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CIRRHOSIS

Cirrhosis is scarring of the liver caused by continuous, long-term liver damage.

Scar tissue replaces healthy tissue in the liver and prevents the liver from working properly.

The damage caused by cirrhosis is irreversible and can eventually become so extensive which may lead to liver failure.

Cirrhosis can be fatal if the liver fails. However, it usually takes years for the condition to reach this stage and treatment can help slow its progression.

Symptoms of cirrhosis 

There are usually few symptoms during the early stages of cirrhosis. Noticeable problems tend to develop as the liver becomes more damaged.

In its early stages, the liver is able to function properly despite being damaged. As the condition progresses, symptoms tend to develop when functions of the liver are affected.

Symptoms of cirrhosis can include:

  • tiredness and weakness
  • loss of appetite
  • weight loss and muscle wasting
  • feeling sick (nausea) and vomiting
  • tenderness or pain around the liver area
  • tiny red lines (blood capillaries) on the skin above waist level
  • very itchy skin
  • jaundice or the yellowish discoloration of the skin and eyes
  • bleeding tendencies
  • hair loss
  • fever and shivering attacks
  • edema or swelling of the legs, ankles and feet due to fluid accumulation
  • ascites or swelling of the abdomen (tummy), due to a build-up of fluid

Also noticeable changes in personality, sleep-wake cycles, level of conciousness and ability to concentrate maybe observed. This is known as encephalopathy and occurs when toxins accumulate and affect the brain due to failure of the liver to detoxify and excrete these substances.

Late-stage symptoms

In the later stages of cirrhosis, gastrointestinal bleeding due to varices may occur as evidenced by vomiting blood or passing tarry, black stools. There is an increased tendency to bleed spontaneously from these sites since blood can’t flow through the liver due to an increased hepatic venous portal pressure (or pressure in the veins of the liver that caries the blood from the gut to the liver).

The increase in blood pressure forces blood through smaller, fragile vessels that line your stomach and gullet (varices). These can burst under high pressure, leading to internal bleeding, which is visible in vomit and/or stools.

Over time, the toxins that would normally be removed from the body by a healthy liver can cause multiple organ failure, followed by death.

Diagnosing cirrhosis 

If cirrhosis is suspected, a detailed medical history must be extracted along with a thourough physical examination to evaluate for signs of chronic liver disease.

A series of test is requested to confirm the diagnosis

Tests

You may have a number of different tests including those described below.

Blood tests

Blood tests may be done to assess liver function and the severity of liver damage. A blood test may be used to measure the levels of the liver enzymes alanine transaminase (ALT) and aspartate transferase (AST) , as these will be raised in the presence of inflammation of the liver (hepatitis).

Scans

Different imaging procedures may be done to visualize the liver such as ultrasonography, transient elastography scan, computerised tomography (CT) scan or a magnetic resonance imaging (MRI) scan. A transient elastography scan is similar to an ultrasound scan carried out during pregnancy (it’s sometimes known as a Fibroscan). These scans can produce detailed images of the liver or check liver stiffness to identify any scarring.

Liver biopsy

A liver biopsy isdone with a fine needle which is inserted into the body (usually between the ribs) to obtain a small sample of liver cells. The sample is sent to a laboratory so it can be examined under a microscope.

The biopsy is usually carried out under local anesthesia, as an outpatient or with an overnight stay in hospital. The outcome of the biopsy will confirm a diagnosis of cirrhosis and may provide more information about the cause. However, transient elastography is increasingly being used as an alternative to a biopsy in the diagnosis of cirrhosis.

Endoscopy

Endoscopy is where an endoscope is passed down the throat and into the stomach.

Images of the oesophagus (tube from your throat to your stomach) and stomach are transmitted to an external screen where any varices (swollen vessels) may be seen.

Grading

There are several different grading systems for cirrhosis according to its severity. One system is the Child-Pugh score which is based on physical examination findings and laboratory tests, grades cirrhosis from A (relatively mild) to C (severe).

An alternative system called model of end-stage liver disease (MELD) uses the results of a blood test to help identify people who need an urgent liver transplant.

 

Treating cirrhosis 

Cirrhosis can’t be cured, so treatment aims to manage the symptoms and any complications and stop the condition getting worse.

It’s usually not possible to reverse liver damage that’s already occurred, although recent research suggests this may eventually be possible in cases where the underlying cause of the liver damage can be successfully treated.

Treatment is likely to take place at a hospital with a specialized hepatology unit, which treats disorders of the liver, gall bladder and biliary ducts.

Stopping cirrhosis getting worse

Taking medication to treat the underlying cause of the liver damage and making healthy lifestyle changes can help stop cirrhosis getting worse and reduce risk of developing further health problems.

Medication

Medication will depend on the cause of damage to the liver.

Such as that in viral hepatitis, anti-viral drugs are given. In autoimmune hepatitis, corticosteroids are given to suppress the immune system from attacking the liver.

Lifestyle changes

Lifestyle modification to stay healthy and reduce further problems include:

  • complete cessation of alcohol intake regardless the etiology, as alcohol consumption increases the rate at which the condition progresses
  • weight loss for overweight and obese individuals
  • regular exercise to reduce muscle wasting
  • practise good hygiene to reduce your chances of developing infections
  • updating vaccination schedules,  such as the annual flu vaccine or travel vaccines
  • before taking any medications, consult with a general practitioner should be done to evaluate if the drug is safe for individuals with liver disease

Malnutrition is common in people with cirrhosis, so it’s important to ensure a balanced diet to get all the nutrients needed.

Restricting salt intake can help reduce the swelling in the legs, feet and abdomen caused by a build up of fluid.

Liver damage will affect it’s ability to store glycogen, a carbohydrate that provides short –term energy. This resluts in muscle breakdown or wasting to provide energy between meals. Therefore, extra calories and protein are needed in the diet.

Healthy snacking between meals can top up calories and protein. It may also be helpful to eat three or four small meals a day, rather than one or two large meals.

Easing symptoms

A number of treatments can ease the symptoms of cirrhosis, including:

  • a low-sodium (salt) diet or tablets called diuretics to reduce the amount of fluid in your body
  • tablets to reduce portal vein pressure and prevent or treat any infection
  • creams to reduce itching

Managing complications of advanced cirrhosis

In cases of advanced cirrhosis, complications caused by the condition may need treatment.

Swollen varices

If blood is present in the vomitus, or stools are noted to have blood or are tarry, varices are likely to be present in the esophagus (the tube that transmits food from the pharynx to the stomach).

Urgent medical attention is required. Immediate consult with the doctor in the emergency department of the nearest hospital is necessary.

Certain procedures can help stop the bleeding and reduce the risk rebleeding, such as:

  • Banding – an endoscopy is carried and a small band is placed around the base of the varices to help control the bleeding.
  • Injection glue therapy – following an endoscopy, a type of medical “super glue” is injected into the varices to make the blood clot, which helps stop the bleeding.
  • A Sengstaken-Blakemore tube with a balloon on the end – a special tube is passed down the throat into the stomach and the balloon is inflated. This puts pressure on the varices and helps stop the bleeding.
  • A transjugular intrahepatic portosystemic stent shunt (TIPSS)– a metal tube called a stent is passed across the liver joining two large veins (the portal vein and hepatic vein). This creates a new route for your blood to flow through, therefore relieving the pressure that causes the varices.

A beta-blocker, such as propanolol, may be given to reduce the risk of bleeding or reduce the severity of any bleed that does occur.

Fluid in the tummy and legs

Ascites (a build-up of fluid in the abdomen) and peripheral oedema (fluid around your legs and ankles) are common complications of advanced cirrhosis. Immediate attention is warranted.

Accumulation of around 20 to 30 litres of free water in the abdominal area will cause difficulty in breathing and early satiety. The main treatments for ascites and oedema are restricting sodium (salt) in the diet and taking diuretic tablets, such as spironolactone or furosemide.

Infection may occur in the presence of ascites, and antibiotic theray may be recommended. Alternatively, antibiotics may be used on a regular basis to prevent infection in people at high risk.

In severe cases of ascites, tubes may be used to drain the fluid from the abdomen. This will usually be repeated every few weeks.

Encephalopathy

Disturbance with normal brain function (encephalopathy) may occur due to the accumulation of toxins normally eliminated by the liver.

The main treatment for encephalopathy is lactulose syrup. This acts as a laxative (it helps clear the bowels) and helps the body remove the toxins that build up in the body when the liver is failing. In some cases, other laxatives or an enema may be used.

Bleeding

Liver failure will affect the ability of the liver to synthesize facotrs needed for normal blood clotting, leading to the increased risk for bleeding. Vitamin K and a blood product called plasma can be given in emergencies.

Therefore, consulting a medical practitioner is recommended before going through medical procedures, including dental work.

Liver transplant

The liver may be severely damaged by scarring. And a liver transplant may be necessary. It is a major procedure that involves removing the diseased liver and replacing it with a healthy donor liver.

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