Diagnosis

Chronic diffuse liver diseases put before the doctor the following basic diagnostic tasks: 1) timely detection of chronic hepatitis and liver cirrhosis; 2) evaluation of the main characteristics of the disease: a) the activity of the pathological process, b) the stage of the disease, b) the degree of violation of the functions of the liver parenchyma, g) the nature of the violation portal blood flow and extent of compensation portal block.
Formed cirrhosis with expressed clinical manifestations usually does not cause diagnostic problems. Recognition of chronic hepatitis and clinically latent developing cirrhosis of the liver, especially in inactive phase, not so easy. The most common early symptoms of these diseases are a pain in the right hypochondrium, weakness, hepatomegaly and sometimes jaundice. This symptom complex, especially in people who have had Botkin's disease, should prompt the physician to the complex clinical and biochemical (with a set of functional liver tests) examination of the patient. In some cases to specify the diagnosis is possible only with lifetime morphological studies of the liver.
To evaluate the activity of the pathological process known value can be changes in patient health and disorders of the functional liver samples. Most significant in this respect, the increasing transaminaz, alkaline phosphatase, 5th LDH isoenzyme and organ-specific for liver enzymes, decrease of activity of cholinesterase, changes of simple and complex proteins. These figures do not always reflect the presence of active disease process in the liver. The most reliable judgement can be made on histological, histochemical changes in liver biopsy sample.
Full judgment about the stage of the disease may be made only on the basis of comprehensive studies, including the use of clinical and biochemical methods in combination with laparoscopy and lifetime histological examination of the liver. Criteria for judgement about the stage of the disease described in the section "Classification" and when discussing individual forms of cirrhosis. Private determining the stage of the disease is differentiation of chronic hepatitis and liver cirrhosis. Late stage of cirrhosis may be distinguished from chronic hepatitis clinical signs. The differentiation between the border of the United States of pathologic process may be made only on the basis of the lifetime of the morphological study of the liver. Laparoscopic sign of the transition of chronic hepatitis to cirrhosis is described Kalk (1954), the picture is mixed nodular liver". Last microscopically characterized by disruption of the structure of hepatic lobules bands of connective tissue. However, morphological study does not allow for precise moment of the beginning of the development of cirrhosis of the liver, because the process is gradual and morphological reconstruction tissue heterogeneous in different parts of the liver. This makes unreasonable desire at all costs to distinguish preecerroticeskih the stage of chronic hepatitis from the initial stage of cirrhosis. X. X. Mansurov (1965) believes that most accurately differentiate chronic hepatitis, liver cirrhosis allows polarographic analysis of serum proteins. For cirrhosis characterized by mild, catalytic wave routine, which is not observed in patients with chronic hepatitis.
The degree of functional disorders not always the extent and prevalence of morphological changes in the liver. In addition, in patients with liver cirrhosis violation of the performance of some biochemical samples may be caused not by changes in hepatocytes, and the presence of venous collaterals for which the blood of the portal vein appear in the bloodstream, bypassing the liver parenchyma.
Criteria to determine the state portal blood flow stated in the section "Portal hypertension".
In differential diagnosis should be aware of the necessity of separating chronic hepatitis and liver cirrhosis from other diseases, accompanied by gepatomegalia (fat and other dystrophy of the liver, granulomatosis liver, benign liver fibrosis, cysts and Echinococcus liver, etc.). No significant difference in chronic hepatitis and dystrophy of liver is possible only with the help of liver biopsy with histochemical her study.
Hepatomegaly in benign fibrosis is no biochemical evidence of active process with long-term observation. But here, reliable data can be obtained only by biopsy of the liver, produced under laparoscopic control. The differential diagnosis between chronic hepatitis (liver cirrhosis) and granulematosny liver can be set on the basis of the anamnesis, available extrahepatic manifestations of syphilis, brucellosis, tuberculosis, sarcoidosis, a positive serological data and biological samples corresponding to these diseases. Even with significant and long-term gepatomegalia caused by granulematosny, usually not detected changes in the functional samples. The greatest differential diagnostic value and in these cases has a liver biopsy. Sometimes by clinical signs difficult way of distinguishing focal changes in the liver (cysts, Echinococcus, tumors, hemangioma, etc.) from chronic hepatitis and liver cirrhosis. In these cases, the proper detection of the disease can help x-ray diagnostics, the use of laparoscopy and method of radioisotope scanning and operational audit.
Morphological type of liver cirrhosis can be most accurately established by comparing the results of laparoscopy and liver biopsy. Here, however, that the recognition of the morphological type of cirrhosis is impossible without the use of these methods. The originality of some of the clinical manifestations makes a real attempt to determine the type of cirrhosis on the basis of the clinical picture of the disease. According to our data, an idea of the type of cirrhosis of the liver, drawn up on the basis of clinical signs, does not coincide with the results of morphological study in 20% of cases. The main clinical features of different types of cirrhosis are given in table. 10.

TABLE 10. Signs for the differentiation of cirrhosis morphological type
  Liver cirrhosis
portal postnecrotic biliary
The main pathological picture Pseudodevice small, homogeneous, connective tissue fibers thin Large pseudodevice various sizes, sometimes containing the unmodified slices or their fragments. Wide belt of connective tissue. The convergence of three or more of the portal triads Lobular structure broken only in the later phase. Inflammatory infiltration and fibrosis around the bile ducts. Signs of beletaza
Picture by laparoscopy The surface of the liver fine, edge sharp thin The surface of the liver krupnopanel, liver strain, similar to a bunch of grapes The liver is enlarged, the surface is smooth or granular, greenish color
Jaundice There is in the late stages, in the early - sometimes with exacerbations Detected early, periodically grows at exacerbation Early and stand revealed
Hepatocellular insufficiency Occurs in the later stages Early occurs during exacerbations increases Occurs in the later stages
Portal hypertension Ahead of functional insufficiency There along with a functional deficiency Develops in the later stages or no
Skin changes "Vascular asterisks", Palmar erythema "Vascular asterisks", Palmar erythema Xanthomas
Bone changes No Sometimes arthralgia without anatomical changes Drumsticks, osteoporosis, increase epiphyses, synovitis
Changes of secondary sexual characteristics Frequent Rare No
Changes in the liver In the early stages increased, later reduced by palpation smooth surface, the sharp edge In the early stages increased, later reduced. The region of the liver uneven, bumpy surface A large, smooth, painful

Recognition morphological type of cirrhosis in the terminal phase is impossible.
The inaccessibility of some methods to a wide range of doctors defines a kind of milestone in the diagnosis of chronic liver disease.
Outpatient possible detection of clinically significant cases and identification of persons who can assume clinically latent chronic active hepatitis or cirrhosis. Further elaboration of the diagnosis can be carried out in hospitals of General type.
The necessity of using special methods of research requires hospitalization, sufficiently equipped with modern equipment.