CIRRHOSIS

What is Cirrhosis?

Cirrhosis is a long lasting (chronic) liver disease in which normal liver cells are damaged and replaced by scar tissue.

Liver cells regenerate in an abnormal pattern, primarily forming nodules (hard, raised areas) that are surrounded by scar tissue. This scar tissue prevents the blood flow to and through the liver. This reduced blood flow affects the way the liver performs important functions such as the processing of nutrients, hormones, and detoxifying drugs and poisons, including alcohol.

In order to better understand the meaning of cirrhosis, we need to discuss the function of the liver.

Liver Blood Flow

Oxygenated blood that has returned from the lungs to the left ventricle of the heart is pumped to all the tissues of the body. This is called the systemic circulation.

After reaching the tissues, blood is returned to the right side of the heart, from where it is pumped to the lungs and then returned to the left side of the heart after taking up oxygen and giving off carbon dioxide. This is called the pulmonary circulation.

Blood from the gut and spleen flow to and through the liver before returning to the right side of the heart. This is called the portal circulation and the large vein through which blood is brought to the liver is called the portal vein.

The liver also receives some blood directly from the heart via the hepatic artery. In the oesophagus, stomach, small intestine and rectum, the portal circulation and veins of the systemic circulation are connected. Under normal conditions, there is little to no back flow from the portal circulation into the systemic circulation.

Bilirubin Secretion

The liver is the site of bile formation. Bile contains bile salts, fatty acids, cholesterol, bilirubin and other compounds. The components of bile are synthesized and modified in the hepatocytes (the main cell type in the liver) and secreted into small bile ducts within the liver itself. These small bile ducts form a branching network of progressively larger ducts that ultimately become the common bile duct that takes bile to the small intestine.

Bilirubin is a yellow pigment that is made up from old red blood cells. Bilirubin is taken up from the blood by hepatocytes, modified in the hepatocytes to a water soluble form and secreted into the bile.

Causes of Cirrhosis

Although very often associated with alcohol abuse, cirrhosis of the liver can result from may causes. Almost any chronic liver disease can lead to cirrhosis. Here are some of the causes:

· Alcoholic liver disease
· Chronic viral hepatitis B ,C and D
· Autoimmune hepatitis
· Inherited metabolic diseases (eg. haemochromatosis, Wilsons disease)
· Chronic bile duct diseases
· Congestive heart failure
· Parasitic infections
· Liver inflammation caused by fatty liver disease
· Long exposure to toxins or drugs

Clinical Features

Cirrhosis does take many years to develop. In patients who are infected with Hepatitis C, somewhere between 2% and 20% of these patients will be found to have cirrhosis twenty years after infection. Even in regard to heavy alcohol consumption, it usually takes many years for cirrhosis to develop.

As cirrhosis is forming, and soon after it has formed, there are often no symptoms at all. The symptoms associated with cirrhosis generally occur when the condition is well advanced. These include:

1. Jaundice: This is caused by a build up of bile in the blood as the liver is unable to secrete this substance.

2. Bleeding: The liver is unable to produce the proteins necessary to help blood clotting.

3. Fluid retention: This can occur in the legs (peripheral oedema) or in the abdomen (ascites).

4. Intense itching: This tends to occur when there are blockages in the bile ducts.

5. Muscle cramping: A common problem in patients with advanced cirrhosis.

6. Changes in mental function: The liver does process toxins which are absorbed from the intestine. When these toxins bypass the liver, they can act as false transmitters in the brain resulting in a confusional state and problems with sleep.

7. Bleeding from the oesophagus: Engorged veins in the bottom of the oesophagus (oesophageal varices) can bleed profusely. This condition is a medical emergency and has a high mortality rate.

Early on in the course of cirrhosis, some non specific symptoms such as lethargy and tiredness can be present. These symptoms however, may or may not be due to the liver function and are suffered by all of us at some time or another.

How does Cirrhosis progress?

Cirrhosis of the liver can only rarely be reversed but treatment of the underlying liver disease may slow or stop the progression. Eg. Treatment for Hepatitis C and B.

Termination of alcohol intake will often stop the progression in alcoholic cirrhosis and for this reason it is important to make this diagnosis early.

Similarly, discontinuation of a hepatotoxic drug or removal of an environmental toxin can stop progression.

 

Treatment of Cirrhosis

The diagnosis if cirrhosis can be suspected by your doctor when he examines you. There can also be clues found in blood test results and in an upper abdominal ultrasound examination.

The gold standard of diagnosis is a liver biopsy. However, as some patients with advanced cirrhosis will have a significant decrease in clotting factors, liver biopsy sometimes cannot be done in the usual manner.

In people with cirrhosis of the liver, treatment must also be directed at the complications.

• Bleeding oesophageal varices can be treated with a tying off or banding of the bleeding area.

• Ascites and oedema are often treated with a low sodium diet plus sometimes medication to reduce the build up of fluid. (Diuretics)

• Certain infections in the abdominal fluid must be treated with antibiotics.

• Bleeding disorders will sometimes respond to vitamin K or clotting factors.

When iron is being retained in the body as in haemochromatosis, removal of a portion of blood every so often, can decrease the amount of iron and often the amount of inflammation in the liver.

If a patient has chronic active hepatitis, then steroids (prednisone) will frequently reduce the inflammation and scarring.

In some instances, patients with hepatitis C related cirrhosis can be treated with medication to reduce the progression of the virus (see section on Hepatitis C Treatment).

Liver transplantation can be an effective treatment of end-stage cirrhosis.

Active drug or alcohol abuse is a contraindication to liver transplantation. However, if people abstain from alcohol for an extended period (usually more than 6 months) and participate in rehabilitation and support groups, they may be considered for liver transplant and will often have a good prognosis.