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Editor-in-chief summary: This article is relatively long. The author is very professional and dedicated to start with an overview of the basic knowledge, classification, symptoms and transmission routes of liver and hepatitis, the status quo and harm in China, the United States and Canada. Immediately afterwards, I will make a statement of various Chinese and Western medicine programs for the prevention and treatment of hepatitis, comparing the advantages and disadvantages of screening, diagnosis, prevention and treatment, with a simple and clear chart. It is very concise and worth reading. (Chelsea98.com/Blog)
The liver is the largest digestive gland in the human body and the central station of material and energy metabolism in the body. It is estimated that there are more than 500 kinds of chemical reactions that occur in the liver, which is an essential organ for life-sustaining activities. At the same time, viruses, alcoholism, obesity, diet, drugs, etc. may cause liver diseases such as hepatitis, alcoholic liver and drug-induced liver, and may develop into liver diseases such as cirrhosis, liver abscess, and primary liver cancer. Among them, hepatitis is the most important liver disease.
Hepatitis is mainly chronic hepatitis, which is divided into chronic viral hepatitis, autoimmune hepatitis, drug-toxic hepatitis, genetic disease, and other chronic hepatitis of unknown cause according to the etiology. The most common viral hepatitis is hepatitis B, which is a worldwide infectious disease. According to data released by the World Health Organization, viral hepatitis has become one of the important threats to global public health. At present, there are approximately 325 million people infected with chronic hepatitis in the world, of which more than 280 million people have hepatitis B infection and 71 million people have hepatitis C infection. The number of people who die from viral hepatitis every year can reach 1.34 million, which is similar to the number of deaths caused by diseases such as AIDS, tuberculosis, and malaria. Among them, 95% viral hepatitis patients are infected with hepatitis B or C virus. Solving the problem of hepatitis B and C infection is the key to eliminating viral hepatitis.
Liver cancer, also known as primary liver cancer, is a relatively rare cancer with high mortality. Like other cancers, liver cancer also begins when cells grow out of control and then invade other normal cell growth spaces. Hepatocellular carcinoma (HCC, primary liver cancer) is one of the leading causes of tumor deaths in the world. The difference in its incidence is related to the difference in the age of patients and the prevalence of HCV and HBV between regions. In 2013, the WHO reported that there were 745,517 deaths from primary liver cancer worldwide, and HCC was the main histological type. In 2010, HCV-related HCC caused approximately 195,700 deaths. Globally, liver cancer is the sixth most commonly diagnosed cancer and the fourth leading cause of cancer deaths in 2018, with approximately 841,000 new cases and 782,000 deaths each year.
Every July 28th is the birthday of Baruch Samuel Blumberg (Baruch Samuel Blumberg), the late 1976 Nobel Prize winner in Physiology and Medicine and discoverer of the pathogenic mechanism of hepatitis B virus and hepatitis B virus. To commemorate this virologist who made outstanding contributions to the development of hepatitis B vaccine, the World Health Organization has designated July 28 each year as World Hepatitis Day since 2011.
In 2016, the World Health Organization's Global Health Sector Strategy proposed a plan to eliminate viral hepatitis. The goal is to reduce the number of new hepatitis B infections by 95% and the number of new hepatitis C infections by 80% by 2030 , Viral hepatitis related mortality was reduced by 65%. If this goal is achieved, it is estimated that 21 million hepatitis C deaths will be reduced and 10 million new hepatitis C infections will be prevented. To achieve this goal, it may be necessary to spend US$41.5 billion on hepatitis C testing, treatment and care, which is US$23.4 billion more than doing nothing, but the money is well spent. Because the elimination of hepatitis C can increase the income of 46.1 billion U.S. dollars, the cost can be recovered by 2027, and the net income of 22.7 billion U.S. dollars in 2030 will eventually be realized.
Types of liver disease
According to the pathogenesis, liver diseases can be generally divided into six categories: viral hepatitis, metabolic liver disease, alcoholic liver damage, drug-induced liver damage, fatty liver disease, and autoimmune liver damage. Among them, viral hepatitis is common. It is also a serious type of liver disease.
- Viral liver disease:
It is a group of infectious diseases mainly caused by liver damage caused by many different hepatitis viruses. According to the diagnosis of etiology, there are at least 5 types of hepatitis viruses, namely hepatitis A, B, C, D, and E (English A, B) , C, D, E), respectively causing viral hepatitis A, B, C, D, E. Viral hepatitis has the characteristics of strong contagion, complicated transmission route, widespread epidemic, and high incidence.
- Non-viral liver diseases include the following 5Species:
(1) Alcoholic liver disease: It is a liver damage disease caused by long-term heavy drinking (alcoholism).
(2) Drug or toxic liver disease: Toxic hepatitis is hepatitis or liver disease caused by chemical poisons (such as phosphorus, arsenic, carbon tetrachloride, etc.), drugs or biological toxins.
(3) Metabolic liver disease: liver disease caused by poor metabolism of a certain substance in the body.
(4) Fatty liver disease: refers to the pathological changes of excessive fat accumulation in liver cells due to various reasons. The fat content of liver cells increases, which may be caused by alcohol abuse, diabetes, high blood fat, and overweight.
(5) Autoimmune hepatitis: It is a chronic progressive liver inflammatory disease mediated by autoimmune response. Its clinical characteristics are elevated serum transaminases, hypergamma-globulinemia, autoantibody positive, histology It is characterized by interface hepatitis dominated by lymphocyte and plasma cell infiltration, and severe cases can rapidly progress to cirrhosis and liver failure. For example, hepatitis caused by lupus erythematosus.
In another broad classification of liver diseases, other types of liver diseases are also included:
(1) Various pathogen infections. Including infections such as viruses, bacteria, and parasites. Such as the most common viral hepatitis; there are also liver abscesses caused by bacterial infections, liver tuberculosis, liver trematodes caused by parasitic infections, amoebic liver abscesses and so on.
(2) Liver space-occupying disease. The so-called occupancy simply means that abnormal or non-liver tissue occupies a certain position in normal liver tissue, and may grow and expand in it, most of which can cause liver or systemic damage. For example, various benign and malignant tumors, liver cysts, liver abscesses, liver echinococcosis, liver hemangioma, intrahepatic bile duct stones, etc.
(3) Congenital or hereditary liver disease. For example, Gilbert syndrome, which is mainly manifested by jaundice, is a congenital liver disease. Others such as multiple liver cysts, cavernous liver hemangioma and so on.
(4) Liver cirrhosis. It is the late manifestation of liver disease after long-term damage to the liver for various reasons. Such as cirrhosis after hepatitis, cirrhosis after schistosomiasis, alcoholic cirrhosis, congestive cirrhosis (more common in chronic heart failure), primary biliary cirrhosis and so on.
(5) Liver cancer. That is, liver malignant tumors can be divided into two categories: primary and secondary. Primary liver malignant tumors originate from the epithelial or mesenchymal tissues of the liver. The former is called primary liver cancer, which is a high-incidence and extremely harmful malignant tumor in my country; the latter is called sarcoma, which is more than primary liver cancer. Rare. Secondary or metastatic liver cancer refers to malignant tumors originating from multiple organs throughout the body that invade the liver. It is more common in liver metastases of malignant tumors in stomach, biliary tract, pancreas, colorectal, ovary, uterus, lung, breast and other organs.
Symptoms of liver disease
The manifestations of liver disease are very subtle, the most prominent symptoms are fatigue and lack of thought of eating; the face is dull and dull; in addition, severe dark circles are the early symptoms of patients with chronic liver disease, most of which are chronic hepatitis B. The specific symptoms are:
1. Digestive tract manifestations: This is the most common liver disease symptom, most liver diseases will occur, such as: nausea, greasiness, poor appetite, malaise, etc., vomiting, diarrhea, splenomegaly and other symptoms may occur. Such symptoms may also be related to hepatogenic ulcer disease caused by chronic liver disease and portal hypertensive enteropathy.
2. Hepatic discomfort: In all liver disease symptoms, liver discomfort and liver pain are more specific. When such symptoms appear, they are first suspected to be caused by liver disease, and traumatic factors should be excluded. Occasionally, normal people also experience temporary pain and discomfort in the liver area, which is relatively rare. Hepatic discomfort and liver pain are often related to liver enlargement and compression of liver capsule. With the progression of the disease, liver enlargement aggravates or decreases, and the nature and degree of liver pain are also different. Liver cancer is generally progressive aggravation, mainly caused by the continuous enlargement of liver cancer tumors and compression of liver capsule.
3. Whole body manifestations: fatigue and fatigue are the most common manifestations of the whole body. Some patients with liver disease may be accompanied by different degrees of jaundice, manifested as yellow urine, yellow eyes and yellow skin, which are the most specific symptoms of liver disease (except physiological jaundice in children). Itchy skin occurs when jaundice is too high. Sudden yellowing of the eyes and skin indicates that he has acute jaundice hepatitis; if patients with chronic hepatitis have jaundice, it indicates that the condition is getting worse.
4. Liver palm spider nevus: Many chronic liver diseases will have liver palm, spider nevus, and liver disease, especially in patients with liver cirrhosis. However, liver palms and spider veins are not specific, and they can be seen in normal people. Therefore, people who have spider veins or liver palms are considered to be symptoms of liver disease.
5. Hepatic ascites: Hepatic ascites usually appears in the late stage of liver disease or when the condition is extremely severe. If liver cirrhosis appears, it means that the liver has entered the advanced stage of cirrhosis.
6. Bleeding tendency: The bleeding phenomenon of liver disease is manifested in the decline of liver function, which is caused by the reduction of blood coagulation factor synthesis. It is easy to cause bleeding gums, hemorrhoids, gastrointestinal bleeding in patients with liver disease, and it is difficult to stop bleeding.
7. Portal hypertension: Portal hypertension refers to increased pressure in the portal system. It often causes esophageal and gastric varices, which is the main cause of gastrointestinal bleeding. Once bleeding occurs, combined with bleeding tendency, the disease is often more dangerous and is one of the main causes of death from liver disease (mainly refers to liver cirrhosis and advanced liver cancer).
8. Hepatic encephalopathy: This is the manifestation of the development of liver disease to the end stage. The symptoms are extremely dangerous and the main cause of death from liver disease.
Transmission route of viral hepatitis
Due to differences in personal physique and disease resistance, for example, people with poor autoimmunity are more likely to contract liver disease. The elderly have a higher risk of infection due to their weaker immunity. The infectious liver disease we often say refers to viral liver disease. The main transmission routes of viral liver disease are mother-to-child transmission, blood transmission, and sexual transmission. Non-viral liver disease is not contagious, mainly alcoholic liver and fatty liver, they are not contagious. These non-viral liver diseases are mainly related to daily life habits.
Immunity is an important antiviral barrier of the human body, especially against viral liver diseases. They are all contagious. In addition to vaccination, it is necessary to improve one's own immunity to resist virus invasion. The "Canadian Boss Dragon Detox Body Sculpting Immune Repair Course and Training" launched by the Canadian Boss Dragon Health Management Center aims to detoxify, reduce fat, repair liver function, and improve immunity, which can completely eliminate the transmission route of viral hepatitis and reverse various viral properties Hepatitis is the North American nutritional medicine course that is worth knowing and learning.
Let's first look at the current status of liver disease in China, the United States, and Canada.
Current status of liver disease in China
China is the country with the heaviest liver disease burden in the world, and more than one-fifth of the people are affected by liver disease. According to incomplete statistics, there are more than 100 million people infected with hepatitis B virus in China, which is a veritable “hepatitis B country”. China's existing serious diseases such as liver cirrhosis and liver cancer, 80% and above are all developed from hepatitis B. This includes hepatitis A, hepatitis B, hepatitis C, cirrhosis, fatty liver, alcoholic liver, drug-induced liver injury, liver cancer, and so on. The National Protect Liver Day (NPLD) is a widely-developed event in which the incidence of hepatitis B, hepatitis C, alcoholic liver and other hepatitis and liver diseases in China is increasing year by year, and people’s health is facing serious threats. It was established to promote the popularization of hepatitis and liver disease knowledge to protect the health of the people. The National Liver Love Day is set on March 18 each year.
Data related to the global burden of disease show that since 1990, the number of people dying from hepatitis-related diseases in China has been on the rise. China is an area with a high incidence of hepatitis B. There are currently about 30 million people with current chronic hepatitis B, and 400,000 people die of liver cirrhosis after hepatitis B each year. In 2017, more than 430,000 people died of hepatitis-related diseases in China, accounting for more than 30% of the world's total; in 2017, more than 410,000 people died of liver cancer in China, accounting for more than half of the world's total. In the first half of 2020, the number of cases and deaths of viral hepatitis in China reached 654,000 and 319, respectively. In 2019, the number of cases and deaths of viral hepatitis were 1.287 million and 575, respectively.
In July 2019, "JOURNAL OF HEPATOLOGY" published an article on the burden of liver disease in China. Let's take a look at many data. According to a report by the International Cancer Research Center in 2018, China's liver cancer incidence rate ranks 9th, only behind a few developing countries or emerging economies, but based on population estimates, China has the largest number of liver cancer patients in the world ; In China, HCC is the second leading cause of cancer deaths. It is estimated that as many as 7 million people (or 0.5% people) in China have liver cirrhosis. According to a recent survey in China, hepatitis B and hepatitis C affect 90 million and 10 million, respectively. The prevalence of metabolic liver disease is also high. For example, NAFLD (non-alcoholic fatty liver disease) is estimated to affect 173 million to 338 million people, and ALD (alcoholic liver disease) is estimated to affect at least 62 million people. These causes contribute to the prevalence of cancer. The impact is great. In the past 30 years, the booming economy has stimulated alcohol consumption, and China has become one of the countries with the highest per capita alcohol consumption in the world. The current prevalence of ALD in China (4.5%) is also very high, similar to the United States (6.2%) and European countries (6%), and much higher than Japan (1.56-2.34%).
According to data from the National Cancer Center of China and China CDC (new cases and deaths per year), in the past 15 years, the number of new cases and deaths of liver cancer in China has gradually stabilized. Thanks to the implementation of the national hepatitis B immunization program in 1992 and the complete free hepatitis B vaccination for all newborns in 2005, the annual incidence of HBV infection and HBV-related deaths have been steadily decreasing since 2005. Although direct antiviral drugs (DAAs) were approved by the CFDA in 2017, it still takes 2-3 years to verify the therapeutic effects of DAAs on Chinese hepatitis C patients. The vast majority of HBV infections in China are vertical mother-to-child infections or infections during youth, which are more likely to develop into chronic and persistent infections; another feature of HBV infection is family gathering.
End-stage liver disease (ESLD) includes liver cirrhosis (LC), chronic liver failure (LF) and hepatocellular carcinoma (HCC). Without effective treatment, all chronic hepatitis will eventually progress to LC, chronic LF and HCC. Cirrhosis is the most important cause of liver disease-related morbidity and mortality. Approximately 7% patients with liver cirrhosis are caused by alcohol abuse. In the areas where schistosomiasis was endemic in central China, 18% patients with liver cirrhosis were caused by schistosomiasis. Liver failure includes ALF, ACLF and chronic liver failure (CLF).
Since the implementation of universal neonatal hepatitis B vaccine in 1992, the positive rate of hepatitis B surface antigen (HBsAg) in the population has dropped from 9.75% to about 6%; the prevalence of hepatitis C has also decreased from 3.2% to 3.2% with strict blood donation screening. Within 1%; due to the improvement of drinking water and food hygiene, the incidence of hepatitis A and hepatitis E has also dropped to a very low level. Now, lifestyle-related alcoholic liver disease (ALD), non-alcoholic fatty liver disease (NAFLD), etc., are playing an increasingly important role in liver diseases in China, and many studies have pointed this out. The prevalence of non-alcoholic fatty liver disease in China has exceeded 29%. There are many risk factors for non-alcoholic fatty liver, a large part of which is related to obesity and excess calories. Studies have confirmed that the prevalence of non-alcoholic fatty liver disease in China and the rising trend of obesity rates are parallel.
Regarding liver disease treatment costs and job loss
Judging from the evolution of liver disease diagnosis and treatment costs in the past ten years, the diagnosis and treatment cost of liver disease has shown a trend of increasing year by year, with an annual increase of about 10%-20%, and the personal burden has also increased. According to survey data, more than 70% of the hepatitis B patients receiving treatment in China have an average annual income of less than 10,000 yuan, about 24.7% rely on borrowed money to see a doctor, and about 45% are unable to conduct formal medical treatment due to insufficient funds. Treatment, about 89% of people think that the cost of diagnosis and treatment of hepatitis B is too high. Therefore, the heavy medical expenses have overwhelmed many hepatitis B patients, which is the main cause of poverty in many families.
According to estimates, nearly one million new patients with liver cirrhosis and about 300,000 liver cancer patients are added to China every year. According to the annual diagnosis rate of 5% of chronic hepatitis patients and the rate of 95% of patients with liver cirrhosis and liver cancer, China's annual direct medical expenses for the treatment of hepatitis B-related chronic hepatitis, cirrhosis and liver cancer (including diagnosis and treatment expenses, hospitalization expenses, and medicine expenses) Etc.) will reach RMB 80 billion-RMB 120 billion.
As the disease progresses, these chronically infected people will gradually develop liver cirrhosis and liver cancer in the next 10-20 years. It is estimated that there are about 300,000 liver cancer patients caused by hepatitis B and C virus infections in China each year. If the treatment cost per case is about 80,000 yuan per year, the total annual treatment cost is about 24 billion yuan. The current drug treatment for hepatitis C is very effective. The drug used to treat hepatitis C cost hundreds of thousands of yuan for a course of treatment, but now it only costs less than 50,000 yuan for a course of treatment, and it is included in the scope of medical insurance reimbursement, which greatly improves the availability of medicines.
The 2009 investigation report on the status of discrimination against hepatitis B in China showed that after being infected with hepatitis B virus, nearly 30% people's school enrollment was affected; 24% people would reduce contact with hepatitis B virus carriers; 24% hepatitis B virus carriers lost their job opportunities due to hepatitis B; 24% people Choose to break up with lovers who are infected with hepatitis B virus; people with 21% will divorce because the other party has hepatitis B. Social discrimination has caused double harm to them by the hepatitis B virus.
In 2010, the Ministry of Human Resources and Social Security, the Ministry of Education, and the Ministry of Health jointly issued the "Notice on Further Regulating the Enrollment and Employment Physical Examination Projects and Maintaining the Enrollment and Employment Rights of Hepatitis B Surface Antigen Carriers" (Human Social Security Department  No. 12 ), cancel the detection of hepatitis B virus infection markers in school and employment physical examinations, and maintain the fair enrollment and employment rights of people infected with hepatitis B virus. At the same time, according to expert suggestions, the detection of hepatitis B virus infection markers in personal health examinations should also be encouraged to encourage individuals to correctly understand their own health status, but they must pay attention to protecting personal privacy and not affecting individual enrollment and employment due to test results.
Current status of liver disease in the United States
In the United States, as many as 20,000 people die from hepatitis B and C each year. There are approximately 1.3 million chronic hepatitis B virus infections in the United States and approximately 2.7 million chronic hepatitis C virus infections. In 2016, the number of people who died of liver cancer was 26,489, an increase from 12,841 in 2000; in 2018, the number of adult liver patients diagnosed in the United States was 4.5 million, and the prevalence of adult liver disease was 1.8%; the prevalence of ALD It was 6.2%; the number of deaths from liver disease was 42,838; 13.1 deaths per 100,000 people. The National Academy of Sciences, Engineering, and Medical Sciences recently issued a strategic report, which stated that these diseases need to be eliminated as serious public health problems by 2030, which means preventing nearly 90,000 deaths from these diseases.
On January 28, 2020, John Elflein wrote an article "Liver Diseases in the United States-Statistics and Facts". The data shows that from 2015 to 2017, more than 65,000 people died from alcohol-related cirrhosis; from 2015 to 2017 , The number of alcohol-related cirrhosis cases in the United States was 64,850; from 2015 to 2017, the incidence of alcohol-related cirrhosis in the United States (per 100,000 people) was 5.9; the mortality rate of liver cirrhosis in 2017 (per 100,000 people) ) Is 11.6; from 2014 to 2018, the number of acute hepatitis C infections in the United States increased from 2,194 in 2014 to 3,621 in 2018. According to Brian Strom, a professor of biomedicine and science at Rutgers University and chairman of the committee that conducted the research, viral hepatitis is not a sufficient priority at all in the United States. Although viral hepatitis ranks seventh among the global fatal diseases, and the number of deaths caused by the hepatitis virus each year is higher than that caused by AIDS, road traffic accidents or diabetes, viral hepatitis research accounts for the US National Health Research The institute studies less than 1% of the budget.
As of September 6, 2020, more than 108,000 people across the United States are waiting for organ transplants. In the United States, there are currently two ways of organ allocation: one is to group patients, and the other is to sort patients. Grouping of patients is defined as the distribution of organs according to the geographic area where the donor hospital or transplant center is located. The entire United States is divided into 11 regions, with 52 so-called donor service areas (DSA). At present, the main organ allocation area is DSA, except for patients with very advanced acute liver failure (case 1), children with very advanced liver disease (case 1b), or patients with a model of end-stage liver disease (MELD) score >35. The MELD score is used to rank patients on the transplant waiting list in the organ distribution center. Currently, most transplants (about 60%) are performed at the local DSA. The main factor affecting the recurrence of HCC after liver transplantation is the condition of the tumor at the time of transplantation. Patients with large tumors, multiple tumors, and tumors invading blood vessels have a higher risk of HCC recurrence after liver transplantation.
The Executive Committee of Biomedicine and Science of Rutgers University in the United States stated that if hepatitis B and hepatitis C are eliminated as a public health problem in the United States by 2030, the current work will require significant changes-including active testing , Diagnosis, treatment and prevention, such as the use of disposable needles. In the United States, new cases of hepatitis C infection caused by injecting drugs account for approximately 75% of 30,500 new cases each year. Therefore, the end of the spread of hepatitis C virus depends on the control of these personnel. For potential addicts, the best strategy to prevent hepatitis C is to combine safe injections and treatment. Treatment with prescription opioid agonists-one example is methadone, which helps relieve symptoms of detoxification. This treatment can prevent the spread of drug overdose and blood-borne infections, but 30 million Americans live in places where these prescriptions are not provided.
Syringe exchange programs are also essential, even in cities that currently do not have enough coverage. Half of the injecting drug population in the United States lives in rural and suburban areas, but these areas only account for 30% of the national syringe exchange program and only account for 8% of the total number of syringes. The syringe exchange program does not encourage new drug users or increase customers to use drugs, but some state laws hinder its operation. The committee recommends expanding access to syringe exchange and opioid agonist treatment. For example, pharmacies may be an ideal environment for syringe exchange because they are easy to implement in most parts of the country and have the ability to provide a private space for personal consultation. Transportation such as trucks or buses can also be used by people in remote areas, rather than just in fixed places, and relatively speaking, community opposition will be relatively small.
The latest study found that the annual economic burden caused by fatty liver in the United States is as high as 32 billion US dollars. Non-alcoholic fatty liver affects approximately 100 million Americans and, according to a pioneering study, costs the U.S. healthcare system $32 billion annually. From 2012 to 2016, the total cost of patients with alcoholic cirrhosis was approximately US$22.7 billion, and the total cost of patients with hepatitis C virus was approximately US$22.6 billion. Data from July 2019 shows that the burden of chronic liver disease in the United States is about 2.5 billion US dollars, and the indirect cost is 10.6 billion US dollars.
The Executive Committee of Biomedicine and Science of Rutgers University in the United States stated that if liver disease is to be eliminated as a public health problem before 2030, there will be no restrictions. Large-scale hepatitis C treatment is necessary, but before 2029 No direct-acting antiviral drug patent expires. Delaying treatment on a large scale until generic drugs are on the market may result in thousands of deaths and a waste of billions of dollars in medical expenses.
Current status of liver disease in Canada
In Canada, all major liver diseases are increasing. Viral hepatitis (especially hepatitis B and C) is far more common and more infectious than many other infectious diseases (including HIV). It affects more than 500 million people worldwide, with an estimated 600,000 people in Canada. According to statistical estimates, one in ten Canadians, or more than three million people, suffer from some form of liver disease. Liver deaths in 95% were due to hepatitis B, alcoholic liver disease, non-alcoholic fatty liver disease and liver cancer. In the last only 8 years, the mortality rate of liver disease has risen by nearly 30%.
Liver failure associated with hepatitis C is the main cause of liver transplantation. Liver cancer is one of the few cancers on the rise, and the mortality rate of liver cancer related to hepatitis B is expected to rise by 50%. In addition, an estimated 25% or 8.5 million Canadians are obese, and fatty liver caused by obesity is the most common liver disease in Canada. In Canada, every 1 liter of per capita alcohol consumption will increase the number of deaths from cirrhosis in men by 16% and the number of deaths in women by 12%.
The most serious consequences of liver disease can be avoided through prevention or early detection, but relevant Canadian agencies admit that they missed the opportunity for intervention. Hepatitis B and C usually have no symptoms until concurrent liver cancer, cirrhosis, and liver failure. Despite the high risk and high prevalence, there is currently no extensive screening program for these two diseases. Babies infected with 90% hepatitis B will have lifelong infections, but only 3 provinces provide universal immunity for newborns. Due to costs, restrictive reimbursement policies, lack of health care resources, and insufficient awareness of patients and primary care providers, hepatitis B patients with less than 10% and hepatitis patients less than 25% were treated. In Canada, many provinces cannot reimburse the most effective hepatitis B medication.
In Canada, there are 600,000 people suffering from hepatitis B and C, and people with 40% have no knowledge of their condition. The Chinese have a higher rate of hepatitis B than other ethnic groups. According to data from the Liver Foundation, of the 300,000 known hepatitis B patients in the country, 60% is of Chinese descent, and half of them live in Ontario. About 10% people in the Chinese community are hepatitis B carriers. Therefore, Chinese family doctors usually conduct hepatitis B tests for new immigrants or new patients, but it is still inevitable that there will be a fish in the net. At present, the Canadian immigration medical examination does not check the hepatitis B virus, so as long as the liver function is normal, there is no need to worry about the failure of the medical examination. Carrying hepatitis B or having three yang and normal liver function will not affect immigration applications.
In 2009, 58% patients who needed government assistance to pay for the drug received a low-cost but less effective drug. This drug is no longer recommended by liver disease experts in the United States or around the world. The only treatment for end-stage liver disease is liver transplantation. In Canada, it is estimated that 5,000 people die of liver disease every year, and about 400 people receive liver transplants. On the list of patients waiting for transplantation, about one-third will die because of a shortage of donated organs.
Liver cancer is the main cause of death for patients with hepatitis B and also the main cause of death for patients with other chronic liver diseases. Although liver cancer can be detected and treated early, the government does not recommend screening high-risk patients. Government agencies spend 5 to 10 times as much on research on diseases that affect significantly fewer people than hepatitis B or C. Only 4 provinces have interdisciplinary teams to provide professional care for liver cancer patients.
Treating liver disease is expensive, but ignoring it will cost more lives and resources. In Canada, there are 400 physicians and specialists treating viral hepatitis, but less than 50 of them treat more than 50 patients each year. Starting from 2006-2009, the cost of inpatient operations (including transplants) for liver disease patients exceeded US$157 million. This estimate does not include all surgical costs, nor does it include hospitalization and doctor costs. Each person’s liver transplant costs more than $100,000, including medical expenses and immunosuppressive drugs. Treating hepatitis B for 10-20 years will cost US$7000-9000 per year, while the cost of treating hepatitis C may be US$20,000-70,000.
Basic methods of liver disease prevention and treatment
1, Screening and diagnosis
Diagnosis is a prerequisite for patients with viral hepatitis to obtain treatment. In addition to testing for hepatitis B virus surface antigen (HbsAg) and hepatitis B virus surface antibody (HBsAb), hepatitis B virus screening should also include hepatitis B core antibody (HBsAb). In 2017, approximately 9% of the 257 million chronic hepatitis B infections in the world was diagnosed as hepatitis, and only 20% of the 71 million chronic hepatitis C infections knew their condition. In order to achieve the goal of eliminating viral hepatitis, screening may need to be carried out in stages. First, pay attention to pregnant women and patients with liver disease to ensure adequate drugs and diagnostic reagents, and then gradually reduce the scope of screening to expand to high-risk groups and the general population. Non-alcoholic liver disease and viral hepatitis are common and increasingly common. These diseases may affect more than 10% population.
Early diagnosis and intervention are the key to effective treatment of liver disease. Therefore, regular physical examination and screening of adults are extremely important. For long-term asymptomatic patients with chronic viral hepatitis, if an accurate diagnosis cannot be obtained, then treatment will be impossible. Eliminating viral hepatitis is a castle in the air. In order to detect liver disease as early as possible, it is very important to have a timely examination. If you have the above situation, you should first go to the hospital for two and a half hepatitis B examinations, liver function, liver B ultrasound, etc. People with alcoholic liver and fatty liver should also strengthen hepatitis C screening, because once infected with hepatitis C and fatty liver, the course of the disease will be accelerated.
According to the "China Maternal and Child Health Development Report (2019)", China provides free AIDS, syphilis, and hepatitis B screening for pregnant women across the country. However, there is currently no large-scale hepatitis B and C screening, but some hospitals have launched free liver disease screening tests for the public. Three positives means that when two and a half pairs of hepatitis B are detected, hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg), and hepatitis B core antibody (anti-HBC) are positive. Dasanyang said that he has been infected with hepatitis B virus in the body, and the virus replicates actively and is highly infectious. Big three positives are positive for e antigen and negative for e antibody, while small three positives are negative for e antigen and positive for e antibody. Normal blood does not contain ALT, which is a metabolic enzyme unique to the liver. When liver cells are damaged (such as hepatitis B virus infection and destruction), the ALT inside the liver cells will leak out into the blood after rupture, and ALT can be detected in the blood at this time. When 1% liver cells are destroyed, the ALT concentration doubles. Therefore, the state of liver cells can be reflected according to the concentration of ALT in the blood.
The 2008 New Centers for Disease Control (CDC) guidelines provide a more favorable environment. Today in the United States, all people born in areas with a high incidence of hepatitis B will be screened. High-incidence areas are defined as areas with an incidence higher than or equal to 2%. It is worth mentioning that it includes all people who have received vaccination. Since hepatitis B is usually infected early in life, people who have acquired immunity may have eliminated the virus early, while long-term chronic infections often still retain the virus in their bodies in adulthood. Therefore, compared with non-communicable diseases, it may be more appropriate to carry out large-scale screening in areas where hepatitis B is endemic. But many basic medical doctors in the United States, even in the ten states with the highest proportion of Asian and Pacific Islander populations (California, New York, Ohio, Washington, Florida, Hawaii, New Jersey, Texas, Illinois) Massachusetts and Massachusetts), did not provide screening for hepatitis B virus in their clinics.
The Canadian Liver Foundation is the first organization in the world to support the "Global Strategy for the Elimination of Viral Hepatitis B and C" declaration. The Foundation recommends that liver enzyme testing be included in the blood test program of the annual physical examination. If the level of AST or ALT increases, additional tests are needed to determine the cause of the increase. Abnormal results of liver enzyme tests can never be ignored. Liver enzyme tests-Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) are the most common blood tests used to determine liver health. Not all abnormal liver tests require treatment for underlying liver disease, but all abnormal liver test results, even the minimal abnormal results, should be investigated for the cause. This type of test is sensitive to liver damage. ALT and AST are usually found in liver cells. When liver cells are damaged, ALT and AST are released from liver cells into the blood. ALT is regarded as a more effective indicator of liver damage, because AST is also present in other organs of the body, such as the heart, as well as other muscles.
Hepatitis C testing may be more important than hepatitis B. The 2020 Nobel Prize in Physiology or Medicine was awarded to the three scientists who discovered the hepatitis C virus, namely Harvey James Alter, Michael Houghton and Charles M. Rice. Since hepatitis C is no longer an incurable disease, the clinical focus has shifted from treatment to diagnosis. Current research has found that large-scale hepatitis C screening seems to be cost-effective, but actual implementation may still be difficult. Currently licensed therapies for hepatitis C virus infection include: polyethylene glycol and standard interferon alpha (IFN), ribavirin (RBV), protease inhibitors (boceprevir, telaprevir and simeprevir) and NS5B nucleoside polymerase inhibitor Sofosbuvir (sofosbuvir)). It is expected that other antiviral compounds will be licensed in the next few years.
Screening for hepatitis C virus infection first requires a serological screening test, followed by a hepatitis C virus ribonucleic acid test (either quantitative or qualitative) to confirm the presence of viremia, and thus prove the existence of chronic infection, because the newly infected person Medium 15-45% will generally clear the virus spontaneously within six months of infection. People who cannot be cleared of hepatitis C virus within six months are defined as having chronic hepatitis C virus infection. They are diagnosed either during routine screening or when symptoms of hepatitis C virus-related liver disease appear.
Monitoring and screening of high-risk groups is the prerequisite and basis for early detection and early treatment of liver cancer (HCC). The American Society for the Study of Liver Diseases (AASLD), the Asia-Pacific Society for Liver Research (APASL), and the "Experts on the Standardized Diagnosis and Treatment of Primary Liver Cancer" issued by China The three consensuses, including the Consensus, all emphasize the early screening and early monitoring of HCC, which are based on evidence-based medical evidence and have high credibility. At present, the selection of high-risk groups is mainly based on age, hepatitis virus (HBV, HCV) infection/carrying, family history of liver cancer, liver cirrhosis, alcoholism and other aspects. Generally speaking, males ≥40 years of age, those with HBV and/or HCV infection or cirrhosis, and alcoholism can be classified as high-risk groups, and the AASLD guidelines list Asian females >50 years of age with HBV carriers as high-risk groups. For the population, APASL believes that the high HBV DNA load (>104 copies/ml) has a higher incidence of HCC. For high-risk populations, inspections are generally performed every 6 months. The views on screening indicators are relatively consistent, mainly including serum alpha-fetoprotein (AFP) and liver ultrasound.
2, Prevention of liver disease
Prevention and treatment of chronic liver diseases (ie, hepatitis B virus infection, hepatitis C virus infection, and alcoholic liver disease) can reduce the economic impact of these diseases, reduce complications related to cirrhosis and the need for liver transplantation. Currently available hepatitis B virus infection prevention measures may have economic advantages in some countries, but preventing hepatitis C virus infection and alcoholic liver disease is still challenging.
Prevention is the most critical step in eliminating viral hepatitis. China has prevented mother-to-child transmission of hepatitis B by letting newborns and the world hepatitis B vaccine. It has reached and exceeded the hepatitis B vaccination target set by the World Health Organization in the Western Pacific region and the target for the positive rate of hepatitis B surface antigen in children under 5 years of age. Most hepatitis B infections occur early in life. Many newborns may be infected with hepatitis B through contact with mother’s blood and secretions at the very beginning of life. In infants and young children, they may also spread horizontally during daily family contact. The three transmission routes of blood transmission, mother-to-child transmission, and sexual transmission are the common transmission methods of hepatitis B and hepatitis C viruses. Every day, attention must be paid to cutting off the transmission route and effective prevention.
The key to blocking the transmission of viral hepatitis is early vaccination. The World Health Organization recommends vaccination for children in all countries where hepatitis B is endemic, including the first vaccination within 24 hours after birth and the subsequent 2-3 vaccination. Current studies have shown that three doses of hepatitis B vaccine with seven valence can provide life-long protection for people above 90%. This measure reduced the number of new hepatitis B infections by 83%, avoided the emergence of 310 million chronic hepatitis B infections, and in the long run can also reduce the risk of chronic liver disease and hepatocellular carcinoma death from 90%.
Mother-to-child transmission is not the main transmission route of hepatitis C, but due to the decrease in the number of people infected with hepatitis C through other transmission routes, the proportion of mother-to-child transmission may increase. Drugs that can cure hepatitis C have appeared, but their safety in pregnant women is still uncertain. To avoid hepatitis C infection from birth, it may be more practical to diagnose and treat hepatitis C before the mother becomes pregnant. Although there is no vaccine for hepatitis C, as long as it is treated with regular medication, patients with over 98% can be cured.
Patients with chronic liver disease must have corresponding preventive measures at different stages. For example, hepatitis B virus carriers should be observed for long-term, regular follow-up, re-examination on time, and pay attention to the development direction of the disease; patients with hepatitis B disease should be treated in time to prevent disease In the direction of liver cirrhosis, patients with chronic active hepatitis eligible for antiviral therapy can be treated with interferon or nucleoside drugs under the premise of economic conditions, and patients who do not meet antiviral therapy can be given liver protection first. Adjuvant therapy for lowering enzymes and yellowing. Patients with chronic hepatitis B should be reviewed regularly, especially those receiving antiviral treatment, and liver histology can be performed in qualified hospitals; patients with liver cirrhosis can be regularly checked for gastroscopy and regular imaging examinations to see if there is cancer; advanced liver People with cirrhosis can undergo liver transplantation if they have conditions.
Primary prevention interventions recommended by WHO:
(1) Use medical injections safely and appropriately;
(2) Safe use and disposal of sharps and waste;
(3) Provide comprehensive harm reduction services for injecting drug users, including sterile injection equipment and effective and evidence-based drug dependence treatment methods;
(4) Test the donated blood for hepatitis B and C (as well as HIV and syphilis);
(5) Prevent contact with blood during sexual intercourse, including continuous condom use.
Secondary prevention interventions recommended by WHO:
(1) Receive education and consultation related to care and treatment programs;
(2) Inoculate hepatitis A and hepatitis B vaccines to prevent co-infection of these hepatitis viruses and protect the liver;
(3) Receive appropriate medical management as soon as possible, including antiviral treatment;
(4) Regular monitoring to obtain the diagnosis of chronic liver disease as soon as possible.
In addition to vaccine preventive measures, other medical-related operations and preventive measures in daily life are also effective. This article will be introduced later (such as blood transfusion, blood donation, drug use, syringes, etc.).
3, Treatment strategy
(1) Three principles for treating liver disease
The first is antiviral; the second is to improve immunity; the third is to restore liver function. Mastering these three principles, viral hepatitis can only talk about repairing the problem. Restoring liver function means restoring liver detoxification function, and in terms of pathological changes, it means improving detoxification function. From the perspective of nutritional medicine, detoxification is the most basic, cutting-edge, and easiest method. For details, please follow the "Canada Boss Dragon Detoxification Body Sculpting Immune Repair Course and Training".
(2) Hepatitis A treatment
* Antiviral drugs: HAV infection is often self-limited, and supportive treatment is taken. Do not take unnecessary drugs. Should not take acetaminophen/acetaminophen and anti-emetic drugs. Drugs that can cause liver damage or metabolize by the liver should be used with caution. Patients with 85% achieved complete clinical and biochemical recovery within 3 months, and almost all patients recovered completely at 6 months.
* A reasonable diet is an important part of the treatment of hepatitis A patients. Therefore, some hepatitis A patients should be prepared with some food that enhances appetite, is conducive to the recovery of the disease, and is nutritionally appropriate.
* Proper rest. For hepatitis A patients, taking rest during the treatment process is a point that requires special attention to avoid overwork. Many hepatitis A patients relapse because of not paying attention to rest.
* Patients with hepatitis A undergoing recuperation at home should go to the hospital for review regularly to monitor the development of the disease in time. Ensure that the treatment is effective.
(3) Hepatitis B treatment
The treatment of hepatitis B mainly includes comprehensive treatment such as anti-viral replication, improving the body's immune function, protecting liver cells, promoting liver cell regeneration, as well as traditional Chinese medicine treatment, basic treatment and psychological treatment. Due to the recurrence of the disease and the continuous positive HBV replication indicators, the following methods can be used according to the situation:
* Antiviral therapy
For chronic HBV infection, antiviral treatment is an important measure for those who continue to be positive for viral replication indicators. The current antiviral drugs are not very satisfactory. After the application, the replication of HBV can be temporarily inhibited, and this inhibition disappears after the drug is stopped, so that the originally inhibited index returns to the original level. Some drugs are slower and take longer to see the effect. Due to the limited curative effect of antiviral drugs and effective only when the virus is actively replicating, the treatment of chronic hepatitis B tends to be combined with drugs in recent years to improve the curative effect.
* Immunomodulatory drugs
⑴ Thymosin: Enhance T cell activity by affecting cAMP. The usage is 10-20mg daily, intramuscular injection or intravenous drip, the course of treatment is 2-3 months.
⑵ Interleukin 2 (IL-2): It can stimulate the proliferation of immune effector cells and induce γ-interferon. The usage is 1000-2000U per day, intramuscular injection, once a day, the course of treatment is 28-56 days. HBeAg turns negative in some patients.
⑶ Lymphokine-activated Killer Cell (Lymphokine-activated Killer Cell, referred to as LAK cell): It is derived by stimulating its precursor cells with lymphokines (such as IL-2 and γ-IFN). It has been reported that some patients with HBeAg and HBV-DNA can turn negative.
* Drugs to protect liver cells
⑴ Progesterone extracted from Silybum marianum (Milk Thistle) seeds can stabilize liver cell membrane and promote liver cell regeneration. The usage is 2 tablets each time, 3 times a day, and the course of treatment is 3 months.
⑵ Glycyrrhizin extracted from licorice is effective against carbon tetrachloride toxic liver damage, and has a better effect on lowering enzymes in the treatment of hepatitis. It has a rebound after stopping the drug. The existing similar product Ganlixin injection has better enzyme-reducing effect than Qianglining. Usage is 150mg adding 10%
Intravenous infusion of glucose solution, once a day, the course of treatment for 1-2 months, pay attention to the prohibition of heart and kidney failure, severe hypokalemia, hypernatremia. Not suitable for pregnant women and infants.
⑶ The usage is 80mg, taken 3 times a day for 3 months. Bifendate, the usage is 15-25mg, taken 3 times a day, after the transaminase is normal, the dosage is reduced and the treatment course is 6 months. Both have the effect of lowering enzymes.
(4) Hepatitis C treatment
The treatment of hepatitis C should adopt a comprehensive treatment plan according to the specific conditions of the patient, including reasonable rest and nutrition, psychological balance, improving and restoring liver function, regulating the body's immunity, anti-virus, anti-fibrosis and other treatments. Because the immune response of some people can clear the infection, new hepatitis C virus infections do not always require treatment. However, when hepatitis C virus infection becomes chronic, treatment is necessary. The goal of hepatitis C treatment is to recover from the disease.
In 2018, WHO received updated guidelines recommending the use of pan-genotypic direct-acting antiviral therapy (DAAs). This therapy can cure most people with hepatitis C virus infection. The treatment time is short (usually 12 to 24 weeks), depending on the presence of cirrhosis.
WHO recommends that all patients with chronic hepatitis C infection over 12 years of age be treated with pan-genotype direct antiviral drugs. In many high-income and upper-middle-income countries, pan-genotypic direct antiviral drugs are still very expensive. However, in many countries (mainly low-income and low-middle-income countries), the prices of these drugs have fallen sharply due to the use of generic drugs.
The availability of hepatitis C virus treatment is improving, but the improvement is extremely limited. In 2017, among the 71 million people infected with hepatitis C virus in the world, an estimated 19% (13.1 million people) knew their diagnosis status. Among those diagnosed with chronic hepatitis C infection, as of the end of 2017, about 5 million people had received direct antiviral treatment. To achieve the hepatitis C virus treatment target of 80% by 2030, much work remains to be done.
In terms of treatment, hepatitis B and C are also quite different. Hepatitis C has become a tuberculosis-like disease after the emergence of curative drugs. In patients without advanced liver disease, treatment takes relatively short time. As hepatitis B lacks curative means, the treatment focus will be placed on long-term disease monitoring and virus suppression, similar to the treatment process of AIDS.
(5) Liver Cirrhosis Treatment
Cirrhosis of the liver is a worldwide problem, accompanied by a huge economic burden. Hepatitis B virus infection, hepatitis C virus infection and alcoholic liver disease are the main causes of liver cirrhosis, but cost-effective prevention strategies can only be used for HBV infection. There are many treatment algorithms for hepatitis B virus infection and hepatitis C virus infection, which may be economically advantageous, depending on the treatment plan adopted; however, there is no effective treatment for alcoholic liver disease, and alcohol withdrawal is still the main treatment strategy .
Despite the recent decline in overall costs, liver transplantation (the only effective treatment for liver cirrhosis) continues to consume a lot of economic resources. More sensitive predictors of disability after liver transplantation can reduce the cost of liver transplantation by adopting interventions to increase productivity and improve the health-related quality of life after liver transplantation.
(6) Acute liver failure
Acute liver failure (ALF) refers to patients without liver disease (mainly liver cirrhosis). Acute severe liver insufficiency occurs due to massive necrosis or loss of liver cell function, leading to hepatic encephalopathy (HE) ) And coagulation dysfunction as the main features of the clinical syndrome. This syndrome is a serious disease, complicated clinical symptoms, and a high mortality rate. It is a serious liver disease that endangers people's health. It is estimated that there are 2,000 cases of ALF each year in the United States, and China is not uncommon. Before liver transplantation, the survival rate of this disease was less than 15%. With the development of liver transplantation, the short-term survival rate exceeded 65%.
* Nutrition therapy. Although patients with acute liver failure have relatively better nutritional status than patients with cirrhosis and end-stage chronic liver disease, they are still characterized by high metabolism. In the absence of contraindications, enteral nutrition support is advocated.
* Protect liver cells and improve liver microcirculation to avoid further necrosis of liver cells.
* Promote liver cell regeneration. "Hepatocyte growth factor" or stem cell therapy can be used to promote DNA synthesis to regenerate liver cells, while also inhibiting liver cell apoptosis.
(7) Treatment of alcoholic liver disease
* Nutrition therapy (omitted).
* Quit drinking. More effective alcohol withdrawal therapy will be beneficial and can greatly reduce the need for liver transplantation and retransplantation.
(8) Non-alcoholic fatty liver disease treatment
* Nutrition therapy (omitted).
* If the patient has diabetes and abnormal glucose metabolism, consider using some drugs for glucose metabolism, such as metformin.
* Pioglitazone can be used if the liver tissue of the patient has lesions.
* If you need to relieve liver oxidation and inhibit oxidative stress, you can use vitamin E, which is a drug recommended by my country and the US Fatty Liver Guidelines.
* There are still many drugs under development, such as obeticholic acid, which are close to the conditions approved by the US Food and Drug Administration. At the same time, the drug Elafibranor successfully developed in India not long ago has the function of regulating the activities of PPAR-α and PPAR-γ, and is the first drug approved for use in the world.
* The most clinically used liver injury treatment drugs in China include glycyrrhizic acid preparation diammonium glycyrrhizinate and so on. Most of the effects of these drugs come from expert opinions and clinical experience, and more clinical evidence is needed to further confirm.
* Before the appearance of drugs for fatty liver, the most basic way to relieve metabolic syndrome was to control blood pressure, blood sugar and blood lipids, and to reduce liver fat consumption through exercise. Because the liver of patients with non-alcoholic steatohepatitis has inflammation, a large number of liver drugs will also increase the burden on the liver, and even some drug interactions may occur. Therefore, in addition to drug treatment, the more definite treatment method now is metabolic surgery, which reduces the capacity of the patient's gastrointestinal tract, quickly produces a feeling of fullness when eating, and reduces appetite. .
(9) Liver Cancer Treatment
Primary liver cancer is one of the most common malignant tumors in clinical practice. The global incidence rate ranks 5th, and the mortality rate ranks 3rd. However, the number of liver cancer incidences in China accounts for about 55% in the world, second only to lung cancer in tumor-related deaths. , Ranking No. 2. In 2010, the American Society for the Study of Liver Diseases (AASLD) and the Asia-Pacific Society for Liver Research (APASL) successively launched the latest clinical guidelines or consensus. The Liver Cancer Professional Committee of the Chinese Anti-Cancer Association and the Clinical Oncology Collaborative Professional Committee (CSCO) and the Liver Cancer Group of the Society of Hepatology of the Chinese Medical Association have formulated my country's "Expert Consensus on the Standardized Diagnosis and Treatment of Primary Liver Cancer."
* Partial hepatectomy: The conditions of patients undergoing partial hepatectomy include: good liver function; the tumor has not grown out of its own vascular environment. These assessments can be determined by liver function tests and imaging tests (CT or MRI and angiography). The doctor will use the Child-Pugh scoring method during the assessment. Grade A patients are most likely to have sufficient liver function for surgery. Type B patients are unlikely to undergo surgery. C patients usually do not choose surgery.
Risks and side effects of partial liver resection: Liver resection is a major operation and can only be performed by skilled and experienced surgeons. Patients should be thoroughly examined and evaluated before surgery. The risks that need attention include: bleeding: part of the liver is rich in blood vessels, and bleeding after surgery is a risk that requires special attention. On the contrary, blood clotting can also damage the liver. Infection, complications of anesthesia, blood clots, pneumonia, etc.
* Liver transplant surgery:
Since Professor Starzl in the United States successfully completed the first human liver transplant in 1963, so far, a total of about 500,000 liver transplants have been completed worldwide. Liver transplantation is the only effective method for the treatment of end-stage liver disease. The operation effect is good, and normal work, study and life can be restored after the operation. The long-term prognosis of liver transplantation is not much different from that of kidney transplantation. As the only effective way to treat end-stage liver diseases (including liver cirrhosis, liver cancer, etc.), liver transplantation has become a routine treatment. The 1-year survival rate after liver transplantation is more than 90%, and the 5-year survival rate is more than 80%. At present, the longest survival time of recipients after liver transplantation in the world is 43 years, while the longest survival record in China is more than 22 years. In China, the annual number of liver transplants in 2018 has reached more than 6,000, and the number of transplants has ranked first in Asia and second in the world. In the United States, the number of people who need liver transplantation a year is between 17,000 and 20,000, but only 7,000 people can get matching organs. In Canada, more than 400 liver transplants are performed every year.
Regarding the applicable standards for liver transplantation.
The United States is mainly based on the Milan (Milan) standard, the University of California, San Francisco (UCSF) standard, etc. The AASLD guidelines recommend that liver transplantation is the first choice for HCC patients who meet the Milan criteria (single tumor diameter ≤ 5 cm or multiple tumors less than 3 and the largest diameter ≤ 3 cm). The Asia-Pacific APASL guidelines recommend liver transplantation for Child-Pugh C cirrhosis patients who meet the Milan criteria. In China, liver transplantation is only used as a supplementary treatment option for patients with liver cancer who cannot be surgically removed, cannot be treated with radiofrequency, microwave, and hepatic artery chemoembolization (TACE), or whose liver function cannot tolerate it. Although there is no unified standard in China, many Chinese units and scholars have successively proposed different standards, including Hangzhou Standard, Shanghai Fudan Standard, West China Standard and Sanya Consensus. They have the same requirements for no large vessel invasion, lymph node metastasis and extrahepatic metastasis, but they have different requirements for the size and number of tumors. Compared with the standards adopted in the United States, the Chinese standards have expanded the scope of application of liver transplantation for liver cancer to varying degrees, so that more patients with liver cancer can benefit from liver transplantation, but they have not significantly reduced the overall survival rate and the survival rate. Tumor survival rate. Multi-center collaborative research is also needed to determine which standard is more beneficial to patients.
* Interventional treatment of liver cancer:
In this regard, China uses TACE therapy, that is, interventional therapy. As a treatment option for unresectable HCC, transcatheter arterial chemoembolization (TACE) has been widely used since 1978 by Professor Yamada of the Faculty of Medicine, Osaka City University, Japan, and has shown good results. Specifically, after the catheter is selectively or superselectively inserted into the target artery supplying the tumor, an appropriate amount of embolic agent is injected at an appropriate speed to occlude the target artery and cause avascular necrosis of the tumor tissue. Embolization with anticancer drugs or drugs combined with particles or microspheres can play a role in chemoembolization, which is called TACE (transcatheter arterial chemoembolization). Most used for the treatment of liver cancer, including: hepatic artery catheterization chemoembolization, or hepatic artery catheterization chemotherapy perfusion. This is currently one of the more commonly used methods for non-surgical treatment of liver cancer. However, in addition to TACE, the United States also has treatment methods such as transcatheter arterial embolization (TAE) and drug-loaded microsphere embolization (DEB-TACE).
* Targeted therapy:
Currently, targeted therapy drugs for liver cancer that have been marketed in the United States include sorafenib and regorafenib. Sorafenib is the first-line drug for systemic therapy introduced by NCCN, and regorafenib is the second-line drug after sorafenib fails, and it has also been introduced in the NCCN guidelines. In China, only sorafenib has been introduced in the guideline. Although regorafenib was approved for the treatment of liver cancer in December 2017, it has not yet been introduced in the guideline.
Also known as biological treatment method or biological response modification treatment method, it is a treatment method that uses the body's own defense mechanism to fight cancer. White blood cells are the body's front line of defense against diseases. Immunotherapy methods methods methods methods methods can stimulate white blood cells in various ways, increase the immune response of cancer, and have little or no effect on healthy tissues. Commonly used immunotherapies in China include immunomodulators (interferon α, thymosin α1, etc.), immune checkpoint inhibitors (cytotoxic T lymphocyte associated antigen 4, CTLA-4; programmed cell death protein-1, PD-1; Programmed cell death protein ligand, PD-L1), tumor vaccines (dendritic cell vaccines, etc.), cellular immunotherapy methods methods methods (cytokine-induced killer cells). In China, the immune checkpoint inhibitor nivolumab is still in phase 3 clinical trials. In the United States, the NCCN guidelines introduced the application of nivolumab, which opened a new era of liver cancer immunotherapy.
* Local ablation therapy, ethanol injection:
It is mainly suitable for early-stage patients with a single tumor less than 5cm in diameter, or less than 3cm in diameter, no more than 3 lesions, no blood vessel or bile duct invasion, and no distant metastasis. At present, it is not recommended to perform local ablation for lesions larger than 5 cm. Ethanol injection (PEI) has been widely used in clinical practice. It is suitable for patients whose tumors are located near the large blood vessels of the hepatic portal, gallbladder, or gastrointestinal, with poor general conditions or recurrence after resection and cannot tolerate surgery. The AASLD guidelines believe that the necrotic effect of radiofrequency ablation is more predictable in tumors of various sizes, and the efficacy of large tumors is significantly better than that of ethanol injection.
* Radiation Therapy:
For localized tumors (mainly in the right liver) with good general conditions and normal liver function, some cases can be cured. It has a certain palliative effect for patients with large tumors or metastases. Those with severe illness can relieve symptoms, such as obstructive jaundice caused by hilar tumors or bile duct compression, and severe pain caused by bone metastases.
(10) Traditional Chinese Medicine Law
* Liver clearing therapy:
Acute hepatitis is due to the hepatitis virus invading the human body as a "pathogenic factor", which causes the body's antagonistic behavior, and various diseases and syndromes appear. When the hepatitis virus is developing rampantly, the liver becomes inflamed and congested, and liver tissue is diffusely damaged. Therefore, apply treatments aimed at the cause of the disease to remove the pathological products, and do not make "helping the dying to be abuse". At this time, we should focus on using effective anti-viral Chinese medicine to reduce its vigor. Although the names of the prescriptions are different, the purpose of clearing away heat and detoxification is the same. Whether it is a new disease or a recurrence of an old disease, as long as it is hyperactive with evil toxins, it is always positive to try this method.
* Soothing liver therapy:
The so-called soothing liver therapy is essentially an "elimination therapy" for the liver. From the perspective of the physiological characteristics of the liver, "the liver governs the release of excretion, and the sex is good." The liver wood should be smooth, and stagnation is the most avoided. The so-called stagnation of liver qi mostly refers to unpleasant emotions. Chinese medicine treats diseases with the most attention to the emotional problems of patients. Shugan pills, Xiaoyao San, Albizia Julibrissin, and Wangyoucao are commonly used clinically. Chronic liver disease, most of "deficiency in the body, while the disease is solid", the righteousness is caused by the evil, and the disease is due to deficiency and timidity but benefit and stagnation. For those who are deficient and stagnant, first remove the stagnation and then make up for the deficiency. The following methods of regulating qi, promoting blood circulation, removing blood stasis, resolving coagulation, dredging collaterals, and removing dampness are nothing more than a means of removing obstacles, so they all belong to the "Shugan therapy".
* Liver protection therapy:
"The liver is the internal organs" has the physiological characteristics of "the body is yin and yang is used". In the later stage of hepatitis, righteous qi declines day by day, and various dysfunctions appear, often with symptoms of deficiency in the presence of excess. The pathogens are always placed on the human body to cause disease, and it is necessary to focus on the physical signs of the human body. Especially for chronic hepatitis, most of the patients present with deficiency syndromes such as fatigue, loss of appetite, full abdominal distension, weak pulse (or thinning), pale tongue and thin fur. Therefore, on the basis of soothing the liver, methods such as assisting yang, nourishing yin, awakening the spleen, and soothing the stomach can be used to invigorate the body's vitality and restore the fatigue of organ functions. This method is based on the characteristics of patients with physical weakness and emphasizes human factors, so it is called liver protection therapy.
* For people with spleen deficiency,
Take ginseng spleen pills, barley, yam, and gorgon porridge; for people with kidney deficiency, you can take Liuwei Dihuang pills, stewed chicken with wolfberry and gastrodia elata; for people with liver irritation, you can take Danzhixiaoyao pills, chrysanthemum tea, etc. Can protect the liver.
* To invigorate the spleen and dampness:
Xiangsha Liujunzi Decoction and Lianpu Yinxuefu Zhuyu Decoction are basic additions and subtractions, and better results can be obtained with dietary adjustments and increased exercise.
* Other single-flavored Chinese medicines, effective and commonly used medicines: Shouwu, Hawthorn, Lotus Leaf, Cassia Seed, Salvia Miltiorrhiza, Zesan, Alisma, Turmeric, Rhubarb, etc.
(11) Nutrition therapy
* Foods that improve liver function: lemons, bananas, grapes, blueberries, citrus, asparagus, tomatoes, spinach, cabbage, bean sprouts, leeks, mustard greens, mushrooms, nuts (especially walnuts), olive oil, avocado, grapefruit, sour Plum, hawthorn, wolfberry, mulberry, lychee, chrysanthemum, garlic, ginger, chives, oats, seaweed, cruciferous vegetables, eggs, chicken liver, pig blood, cheese, salmon, etc. Specific ingredients and cooking methods, Please consult the author of this article.
* Healthy carbohydrates: oats, purple sweet potatoes, lilies, dates, beets, carrots, and appropriate amount of healthy sugars (such as maple sugar, honey, brown sugar, natural fruit sugar, etc.).
* Soup and porridge: Chicken bone soup, tofu and fish belly soup, Xiaochaihu soup, millet porridge, winter melon porridge, Yinchen porridge, etc.
* Beverages: yogurt, lemonade, garlic water, green tea, black tea, cassia tea, weak coffee, green ginger tea, vinegar, etc.
* Foods to avoid: alcohol, foods containing preservatives, moldy foods, sunflower seeds, high salt, carbonated drinks, etc.
* General functional nutritional preparations include:
Calcium magnesium zinc, VA, VB, VC, VE, coenzyme Q10, milk thistle, Antrodia camphorata, Spirulina, Gynostemma, curcumin, astaxanthin, proanthocyanidins, digestive enzymes, probiotics, etc.,
Please consult the author of this article for specific formulations and dosages.
Health management of liver disease
Cautionary reminder: Get hepatitis B vaccine as soon as possible to prevent hepatitis B; if there are other related vaccines, please consult a doctor or health care professional, and try to use safe vaccines.
1, Seven groups of people urgently need liver health management
(1) People with yellowing complexion and whites of eyes and jaundice need to nourish the liver. People with poor liver often have yellowing complexion, white eyes or yellow skin, which is the so-called jaundice symptom, which requires liver health management.
(2) Limbs are weak and tired easily. Those who are lazy and move less need to nourish the liver. This is mainly because if the liver function is abnormal, the intermediate metabolism of carbohydrate, protein, fat, etc. leads to insufficient energy production, the human body is prone to fatigue, physical strength declines, poor spirits, and liver damage results in poor bile excretion. Alkaline esterase is reduced, affecting the normal physiological functions of neuromuscular. Therefore, when you are tired and do not think about eating or drinking, you need to manage liver health in time.
(3) People who are short-tempered, irritable, and emotionally irritable need to nourish the liver. Liver likes and dislikes depression, often angry and angered, mostly because of the stagnation of liver qi, the circulation of qi and blood in the whole body is disordered, and other viscera and organs are disturbed. Although there may be no symptoms for a while, it does plant a lot of time bombs for liver health. Therefore, people who are often angry, irritable, moody, and full of abdomen need timely management of liver health.
(4) Those who dislike greasy and yellow urine need to pay attention to liver function. The main reason is that the function of the liver to secrete and produce bile is weakened, so that the liver's ability to digest fat is weakened, so the phenomenon of greasiness will appear. The liver excretion of bile is blocked, and the bilirubin in the blood increases. If too much bilirubin is excreted by the kidneys, yellow urine will appear. Therefore, people with this symptom should pay attention to liver health management.
(5) Abnormal urine color. People can observe their urine color when urinating. If the color of urination is transparent or yellowish, then it is a healthy urine color. After suffering from liver disease, the red blood cells in the body are destroyed, causing a large amount of bilirubin to be excreted in the urine, and the color of the urine will become yellow. If the liver disease is more serious, the yellow will become darker.
(6) Acne. Because the liver is responsible for detoxification, if this task cannot be successfully completed, a large amount of toxins will accumulate in the body. These toxins will affect the body's luteal hormone metabolism, and after it becomes disordered, the secretion of sebaceous glands will increase, and a large number of acne will grow on the face, neck, chest, back and other parts.
(7) A dull pain in the upper abdomen. When some people have dull pain in the upper abdomen, they usually don’t think of the liver. They usually think it’s a problem with the stomach. Drinking a little hot water can relieve the symptoms. Although there is no obvious pain nerve in the liver, it is outside the liver. There is a layer of liver capsule full of painful nerves. If the liver disease is more serious, the liver capsule becomes swelled, which will cause it to be excessively stretched and make people feel liver pain.
2, General health management of liver disease
(1) Proper rest: People with obvious symptoms or severe illness should emphasize bed rest. Bed rest can increase liver flow and help recovery. People with mild illness should not feel tired after the activity;
(2) Reasonable diet: Appropriate high-protein, high-calorie, high-vitamin digestive food is beneficial to liver repair, and it is not necessary to overemphasize high nutrition to prevent fatty liver and avoid drinking alcohol;
(3) Psychological balance: to enable patients to have a correct outlook on disease, and to have patience and confidence in the treatment of hepatitis. Do not rush to the doctor to avoid delay in treatment;
(4) Fat and weight loss: Half of obese people may have mild fatty liver, but in severely obese patients, the incidence of fatty liver can reach 61%. The intake of high-calorie diets in obese patients is also a factor in the formation of fatty liver. The accumulation of fat in the liver is directly proportional to body weight. After weight control of obese patients, the degree of fatty liver is reduced. Conversely, weight gain will increase fatty liver. This shows that the fatty liver of obese patients is part of the total body fat. Reducing nutrient aid and weight control can improve fatty liver. For fat loss and weight loss, please pay attention to "Canada Dr. Dragon Detox Body Sculpting Immune Repair Course and Training".
(5) For patients with hepatitis B and C infections, it is recommended to review liver function every six months, perform quantitative tests for hepatitis B and hepatitis C viruses, check A-fetoprotein, and perform liver color Doppler ultrasound; patients with anti-viral indications should strictly follow the doctor’s instructions for anti-viral The treatment should not be stopped casually.
(6) Liver cirrhosis patients undergo liver ultrasound examination every 6 months to screen for liver cancer, because liver cancer patients with 80% have liver cirrhosis. Patients with a family history of liver cancer, patients with HIV or HCV infection, and people with fatty liver should all be tested for liver cancer.
3, Daily dietary guidelines for viral hepatitis
(1) Virus carriers should not eat more high-fat foods; fast animal livers; avoid tobacco and alcohol; take less drugs; should pay attention to work and rest; avoid excessive fatigue and staying up late;
(2) Virus carriers should eat more fresh vegetables, such as greens, celery, spinach, cucumbers, tomatoes, etc.;
(3) Virus carriers should be supplemented with adequate vitamins: vitamin B, vitamin A, vitamin C, vitamin K and folic acid, etc. Vitamin foods help patients increase the supply of vitamins, and are beneficial to the repair and enhancement of liver cells. The detoxification function improves the body's immunity. You should eat more apples, pears, bananas, grapes, citrus, etc.;
(4) An appropriate amount of healthy carbohydrate has a protective effect on protein and can promote the utilization of amino acids by the liver;
(5) Fermented milk products, eggs, fish, lean meat, fermented soy products, etc. should be taken more daily to facilitate the use of protein for repair, to facilitate the regeneration and repair of liver cells, and to improve immunity;
(6) Eat more foods containing trace elements and minerals. Patients usually lack trace elements such as zinc, manganese, and selenium, and some also lack minerals such as calcium, phosphorus, and iron. Therefore, it should be suitable to supplement foods containing trace elements and minerals, such as yogurt, seaweed, oysters, shiitake mushrooms, sesame, jujube, wolfberry, etc., which is of great benefit;
(7) Ingest more healthy yogurt, healthy fermented food, probiotics, live micro-ecological bacteria, micro-ecological preparations, etc., which is conducive to the restoration of liver function;
(8) Avoid spicy food, alcohol, smoking, processed food, abuse of supplements, abuse of hormones, and abuse of antibiotics, etc.;
(9) Avoid diets high in copper, and eat less foods with high copper content such as jellyfish, squid, shrimp, and snails.
4, Acupoints nourish the liver and protect the liver
Taichong, Dadun, Taixi, Ganshu, Xingjian, Qimen, Sanyinjiao, and bilateral ribs. Please consult a professional or the author of this article.
Liver disease is the most common disease in the human body, but the liver has a better compensatory function and there is no pain nerve, making most patients feel nothing for a long time after the illness. Because there is a layer of capsule on the surface, there are nerves. Severe lesions and cancer have changed the size of the liver, affecting the surrounding tissues and the outer membrane nerves of the liver. That is to say, it will not gradually develop until the disease progresses to a certain extent. Symptoms such as liver pain, decreased appetite, fatigue, weight loss, etc., will not show up until the late stage such as jaundice, ascites, hematemesis, and coma.
In particular, although liver disease is not easy to detect in the early stage, it can be prevented, especially in high-risk groups. From the previous analysis, apart from vaccines, it is the health awareness of each of us, paying attention to the details of daily life, such as weight control, healthy eating and so on. Related articles include "Talking about drug-induced liver damage and drug-induced hepatitis", "The current situation of hepatitis in China, the United States and Canada & multi-nutrition therapy". Please stay tuned.
8. Chinese Society of Clinical Oncology (CSCO) Guidelines for Diagnosis and Treatment of Primary Liver Cancer 2020
*** Every article, Hui Zhou’s experts carefully write, edit and check, please trust the expert’s advice,If you have any questions, please email firstname.lastname@example.org *** Huizhou Million Dragon Health Project Dr. Kyle Long, registered dietitian, registered health manager. Personalized improvement of FAH financial quotient, adverse quotient and health quotient-from sincerity, clarity, and efficiency of the smart fund