Liver Cirrhosis
OVERVIEW | CAUSES | RISK FACTORS | SYMPTOMS | COMPLICATION | DIAGNOSIS | TREATMENT | PREVENTION | REFERENCES
OVERVIEW
Cirrhosis is a late-stage liver disease in which healthy liver tissue is replaced with scar tissue and the liver is permanently damaged. Scar tissue keeps your liver from working properly.
Many types of liver diseases and conditions injure healthy liver cells, causing cell death and inflammation. This is followed by cell repair and finally tissue scarring as a result of the repair process.
The scar tissue blocks the flow of blood through the liver and slows the liver’s ability to process nutrients, hormones, drugs and natural toxins (poisons). It also reduces the production of proteins and other substances made by the liver. Cirrhosis eventually keeps the liver from working properly. Late-stage cirrhosis is life-threatening.
CAUSES
The most common causes of cirrhosis of the liver are:
- Alcohol abuse (alcohol-related liver disease caused by long-term [chronic] use of alcohol).
- Chronic viral infections of the liver (hepatitis B and hepatitis C).
- Fatty liver associated with obesity and diabetes and not alcohol. This condition is called non-alcoholic steatohepatitis.
Anything that damages the liver can lead to cirrhosis. Other causes include:
- Inherited diseases:
- Alpha-1 antitrypsin deficiency (build-up of an abnormal protein in the liver)
- Hemochromatosis (excess iron stored in the liver).
- Wilson disease (excess copper stored in the liver).
- Cystic fibrosis (sticky, thick mucus builds up in the liver).
- Glycogen storage diseases (liver can’t store or break down glycogen, a form of sugar).
- Alagille syndrome (born with fewer than normal number of bile ducts; affects bile flow and causes jaundice).
- Autoimmune hepatitis (your body’s own immune system attacks healthy liver tissue causing damage).
- Diseases that damage or block bile ducts in the liver (tubes that carry bile from the liver to other parts of digestive system; bile helps digest fats):
- Primary biliary cholangitis (bile ducts become injured, then inflamed, then permanently damaged).
- Primary sclerosing cholangitis (inflammation of the bile ducts leads to scarring and narrowing of the ducts and buildup of bile in the liver).
- Blocked bile duct (can cause infections, backup of products in the liver).
- Biliary atresia (infants are born with poorly formed or blocked bile ducts, causing damage, scarring, loss of liver tissue and cirrhosis).
- Chronic heart failure (causes fluid to back up in your liver, swelling in other areas of your body and other symptoms).
- Rare diseases, such as amyloidosis, in which abnormal deposits in the liver of an abnormal protein called amyloid disrupts normal liver function.
Changes from liver diseases that lead to cirrhosis are gradual. Liver cells are injured and if injury – from whatever cause – continues, liver cells start to die. Over time, scar tissue replaces the damaged liver cells and the liver can’t function properly.
RISK FACTORS
You are more likely to get cirrhosis of the liver if you:
- Abuse alcohol for many years.
- Have viral hepatitis.
- Have diabetes.
- Are obese.
- Inject drugs using shared needles.
- Have a history of liver disease.
- Have unprotected sex.
SYMPTOMS
Cirrhosis often has no signs or symptoms until liver damage is extensive. When signs and symptoms do occur, they may include:
- Fatigue
- Easily bleeding or bruising
- Loss of appetite
- Nausea
- Swelling in your legs, feet or ankles (edema)
- Weight loss
- Itchy skin
- Yellow discoloration in the skin and eyes (jaundice)
- Fluid accumulation in your abdomen (ascites)
- Spiderlike blood vessels on your skin
- Redness in the palms of the hands
- For women, absent or loss of periods not related to menopause
- For men, loss of sex drive, breast enlargement (gynecomastia) or testicular atrophy
- Confusion, drowsiness and slurred speech (hepatic encephalopathy)
When to see a doctor
Make an appointment with your doctor if you have any of the signs or symptoms listed above.
COMPLICATIONS
There are many complications of cirrhosis of the liver. Because cirrhosis develops over many years, some of these complications may be your first noticeable signs and symptoms of the disease.
Portal hypertension
This is the most common serious complication. Portal hypertension is an increase in the pressure in your portal vein (the large blood vessel that carries blood from the digestive organs to the liver). This increase in pressure is caused by a blockage of blood flow through your liver as a result of cirrhosis. When blood flow through veins is partially blocked, veins in your esophagus, stomach or intestines can become enlarged (a condition called varices). As the pressure in these veins builds, the veins can bleed or even burst, causing severe internal bleeding.
Additional complications of portal hypertension include:
- Swelling (edema) in your legs, ankles or feet.
- Buildup of fluids in your abdomen (called ascites).
- Swelling/enlargement of your spleen (splenomegaly).
- Formation and dilation (expansion) of blood vessels in the lungs (hepatopulmonary syndrome), leading to low levels of oxygen in the blood and body and shortness of breath.
- Failure of kidney function as a result of having portal hypertension as a complication of cirrhosis (hepatorenal syndrome). This is a type of kidney failure.
- Confusion, difficulty thinking, changes in your behavior, even coma. This occur when toxins from your intestines aren’t removed by your damaged liver and circulate in the bloodstream and buildup in your brain (a condition called hepatic encephalopathy).
Hypersplenism
Hypersplenism is an overactive spleen. This condition causes quick and premature destruction of blood cells.
Infections
Cirrhosis increases your risk of getting and fighting serious infections, such as bacterial peritonitis (infection of the tissue that lines the inner wall of your abdomen).
Malnutrition
Your liver processes nutrients. A damaged liver makes this more difficult and leads to weight loss and general weakness.
Liver cancer
Most people who develop liver cancer have cirrhosis of the liver.
Liver failure
Many diseases and conditions cause liver failure including cirrhosis of the liver. As its name implies, liver failure occurs when your liver isn’t working well enough to perform its many functions.
DIAGNOSIS
People with early-stage cirrhosis of the liver usually don't have symptoms. Often, cirrhosis is first detected through a routine blood test or checkup. To help confirm a diagnosis, a combination of laboratory and imaging tests is usually done.
Tests
Your doctor may order one or more tests that may suggest a problem with your liver, including:
- Laboratory tests. Your doctor may order blood tests to check for signs of liver malfunction, such as excess bilirubin, as well as for certain enzymes that may indicate liver damage. To assess kidney function, your blood is checked for creatinine. You'll be screened for the hepatitis viruses. Your international normalized ratio (INR) is also checked for your blood's ability to clot.
Based on the blood test results, your doctor may be able to diagnose the underlying cause of cirrhosis. He or she can also use blood tests to help identify how serious your cirrhosis is. - Imaging tests. Magnetic resonance elastography (MRE) may be recommended. This noninvasive advanced imaging test detects hardening or stiffening of the liver. Other imaging tests, such as MRI, CT and ultrasound, may also be done.
- Biopsy. A tissue sample (biopsy) is not necessarily needed for diagnosis. However, your doctor may use it to identify the severity, extent and cause of liver damage.
If you have cirrhosis, your doctor is likely to recommend regular diagnostic tests to monitor for signs of disease progression or complications, especially esophageal varices and liver cancer. Noninvasive tests are becoming more widely available for monitoring.
TREATMENT
Treatment for cirrhosis depends on the cause and extent of your liver damage. The goals of treatment are to slow the progression of scar tissue in the liver and to prevent or treat symptoms and complications of cirrhosis. You may need to be hospitalized if you have severe liver damage.
Treatment for the underlying cause of cirrhosis
In early cirrhosis, it may be possible to minimize damage to the liver by treating the underlying cause. The options include:
- Treatment for alcohol dependency. People with cirrhosis caused by excessive alcohol use should try to stop drinking. If stopping alcohol use is difficult, your doctor may recommend a treatment program for alcohol addiction. If you have cirrhosis, it is critical to stop drinking since any amount of alcohol is toxic to the liver.
- Weight loss. People with cirrhosis caused by nonalcoholic fatty liver disease may become healthier if they lose weight and control their blood sugar levels.
- Medications to control hepatitis. Medications may limit further damage to liver cells caused by hepatitis B or C through specific treatment of these viruses.
- Medications to control other causes and symptoms of cirrhosis. Medications may slow the progression of certain types of liver cirrhosis. For example, for people with primary biliary cirrhosis that is diagnosed early, medication may significantly delay progression to cirrhosis.
Other medications can relieve certain symptoms, such as itching, fatigue and pain. Nutritional supplements may be prescribed to counter malnutrition associated with cirrhosis and to prevent weak bones (osteoporosis).
Treatment for complications of cirrhosis
Your doctor will work to treat any complications of cirrhosis, including:
- Excess fluid in your body. A low-sodium diet and medication to prevent fluid buildup in the body may help control ascites and swelling. More-severe fluid buildup may require procedures to drain the fluid or surgery to relieve pressure.
- Portal hypertension. Certain blood pressure medications may control increased pressure in the veins that supply the liver (portal hypertension) and prevent severe bleeding. Your doctor will perform an upper endoscopy at regular intervals to look for enlarged veins in the esophagus or stomach (varices) that may bleed.
If you develop varices, you likely will need medication to reduce the risk of bleeding. If you have signs that the varices are bleeding or are likely to bleed, you may need a procedure (band ligation) to stop the bleeding or reduce the risk of further bleeding. In severe cases, you may need a small tube — a transjugular intrahepatic portosystemic shunt — placed in your vein to reduce blood pressure in your liver. - Infections. You may receive antibiotics or other treatments for infections. Your doctor also is likely to recommend vaccinations for influenza, pneumonia and hepatitis.
- Increased liver cancer risk. Your doctor will likely recommend periodic blood tests and ultrasound exams to look for signs of liver cancer.
- Hepatic encephalopathy. You may be prescribed medications to help reduce the buildup of toxins in your blood due to poor liver function.
Liver transplant surgery
In advanced cases of cirrhosis, when the liver ceases to function, a liver transplant may be the only treatment option. A liver transplant is a procedure to replace your liver with a healthy liver from a deceased donor or with part of a liver from a living donor. Cirrhosis is one of the most common reasons for a liver transplant. Candidates for liver transplant have extensive testing to determine whether they are healthy enough to have a good outcome following surgery.
Historically, those with alcoholic cirrhosis have not been liver transplant candidates because of the risk that they will return to harmful drinking after transplant. Recent studies, however, suggest that carefully selected people with severe alcoholic cirrhosis have post-transplant survival rates similar to those of liver transplant recipients with other types of liver disease.
For transplant to be an option if you have alcoholic cirrhosis, you would need:
- To find a program that works with people who have alcoholic cirrhosis
- To meet the requirements of the program, which would include lifelong commitment to alcohol abstinence as well as other requirements of the specific transplant center
Reduce your risk of cirrhosis by taking these steps to care for your liver:
- Do not drink alcohol if you have cirrhosis. If you have liver disease, you should avoid alcohol.
- Eat a healthy diet. Choose a plant-based diet that's full of fruits and vegetables. Select whole grains and lean sources of protein. Reduce the amount of fatty and fried foods you eat.
- Maintain a healthy weight. An excess amount of body fat can damage your liver. Talk to your doctor about a weight-loss plan if you are obese or overweight.
- Reduce your risk of hepatitis. Sharing needles and having unprotected sex can increase your risk of hepatitis B and C. Ask your doctor about hepatitis vaccinations.
If you're concerned about your risk of liver cirrhosis, talk to your doctor about ways you can reduce your risk.
REFERENCE
- https://my.clevelandclinic.org/health/diseases/15572-cirrhosis-of-the-liver
- https://www.mayoclinic.org/diseases-conditions/cirrhosis/diagnosis-treatment/drc-20351492
- https://www.niddk.nih.gov/health-information/liver-disease/cirrhosis
