Definition
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.
Epidemiology
Each year, approximately one million deaths are due to complications of cirrhosis, making cirrhosis the 11th most common cause of death globally. Cirrhosis and chronic liver disease were the tenth leading cause of death for men and the twelfth for women in the United States in 2001, killing about 27,000 people each year.
Stages of Cirrhosis
Cirrhosis in itself is already a late stage of liver damage. In the early stages of liver disease there will be inflammation of the liver. If this inflammation is not treated it can lead to scarring (fibrosis). At this stage it is still possible for the liver to heal with treatment.
If fibrosis of the liver is not treated, it can result in cirrhosis. At this stage, the scar tissue cannot heal, but the progression of the scarring may be prevented or slowed. People with cirrhosis who have signs of complications may develop end-stage liver disease (ESLD) and the only treatment at this stage is liver transplantation.
Stage 1: It involves some scarring of the liver, but few symptoms. This stage is considered compensated cirrhosis, where there are no complications.
Stage 2: It includes worsening portal hypertension and the development of varices.
Stage 3: It involves the development of swelling in the abdomen and advanced liver scarring. This stage marks decompensated cirrhosis, with serious complications and possible liver failure.
Stage 4: It can be life threatening and people have develop end-stage liver disease (ESLD), which is fatal without a transplant.
Cirrhosis risk factors
A number of factors increase the risk of developing cirrhosis of the liver. Risk factors include:
- Alcohol dependence and alcoholism
- Chronic hepatitis B, C or D
- Coronary artery disease (due to atherosclerosis or hardening of the arteries, or other causes)
- Diabetes (chronic disease that affects your body’s ability to use sugar for energy)
- Exposure to certain toxins such as arsenic
- High triglyceride blood levels
- Intestinal bypass surgery
- Long-term treatment with corticosteroids
- Obesity
Reducing your risk of developing cirrhosis of the liver
Not all people who are at risk of cirrhosis of the liver will develop the condition. However, you can significantly lower your risk of developing cirrhosis of the liver by:
- Avoiding risk factors for hepatitis, such as having unprotected sex with more than one partner, or sharing needles for tattooing or drug use
- Not drinking alcohol, or limiting alcohol intake to one drink per day for a woman and two drinks per day for a man
- Seeking regular medical care and following your treatment plan for chronic diseases and conditions, such as diabetes, obesity, high cholesterol, high blood pressure, and coronary artery disease
Causes of Cirrhosis
The most common causes of cirrhosis include heavy alcohol consumption and chronic hepatitis C. Due to rising rates of obesity, the incidence of nonalcoholic fatty liver disease is also increasing. Many people with cirrhosis have more than one cause of liver damage.
Causes of cirrhosis (from most common to less common) include:
- Chronic hepatitis C
- Alcohol-related liver disease
- Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH)
- Chronic hepatitis B
- Autoimmune hepatitis
- Diseases that damage, destroy, or block the bile ducts
- Inherited diseases that affect the liver
- Hepatitis D and E (rare viral infections)
- Drug reactions, toxins, and infections
Symptoms of Cirrhosis
There may be no symptoms, or symptoms may come on slowly, depending on how well the liver is working. Often, it is discovered by chance when an x-ray is done for another reason.
Early symptoms include:
- Fatigue and loss of energy
- Poor appetite and weight loss
- Nausea or belly pain
- Small, red spider-like blood vessels on the skin
As liver function worsens, symptoms may include:
- Fluid buildup in the legs (edema) and in the abdomen (ascites)
- Yellow color in the skin, mucous membranes, or eyes (jaundice)
- Redness on the palms of the hands
- In men, impotence, shrinking of the testicles, and breast swelling
- Easy bruising and abnormal bleeding, most often from swollen veins in the digestive tract
- Confusion or problems thinking
- Pale or clay-colored stools
- Bleeding from upper or lower intestinal tract
Complications of Cirrhosis
Cirrhosis can cause other health problems such as:
Portal hypertension: The portal vein carries blood from your intestines and spleen to your liver. Cirrhosis slows the normal flow of blood. That raises the pressure in the portal vein. This is called portal hypertension.
Enlarged blood vessels: Portal hypertension may cause abnormal blood vessels in the stomach (called portal gastropathy and vascular ectasia) or enlarged veins in the stomach and the food pipe or esophagus (called varices). These blood vessels are more likely to burst due to thin walls and higher pressure. If they burst, severe bleeding can happen. Seek medical attention right away.
Ascites: Fluid collecting in your belly. This can become infected.
Kidney disease or failure.
Easy bruising and severe bleeding: This happens when the liver stops making proteins that are needed for your blood to clot.
Type 2 diabetes: When you have cirrhosis, your body does not use insulin properly (insulin resistance). The pancreas tries to keep up with the need for insulin by making more, but blood sugar (glucose) builds up. This causes type 2 diabetes.
Liver cancer: You will be screened with an imaging test (ultrasound, for instance) and sometimes blood tests every 6 months if you have cirrhosis.
Diagnosis and test
To diagnose cirrhosis, we begin with a thorough conversation to understand your symptoms, and a physical examination. Your doctor may determine that additional tests are necessary. They may include:
- Blood test
- Imaging tests: CT scan, MRI or ultrasound to look for signs of the disease on the liver.
- Noninvasive modalities for the staging of fibrosis (see the next section)
- Endoscopy: To look for abnormal veins particularly in the esophagus, stomach, and intestines.
- Liver function test: A group of tests used to check for liver inflammation and liver damage.
- Liver biopsy: Removing tissue for examination under a microscope by fine needle aspiration using endoscopic ultrasound (EUS), which involves using an endoscope, a lighted, flexible tube about the thickness of a finger, to examine the liver and create detailed pictures using ultrasound imaging.
Treatment
Cirrhosis of the liver is incurable but, in some cases, treatment can help to reduce the likelihood that the condition will become worse.
Treatment options include:
- Treating the underlying cause of liver damage – For example, treating the underlying hepatitis (B or C) virus infection, or the removal of blood to lower iron levels in haemochromatosis
- Making dietary and lifestyle changes – A nutritious low-fat, high-protein diet and exercise can help people to avoid malnutrition
- Avoiding alcohol – Alcohol damages the liver and harms remaining healthy tissue
- Taking certain medications – Such as beta-blockers to reduce blood pressure and lower the risk of bleeding or diuretics to remove excess fluid
- Avoiding certain medications that can make the symptoms worse – Such as non-steroidal anti-inflammatory drugs (NSAIDs), opiates or sedatives
- Having regular medical check-ups – Including scans to check for liver cancer
- Having regular endoscopic procedures to check whether there are varicose veins within the oesophagus or stomach
- Having a liver transplant – An option that may be considered in severe cases
Cirrhosis prevention
The best way to avoid cirrhosis is to avoid the underlying conditions that cause it.
- Know the risk factors for hepatitis B and hepatitis C and avoid them as much as possible.
- Avoid risky behaviors such as alcohol abuse, IV drug use, and unprotected sexual intercourse.
- Drink alcohol only in moderation, if at all.
- Develop healthy habits. Avoid using tobacco. Eat a healthy diet, get plenty of physical activity and rest, and maintain your weight in a healthy range.
- Talk to your health care provider before taking vitamin supplements. Large doses of vitamins and minerals, especially vitamin A, iron, or copper, can actually worsen liver damage.
- Hepatitis B immunizations are available to health care workers and others at high risk of contacting the disease. Immunization of all American children against hepatitis B, now required, will reduce the incidence of cirrhosis in the future.
- No effective hepatitis C vaccination is available.