Cirrhosis

Cirrhosis is a late-stage liver disease in which healthy liver tissue is replaced by scar tissue, permanently damaging the liver and preventing it from functioning properly. The liver is a vital organ responsible for many critical functions, including filtering toxins from the blood, producing proteins for blood clotting, and metabolizing nutrients. When cirrhosis occurs, the extensive scarring obstructs blood flow through the liver, impairing its ability to perform these essential tasks. This progressive scarring can be caused by various factors, most commonly chronic alcohol abuse and chronic viral hepatitis. Cirrhosis is irreversible and can lead to liver failure, a life-threatening condition.

Causes:

Cirrhosis is the result of long-term and continuous damage to the liver from various underlying conditions. The liver attempts to repair itself after injury, but over time, this leads to the formation of scar tissue instead of healthy cells.

• Chronic Alcohol Abuse:
  • One of the most common causes in Western countries. Excessive alcohol consumption can damage liver cells, leading to inflammation (alcoholic hepatitis) and eventually cirrhosis.
• Chronic Viral Hepatitis:
  • Hepatitis B and Hepatitis C: These viral infections can cause chronic inflammation and damage to the liver over many years, leading to cirrhosis. Hepatitis C is a leading cause of cirrhosis and liver transplantation worldwide.
• Non-Alcoholic Steatohepatitis (NASH):
  • A severe form of non-alcoholic fatty liver disease (NAFLD), where fat builds up in the liver, leading to inflammation and liver cell damage. It is often associated with obesity, diabetes, high cholesterol, and metabolic syndrome. NASH can progress to cirrhosis.
• Autoimmune Hepatitis:
  • A condition where the body’s immune system mistakenly attacks and damages liver cells, causing inflammation and scarring.
• Bile Duct Diseases:
  • Primary Biliary Cholangitis (PBC): A chronic disease that destroys the small bile ducts in the liver.
  • Primary Sclerosing Cholangitis (PSC): Inflammation and scarring of the large bile ducts.
  • Both lead to bile backup, liver damage, and cirrhosis.
• Genetic (Inherited) Diseases:
  • Hemochromatosis: A disorder causing excessive iron absorption and buildup in the liver.
  • Wilson’s Disease: A disorder causing excessive copper accumulation in the liver.
  • Alpha-1 Antitrypsin Deficiency: A genetic disorder that can lead to liver damage.
• Certain Drugs and Toxins:
  • Prolonged use of certain medications (e.g., methotrexate, amiodarone) or exposure to environmental toxins can cause liver damage leading to cirrhosis.
• Chronic Heart Failure: Severe, long-standing right-sided heart failure can cause blood to back up into the liver, leading to liver congestion and eventually cirrhosis (cardiac cirrhosis).

Symptoms:

In its early stages, cirrhosis often has no signs or symptoms. As liver function worsens, a wide range of symptoms can appear, affecting multiple body systems.

• Early Symptoms (often vague):
  • Fatigue and weakness.
  • Nausea and loss of appetite.
  • Unexplained weight loss.
  • Itching.
  • Vascular spiders (spider angiomas – small, red, spider-like blood vessels on the skin).
• Later Symptoms (as liver function declines):
  • Jaundice: Yellowing of the skin and eyes, and dark urine, due to bilirubin buildup.
  • Edema and Ascites: Swelling in the legs (edema) and abdomen (ascites) due to fluid retention and reduced production of albumin (a blood protein).
  • Easy Bruising and Bleeding: Due to decreased production of clotting factors by the liver.
  • Hepatic Encephalopathy: Accumulation of toxins (like ammonia) in the brain, leading to confusion, memory problems, personality changes, slurred speech, and in severe cases, coma.
  • Portal Hypertension: Increased pressure in the portal vein (which carries blood to the liver), leading to:
    • Enlarged spleen (splenomegaly).
    • Varices (enlarged veins) in the esophagus or stomach, which can rupture and cause life-threatening bleeding.
  • Kidney Dysfunction (Hepatorenal Syndrome): A severe complication where kidney function rapidly declines.
  • Increased Sensitivity to Medications: Due to the liver’s reduced ability to metabolize drugs.
  • Liver Cancer (Hepatocellular Carcinoma): Cirrhosis is a major risk factor for liver cancer.
  • Muscle Wasting (Cachexia).
  • Asterixis (“Flapping Tremor”): A tremor of the hand when the wrist is extended, often seen with hepatic encephalopathy.

Diagnosis:

Diagnosing cirrhosis involves a combination of medical history, physical examination, blood tests, and imaging studies. A liver biopsy is often used to confirm the diagnosis and assess the extent of scarring.

• Medical History and Physical Exam: The doctor will inquire about alcohol use, medical conditions (e.g., hepatitis, diabetes), and symptoms. The exam may reveal jaundice, ascites, spider angiomas, or an enlarged liver/spleen.
• Blood Tests:
  • Liver Function Tests (LFTs): Elevated AST, ALT (liver enzymes), bilirubin, and prolonged prothrombin time (PT/INR) indicate liver damage and impaired function.
  • Albumin Levels: Low albumin suggests impaired liver synthesis.
  • Complete Blood Count (CBC): May show anemia or low platelet count.
  • Tests for Underlying Causes: Such as hepatitis B/C viral markers, autoimmune antibodies, iron studies (for hemochromatosis), copper levels (for Wilson’s disease).
• Imaging Tests:
  • Ultrasound: Can show liver size, texture, presence of fatty liver, ascites, and portal vein flow.
  • CT Scan (Computed Tomography) or MRI (Magnetic Resonance Imaging): Provide more detailed images of the liver, spleen, blood vessels, and can detect liver masses.
  • Transient Elastography (FibroScan): A non-invasive test that measures liver stiffness, which correlates with the degree of fibrosis/scarring.
• Liver Biopsy:
  • Considered the gold standard for confirming cirrhosis and determining its cause and severity. A small sample of liver tissue is removed and examined under a microscope.
  • Less frequently used now with advancements in non-invasive tests, but still important in certain cases.

Treatment:

Treatment for cirrhosis focuses on slowing the progression of liver damage, managing symptoms and complications, and preventing further deterioration. In advanced stages, a liver transplant may be the only option.

• Treating the Underlying Cause:
  • Alcohol Abstinence: Essential for alcoholic cirrhosis.
  • Antiviral Medications: For chronic hepatitis B or C.
  • Weight Loss and Lifestyle Changes: For NAFLD/NASH.
  • Immunosuppressants: For autoimmune hepatitis.
  • Chelation Therapy: To remove excess iron (hemochromatosis) or copper (Wilson’s disease).
  • Medications to Treat Bile Duct Diseases: (e.g., ursodeoxycholic acid for PBC).
• Managing Complications:
  • Diuretics: To reduce fluid retention (ascites, edema).
  • Dietary Sodium Restriction: To help manage fluid retention.
  • Lactulose and Rifaximin: For hepatic encephalopathy (to reduce ammonia levels).
  • Endoscopic Band Ligation or Sclerotherapy: To treat esophageal varices and prevent bleeding.
  • Beta-Blockers: To reduce portal hypertension.
  • Paracentesis: Removal of large amounts of fluid from the abdomen (ascites) using a needle.
  • Transjugular Intrahepatic Portosystemic Shunt (TIPS): A procedure to create a shunt within the liver to reduce portal hypertension, used for refractory ascites or bleeding varices.
  • Regular Screening for Liver Cancer: (Ultrasound and alpha-fetoprotein blood tests) every 6 months.
• Nutritional Support: Maintaining adequate nutrition is crucial. A balanced diet, sometimes with specific protein adjustments for encephalopathy, is recommended.
• Liver Transplantation:
  • For end-stage cirrhosis where the liver has failed and other treatments are no longer effective.
  • This is a complex procedure with strict eligibility criteria.

Living with cirrhosis requires close monitoring and multidisciplinary care. Regular follow-up with a hepatologist (liver specialist) is essential to manage the condition and improve prognosis.