
Development of portal hypertension
collagen formation, fibrosis
With increased blood stagnation, the growth of connective tissue increases, the destruction of the structure of the liver

Symptoms of cardiac cirrhosis of the liver

For cirrhosis of the liver associated with cardiac pathology, all the symptoms of other types of the disease are characteristic:

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
Increase in body temperature
Signs of hepatic encephalopathy (changes in the rhythm of sleep and wakefulness, difficulty in performing habitual activities, changes in behavior, etc., up to impaired consciousness)
Pain in the right hypochondrium
Enlarged liver, spleen
Head of a jellyfish - expansion of veins on the skin of the abdomen

There are also signs that are typical for a stagnant liver:

The disappearance or reduction of symptoms of cardiac cirrhosis after treatment of heart failure, bringing positive results
On initial stages process, the liver is enlarged, soft to the touch, in later stages the liver becomes a typical dense consistency
On 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 - a decrease in stercobilin), blood biochemistry (increased transaminases, alkaline phosphatase, gamma-GGT, fructose-1-phosphate aldolase, arginase, prothrombin time, bilirubin, globulin, decrease in albumin, cholesterol, fibrinogen, prothrombin.

On ultrasound, an enlarged liver with a uniformly increased echogenicity, an enlarged spleen is determined. 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 restriction of 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:

Cardiac glycosides (digoxin, dobutamine) are used to strengthen and protect the myocardium
Beta-blockers (atenolol, bisoprolol, metoprolol, propranalol, bopindolol, timolol) are necessary to normalize blood pressure
Diuretic drugs (hypothiazid, spironolactone, furosemide) reduce swelling, they also help in the treatment of ascites

used to treat cardiac cirrhosis of the liver various groups drugs, depending on the degree of activity and stage of compensation:

Vitamin therapy (vitamins of groups B, C are prescribed)
Hepatoprotectors - drugs that protect the liver from damage (Essentiale, Heptral)
If complications arise, 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, life expectancy is no more than 3 years. With the development of bleeding, the prognosis is poor: mortality is about 40%.

Ascites also affects life expectancy for the worse. Survival at 3 years is only 25%.

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

Heart failure can be divided into:

systolic;
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.

organic disorders;
Functional disorders;
birth defects;
Acquired diseases, etc.

HF symptoms

Physically, HF manifests itself in a decrease in working 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 HF is characterized by a whole list of liver disorders. Severe liver congestion is almost always asymptomatic and is detected only in laboratory and clinical studies. The main pathologies for the development of hepatic dysfunction include:

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

Complications of heart failure

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

The deterioration in perfusion received sharp decline cardiac output, can result in hepatocellular necrosis with elevated serum aminotransferase index. Liver shock, or cardiogenic ischemic hepatitis, is the result of severe hypotension in patients with HF.

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

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

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

Factors causing stagnation in the liver

Such reasons include:

Constrictive pericarditis;
Severe pulmonary hypertension;
mitral valve stenosis;
Tricuspid valve insufficiency;
Pulmonary heart;
cardiomyopathy;
Consequences of the Fontan operation, with pulmonary atresia and hypoplastic syndrome of the left cardiac sections;
Tricuspid regurgitation (in 100% of cases). It occurs due to right ventricular pressure on the veins and sinusoids of the liver.

With an approximate study of the structure of the congestive liver, its general increase is observed. The color of such a liver acquires a purple or reddish hue. At the same time, it is supplied 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 sinus congestion and hemorrhages. Indifference and inaction in this matter leads to cardiac fibrosis and cirrhosis of the liver of the cardiac type.

Profound systemic hypotension in myocardial infarction, exacerbation of HF, 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 is 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 infectious hepatitis we don't watch.

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

Temporal development of cardiogenic ischemic hepatitis varies from 1 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:

shortness of breath;
Orthopnea;
Paroxysmal nocturnal dyspnea;
cough;
Rapid onset of fatigue.

Right-sided CH is characterized by:

peripheral edema;
Ascites;
Hepatomegaly;
Dull stretching pains in the upper right quadrant of the abdomen (rare).

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

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

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

Diagnostics

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

A congestive liver is seen in chronic heart failure, which is frequent complication all organic heart diseases (malformations, hypertension and coronary diseases, constrictive pericarditis, myocarditis, infective endocarditis, fibroelastosis, myxoma, etc.), a number of 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 heart failure, decades pass before the first signs of heart failure appear, and sometimes it develops quite quickly after organic lesion hearts.

Clinical picture

The first signs of chronic heart failure are palpitations and shortness of breath during physical exertion. Over time, tachycardia becomes constant, and shortness of breath occurs at rest, cyanosis appears. IN lower sections lungs auscultated moist rales. The liver enlarges, edema appears on the legs, then the fluid accumulates in the subcutaneous tissue and on the body, in the serous cavities, anasarca develops.

At the first stages of heart failure, the liver increases in the anteroposterior direction and is not determined by palpation. An enlarged liver can be detected using instrumental research(rheohepatography, ultrasound). With an increase in heart failure, the liver noticeably enlarges, while it is palpated in the form of a painful edge protruding from the hypochondrium. Soreness of the liver on palpation is associated with stretching of its capsule. The severity and pressing pains in the right hypochondrium, bloating. The liver is noticeably enlarged, sensitive or painful, its surface is smooth, the edge is sharp. Often there is jaundice. Functional liver tests are moderately changed. These changes are reversible in most cases.

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

Diagnostics

Identifies a disease that may be the cause of heart failure. The correct assessment of tachycardia and the detection of signs play an important role. venous congestion. Of no small importance is the favorable dynamics of symptoms during treatment with cardiac glycosides and diuretics.

Treatment

Treatment is successful with proper recognition of the underlying disease that led to heart failure and appropriate causal therapy. Patients are limited to physical activity, fluid and salt intake.

With insufficient effectiveness of general measures, cardiac glycosides are used internally, for a long time or constantly (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 and the method of its use are determined by the degree of edematous syndrome, the stage of heart failure and tolerability.