When the liver can’t take any more
View(s):The liver is a large organ (weighing about three pounds) that is located in the right upper abdomen, beneath the rib cage. Cirrhosis is the term used to describe a diseased liver that has been severely scarred, usually due to many years of continuous injury.
The liver performs many functions that are essential to life including:
Cleansing toxins from the blood
Metabolising medications Producing blood proteins that are essential for normal blood clotting
Manufacturing albumin, a protein that is required for maintaining normal fluid balance in the body
Producing bile that is required for digestion of dietary fat
The liver is able to repair itself when it has been injured as a result of diseases like hepatitis. The process of healing involves the creation of scar tissue. Thus, repeated or continuous injury to the liver (such as occurs with heavy alcohol use) can cause significant scarring in the liver. The body is able to tolerate a partially scarred liver without serious consequences. Eventually, the scarring can become so severe that the liver is no longer able to perform its normal functions.
Causes
Cirrhosis has many causes. It is important to determine the cause of cirrhosis because the treatment and outcome of underlying conditions can vary. In most cases, the cause of cirrhosis can be identified.
In about five percent of patients, it is not possible to identify the cause; such patients are said to have idiopathic cirrhosis.
Some of the most common causes of cirrhosis include:
Longstanding alcohol abuse
Chronic hepatitis (B or C)
Other causes include:
Non-alcoholic steato hepatitis or NASH (a condition in which fat and scar tissue accumulate in the liver)
Hemochromatosis (a condition in which there is too much iron in the body)
Autoimmune hepatitis (a condition in which the body’s immune system recognises the liver as foreign)
Wilson’s disease (a rare disease of copper metabolism)
Signs and symptoms
People with cirrhosis may have symptoms related to the underlying cause of the liver disease, symptoms directly related to the cirrhosis, or no symptoms at all.
Symptoms due to cirrhosis — A common symptom is fatigue but many people with early cirrhosis have few or no symptoms. As the cirrhosis progresses, symptoms develop because the liver is no longer able to perform its normal functions. The rate at which symptoms develop depends upon the underlying liver disease, treatments used, and individual factors.
In some patients, symptoms do not develop for years, even after the liver has become cirrhotic. In others, symptoms never develop because the cause of the liver disease is eliminated.
Scarring makes it difficult for blood to flow through the liver. As a result, veins in other parts of the body outside of the liver become abnormally expanded. Abnormally expanded blood vessels are referred to as varices.
One place where varices are commonly found is in the esophagus, the swallowing tube connecting the mouth with the stomach. When the pressure in the varices reaches a certain level, the varices can burst, which can cause massive bleeding (known as variceal bleeding).
Body fluids accumulate as a result of liver scarring and a decreased ability to manufacture blood proteins. Fluid is typically seen in the legs (oedema) and abdomen (ascites) and sometimes in the lung (pleural effusion).
Ascites causes the abdomen to enlarge, which can cause shortness of breath and a feeling of fullness. The ascitic fluid provides an environment where bacteria can grow, increasing the risk of infection.
Patients with cirrhosis are at risk of easy bruising and bleeding. This is a result of two problems:
- First, levels of the blood cells (platelets) that are essential to form clots can be severely decreased.
- Second, certain blood proteins made by the liver (called clotting factors) are decreased.
Once bleeding starts (such as with variceal bleeding), it can be severe.
Hepatic encephalopathy is a condition that develops when the liver is unable to break down toxins normally found in the bloodstream, such as ammonia. In this condition, confusion or even coma are caused by toxins that build up in the blood. In the early stages, a patient may experience mild symptoms, such as difficulty sleeping or sleeping too much. Advanced hepatic encephalopathy can cause confusion, delirium, and even coma. Hepatic encephalopathy can develop suddenly and may become a medical emergency. Hospitalisation is usually required for initial treatment of severe confusion or coma.
Patients with cirrhosis have decreased function of their immune system and are therefore at increased risk of bacterial infections. Malnutrition is common in patients with cirrhosis. Malnutrition can cause loss of muscle in various areas of the body. Many patients with advanced cirrhosis have jaundice. The degree of jaundice can be measured with a laboratory value called the total bilirubin. Normally, the total bilirubin in blood should be less than 1 mg/dL. Once the bilirubin reaches 3 mg/dL, the whites of the eyes become yellow. Higher levels often causes yellowing of the skin.
People with cirrhosis are at increased risk for developing liver cancer (hepatocellular carcinoma). The risk depends in part upon the underlying cause of cirrhosis.
Diagnosis
Several tests are used to confirm the diagnosis of cirrhosis and to determine the underlying cause. Other tests are useful for determining the severity of cirrhosis and for monitoring complications.
Liver biopsy — The best way to confirm the diagnosis of cirrhosis is by obtaining a small piece of tissue from the liver with a special needle (a liver biopsy).
Imaging tests — A variety of imaging tests, such as an ultrasound scan, CT scan, or MRI, can suggest that a person has cirrhosis. These tests describe the appearance of the liver or related complications, such as varices or ascites. However, these tests are not used to diagnose cirrhosis, and cannot replace a liver biopsy.
Physical examination — Patients with cirrhosis may have several physical signs of their condition. These include one or more of the following: Jaundice (yellow skin and whites of the eyes), a distended, fluid-filled abdomen (ascites),an enlarged liver or spleen, oedema (swelling, mostly of the legs), enlarged breast tissue (in men), redness of the palms (palmar erythema) .
Laboratory tests — Laboratory tests often reveal abnormal blood chemistries, low protein counts, low platelet counts, and increased bilirubin. However, these tests may be normal in people with early cirrhosis. Laboratory testing can often reveal the specific underlying cause of cirrhosis.
There are several other laboratory tests that are being developed that can allow for the diagnosis of cirrhosis without a liver biopsy ( eg. liver fibroscan). They are not yet widely available.
Treatment
There have been major advances in the treatment of cirrhosis in the past few decades. In particular, the ability to recognize complications of cirrhosis has led to improved treatments aimed at preventing them. One of the biggest advances in cirrhosis treatment is liver transplantation, a procedure in which the diseased liver is replaced with a new healthy liver.
Some of the other advances include: Use of medications (such as beta blockers) to reduce the pressure inside varices to decrease the risk of variceal bleeding.
The development of treatments for hepatic encephalopathy.
The development of treatments for underlying liver disease. Some of these treatments may even reverse cirrhosis when it is in its early stages.
Patients with cirrhosis should be seen regularly by their healthcare provider, who will monitor for complications. In most cases, the following measures are recommended:
Vaccination
Patients with cirrhosis are typically vaccinated against hepatitis A and B. Pneumococcal vaccine and yearly influenza vaccine are often recommended.
Avoid substances that can injure the liver
Patients with cirrhosis should avoid consuming substances that can further damage the liver. The most common of these is alcohol. Patients should also check with their healthcare provider before taking any new medication (prescription, nonprescription, herbal, vitamins, supplements).
Screen for and treat varices
Patients with cirrhosis should undergo an upper endoscopy to determine if varices (expanded blood vessels) are present in the esophagus, the tube that connects the mouth and stomach.
Treat ascites and edema
Ascites and edema can lead to complications, particularly infection. Ascites can also cause a person to feel short of breath or full. Thus, treatment is usually recommended to reduce the amount of fluid that collects in the lower legs and abdomen. Treatment usually involves taking one or more diuretic pills (fluid pills) and following a low sodium (salt) diet.
Some patients do not get adequate relief with fluid pills alone. Such patients often require periodic drainage of the fluid (paracentesis). This is done by inserting a needle into the abdomen and withdrawing fluid from the space around the abdominal organs.
TIPS
A TIPS (transjugular intrahepatic portosystemic shunts) procedure may be recommended to treat ascites if diuretics, paracentesis, and changes in diet are not completely successful in relieving ascites. During the procedure, a radiologist places a device within the liver to reduce the blood pressure in the portal vein. The procedure is usually performed with local anaesthesia and sedation.
Screen for liver cancer— Patients with cirrhosis should have screening tests to detect hepatocellular carcinoma (cancer of the liver). Screening usually requires the patient to have an ultrasound examination of the liver and a blood test every 6 to 12 months.
Screen for encephalopathy — Patients with cirrhosis can develop confusion, which is sometimes subtle. A change in the sleep pattern (insomnia or sleeping too much) may be an early sign. Detecting confusion is important since treatment is available and the confusion itself can lead to serious problems (eg, an automobile accident).
Dietary advice — Patients with advanced cirrhosis may require specialized diets that include lower amounts of salt. Salt restriction is usually recommended for patients with early cirrhosis who tend to accumulate fluid. It is important to eat a healthy diet with adequate calories and nutrient-rich foods.
Exercise — Exercise is generally safe for people without advanced stage cirrhosis. Exercise may increase the risk of variceal bleeding in patients with advanced disease (such as those who have ascites or varices).
Liver transplantation
Consider liver transplantation — Not all patients with cirrhosis will require a liver transplantation, and many are not eligible for one.
Liver transplantation involves the replacement of a diseased liver with a healthy liver. The majority of donated livers come from people who have suffered brain death for one reason or another. More recently, living donors have been able to donate a portion of their liver.
Approximately 80 percent of people will be alive one year after liver transplantation, and the majority of these will be alive five years after transplantation. This is compared to almost certain death in patients with very advanced cirrhosis who do not receive a transplant.
The prognosis after transplantation depends in part upon the underlying cause of the liver disease, some of which recur following transplantation. As an example, most patients who undergo transplantation for hepatitis C will develop recurrent hepatitis C after transplantation. A major problem is that the recurrent disease tends to progress relatively quickly in those with a transplanted liver when compared to hepatitis C in patients who have not undergone transplantation.
Other major concerns following transplantation are the risk of powerful drugs used to suppress the immune system, which have many side effects, and the risk of rejection of the transplanted organ.
The transplantation process is elaborate, involving an extensive screening process for eligibility. Thus, not all patients with cirrhosis are eligible, and only those with the most advanced, severe cirrhosis are placed on the transplant registry. Furthermore, not all patients with cirrhosis will require a transplantation since the disease can remain relatively stable for many years, particularly if the cause of the cirrhosis (eg, alcohol) is eliminated.
New treatments
Treatments for various causes of liver disease are rapidly being developed, some of which may be helpful even after the disease has progressed to cirrhosis. For example, the use of pegylated interferon plus ribavirin in patients with hepatitis C. The treatment is not successful in all patients with hepatitis C, but in those whose virus can be eliminated, the liver’s function can substantially improve while the degree of scarring lessens.
Another exciting avenue of research is the development of drugs that are aimed at slowing or reversing the processes leading to cirrhosis. These treatments have the potential to prevent some of the complications of liver disease, even if the underlying cause cannot be eliminated. Unfortunately, these drugs are still many years away from being commercially available.
Family implications
A diagnosis of cirrhosis can be difficult for a patient’s family. Thus, it is important that close family members learn as much as possible about the diagnosis and available treatments. Family members may be at an increased risk of liver disease, depending upon the cause of the cirrhosis and should be tested for hepatitis B or C if these infections are the cause of cirrhosis. In addition, some forms of liver disease, such as Wilson’s disease and hemochromatosis, are inheritable and thus may require specific testing in family members.