What is Cirrhosis?

The process known as cirrhosis can affect several organs in the body but it is most often associated with the liver. Several different diseases may affect the liver resulting in liver cirrhosis.

Whatever the cause, liver cirrhosis can be a serious problem as it destroys normal liver cells called hepatocytes and replaces these cells with dead, fibrous, scar tissue (fibrosis). This has several implications. The major problem is that fewer and fewer hepatocytes are left in the liver and therefore, liver function deteriorates. This may initially go unnoticed, as the liver has a huge reserve capacity. But as more and more hepatocytes are replaced with scar tissue, eventually, the liver is unable to meet the body’s demands and symptoms of liver failure then develop. Secondly, as scar tissue increases, there is disruption of normal blood flow through the hepatic circulation. This creates a back pressure effect on the blood vessels which supply blood to the liver.

Cirrhosis generally occurs slowly but progresses during many months or years to destroy healthy liver cells unless the underlying cause is treated. Initially, there may be no symptoms, then mild, non-specific symptoms may develop before eventually, symptoms of liver failure ensue. Although progression may be halted by treating the underlying cause, the damage already done to the liver is irreversible. If the damage is too severe and liver failure develops, the only solution may then be a liver transplant.

In the UK, the main causes of liver cirrhosis are alcohol abuse (see “Alcoholic Liver Cirrhosis” for further details) and hepatitis C infection (see “Hepatitis C” for further details). But, worldwide, other conditions such as hepatitis B may be more of a risk.

SYMPTOMS AND SIGNS OF LIVER CIRRHOSIS

Depending on many different factors, patients may suffer from 1 or 2 mild symptoms, or several serious symptoms and/or signs. The possible symptoms are listed below;

• None: liver disease may be found incidentally,
• A feeling of being unwell,
• Fatigue,
• Nausea,
• Vomiting,
• Diarrhoea,
• Weight loss,
• Dry eyes and mouth,
• Red or pink, blotchy, mottled patches on the palms of hands (palmer erythema),
• Abnormal small blood vessels on the surface of the skin, mainly on the face, chest and arms (spider naevi),
• Abdominal pain or discomfort,
• Itching of skin,
• Enlargement of the liver (hepatomegaly),
• Jaundice: yellowing of the skin and whites of the eyes,
• Passing dark urine: associated with jaundice,
• Passing pale or clay coloured stools: associated with jaundice,
• Bruising,
• Bleeding from any site e.g. gums, nose, wounds, rectum, vagina,
• Abdominal distension from fluid collecting in the abdomen (ascites),
• Vomiting of blood (haematemesis), from oesophageal varices,
• Confusion and an altered level of consciousness (hepatic encephalopathy),
• Coma,
• Death.

COMPENSATED AND DECOMPENSATED CIRRHOSIS

Cirrhotic liver patients can be divided into 2 groups; those with compensated cirrhosis and those with decompensated cirrhosis. Compensated cirrhotics have no complications and so are easier to treat and tend to have a good prognosis providing they stop drinking alcohol. Liver disease does not progress in this instance.

Those with decompensated cirrhosis have serious complications and are much more challenging to manage. The problems which may arise include;

1. Bleeding Oesophageal Varices

As cirrhosis develops, the blood circulation through the liver is disrupted. As a result, back pressure in the vessels that supply the liver with blood is created. This back pressure leads to the protrusion of varices (varicose vein like vessels) in the gullet (oesophagus). These may bleed heavily and this bleeding can be very difficult to control. Patients must be rushed into hospital for an endoscopy to be carried out. This enables the vessels to be isolated and the bleeding stopped. But, despite this, many patients lose too much blood and die of shock. In those that survive, medicines such as beta-blockers (propranolol) are given which reduce the risk of further bleeding.

Some patients may undergo a “diagnostic” endoscopy. This is when there has been no bleeding. Varices may still be found. Beta-blockers can be started with the hope of reducing the risks of any future bleed occurring.

2. Acsites

This is a build up of fluid in the abdominal cavity. It can cause abdominal swelling (distension) and discomfort. Treatment for acsites involves a low salt diet, reduced fluid intake, treatment with a medicine called a diuretic (a water tablet) and drainage of the fluid from the abdomen using catheters or special drainage tubes in a process called paracentesis.

3. Hepatic Encephalopathy

This complication occurs as patients become confused and have altered levels of consciousness. Encephalopathy usually happens when there is serious liver damage as a result of which several other problems occur. These may include changes to the salt and electrolyte balance in blood, bleeding from the gullet, stomach or intestines, constipation, the presence of infections or the over use or inappropriate use of medication such as pain killers or sedatives.

The key biochemical change that is thought to cause encephalopathy is an increased level of ammonia in the brain. Treatment of encephalopathy therefore involves treating the underlying reason for the encephalopathy such as treating infections or controlling bleeding and reducing ammonia levels. Ammonia may be reduced by giving lactulose syrup which is a laxative. Lactulose decreases the production of ammonia in the gut and also its absorption into the blood circulation. Therefore, lactulose may need to be taken over the longer term to prevent hepatic encephalopathy.

THE CAUSES OF CIRRHOSIS

There are many causes of cirrhosis. Most are related to liver disease although some conditions primarily affect other organs initially. Examples include;

• Autoimmune Hepatitis: please read “Autoimmune Hepatitis” for further details,

• Alcoholic Liver Disease: please read “Alcoholic Liver Disease” for further details,

• Viral Hepatitis: Please read “Hepatitis A”, “Hepatitis B” and “Hepatitis C” for further details,

• Genetic conditions such as Haemochromatosis (an excess of iron build up in the liver and other organs), Wilson’s Disease (an excess of copper build up in the liver and other organs) and several others,

• Biliary Tract Obstruction: from diseases such as cancer of the bile ducts or pancreas, Primary Biliary Cirrhosis (PBC) or Primary Sclerosing Cholangitis (PSC). Please read the appropriate pages for further details regarding these conditions,

• Heart Failure: causing high blood pressure and congestion of the liver,

• Exposure to certain medicines, especially in overdose or misuse,

• Exposure to many toxins or poisons.

DIAGNOSING LIVER CIRRHOSIS

Depending on the symptoms you complain of and the signs detected by your doctor, several tests can be done in order to gauge your liver function. A blood test is quick and simple but can measure many useful parameters which can suggest liver damage. Mainly, this is done by the measurement of;

• Bilirubin: the by-product of the continual turn over of red blood cells,
• Alkaline phosphatase (AP): can indicate an obstruction in the biliary tract,
• Albumin: a circulating protein in the blood,
• Alanine aminotransferase (ALT or SGPT): a liver enzyme,
• Aspartate aminotransferase (AST or SGOT): a liver enzyme,
• Gamma GT: a liver enzyme,
• INR or clotting screen: to determine the ability of the blood to clot properly,
• And many others.

An ultrasound can be arranged. This will enable the sonographer (a doctor or specialist ultrasound scan operator) to visualise the shape, size and texture of the liver, other abdominal organs and determine whether any masses are present within the liver.

Further detailed scanning with CT or MRI scanners can visualise other aspects of the liver structure in more detail. Ultimately, a liver biopsy may be required to establish the diagnosis of cirrhosis and also its extent. A biopsy is when a small piece of living tissue is removed from an organ for analysis under a microscope. This can be done in 3 ways;

1. Percutaneous Liver Biopsy

This can be done unguided or guided by ultrasound. After the position of the liver has been established, a local anaesthetic is injected into the skin. This is usually done over the upper right side abdomen or between the lower ribs. After the skin is numb, the doctor makes a small incision into the skin and inserts a needle (sometimes called a Trucut) into the wound. This is inserted into the liver and removed. It will contain a small sample of liver tissue.

2. Laparoscopic Liver Biopsy

This is usually done under general anaesthetic. With this approach, a small thin tube containing a light and camera is inserted into the abdomen. Through a separate small incision, another instrument is used to target specific areas of the liver to collect samples which are then removed.

3. Transjugular Liver Biopsy

This approach is sometimes used when a patient has severe clotting problems or when there is fluid in the abdomen. It is done in an X-ray unit. A catheter is inserted into a vein in the neck. This is then guided to the liver. A biopsy needle is then passed through the catheter until it travels down to the liver. A sample of liver tissue is then obtained and removed. This is generally a less risky approach compared to the percutaneous approach.

TREATMENT OF LIVER CIRRHOSIS

There is no cure for this. Treatment aims are to halt the progress of cirrhosis by treating the cause of the cirrhosis itself and by treating the symptoms and complications of cirrhosis as and when they arise. Occasionally, preventative measures can be taken. For example, an endoscopy may reveal the presence of oesophageal varices before they bleed. These can therefore be treated.

Regardless of the cause of cirrhosis, patients are always advised to stop drinking alcohol. All medicines the patient takes are reviewed as some may be unsafe in these instances. These include simple over-the-counter products such as paracetamol and cold & flu remedies.

Despite the many supportive measures that may be employed, if the underlying cause is not or cannot be treated, then cirrhosis will continue to progress. Liver transplantation may then be the only option.

HOW CAN CIRRHOSIS BE PREVENTED?

The main factor here is to try to avoid the underlying causes of cirrhosis. Some causes such as alcohol abuse and infections like hepatitis may be avoidable whereas genetic or metabolic problems are unavoidable. Therefore, advice regarding sensible drinking must be heeded. Medication which patients take must be disclosed to a doctor or pharmacist, especially if patients already suffer from some form of liver disease. Occupational risk factors for hepatitis B must be reduced. For these individuals, vaccinations for hepatitis B should be strongly encouraged. Hepatitis A should be avoided by not eating or drinking contaminated food or water. If traveling to high risk areas, this advice should be adhered to strictly. Both hepatitis B and C may be contracted though unprotected sexual intercourse, the sharing of dirty drug injecting equipment and transfusions of blood which have not been screened. Fortunately, most countries now screen donated blood for all blood borne infections prior to making it available for transfusion. Some centres will also allow autotransfusions where patients themselves donate blood in advance of surgery. Their own blood is then transfused back into themselves as required. Clearly, sexual behaviour should be modified to reduce these risks and the use of injectable street drugs should be avoided totally.