Cirrhosis
The liver is a large organ that sits in the right upper abdomen, just under the right lung. The liver makes proteins, eliminates waste material from the body, produces cholesterol, stores and releases glucose energy and metabolizes many drugs used in medicine. It also produces bile that flows through bile ducts into the intestine where it helps to digest food. The liver receives blood from two different sources—the heart and the intestine. All of this blood flows through the liver and returns to the heart.
Many types of chronic injury to the liver can result in scar tissue. This scarring distorts the normal structure and regrowth of liver cells. The flow of blood through the liver from the intestine is blocked and the work done by the liver, such as processing drugs or producing proteins, is hindered.
Cirrhosis can be caused by many things, some known and others unknown:
- Alcohol—Using alcohol in excess is the most common cause of cirrhosis in the United States.
- Chronic Viral Hepatitis—Hepatitis B and Hepatitis C hepatitis, as well as other viruses can infect and damage the liver over a prolonged time and eventually cause cirrhosis.
- Chronic Bile Duct Blockage—This condition can occur at birth (biliary atresia) or develop later in life (primary biliary cirrhosis). The cause of the latter remains unknown. When the bile ducts outside the liver become narrowed and blocked, the condition is called primary sclerosing cholangitis. This condition is often associated with chronic ulceration of the colon (colitis).
- Abnormal Storage of Copper (Wilson’s Disease) or Iron (Hemochromatosis)— These metals are present in all body cells. When abnormal amounts of them accumulate in the liver, scarring and cirrhosis may develop.
- Drugs and Toxins—Prolonged exposure to certain chemicals or drugs can scar the liver.
- Autoimmune Hepatitis—This chronic inflammation occurs when the body’s protective antibodies fail to recognize the liver as its own tissue. The antibodies injure the liver cells as though they were a foreign protein or bacteria.
- Cystic Fibrosis and Alpha 1-antitrypsin Deficiency—These disorders are inherited.
- Non-alcoholic fatty liver disease (NAFLD)—The obesity epidemic in the United States has increased recognition and treatment of this condition. Many patients with NAFLD often seek attention for abnormal liver tests or changes in the texture of the liver found incidentally on a CAT scan or ultrasound done for other reasons. Patients with NAFLD often have the metabolic syndrome which consists of a high blood pressure, high cholesterol and lipids, and diabetes. If left untreated, NAFLD can progress to cirrhosis and eventually require liver transplantation.
Cirrhosis takes years to develop. During this time, there are usually no symptoms, although fatigue, weakness and decreased appetite may occur and worsen with time. When cirrhosis is fully developed, a number of signs may be present:
- Fluid Retention in the Legs and Abdomen— The liver produces a protein, called albumin, that holds fluid in blood vessels. When the blood level of albumin falls, fluid seeps out of the tissues into the legs and abdomen, causing edema (fluid accumulation) and swelling.
- Jaundice—The liver produces bile that normally flows into the intestine. With advanced cirrhosis, bile can back up into the blood, causing the skin and eyes to turn yellow and the urine to darken.
- Intense Itching—Certain types of cirrhosis, such as chronic bile duct blockage, can produce troublesome itching.
- Gallstones—Cirrhosis causes the abnormal metabolism of bile pigment. Because of this, gallstones develop twice as often in cirrhosis patients as in those without the disorder.
- Coagulation Defects—The liver makes certain proteins that help clot blood. When these proteins are deficient, excessive or prolonged bleeding happens.
- Mental Function Change—The liver processes toxins from the intestine. When these substances escape into the bloodstream, as occurs in severe cases of cirrhosis, a variety of changes in mental function can develop.
- Esophageal Vein Bleeding—In advanced cirrhosis, intestinal blood bypasses the liver and flows up and around the esophagus (the food tube) to the heart. The veins in the esophagus dilate (widen) and may rupture, causing slow or massive intestinal bleeding.
The physician can always suspect cirrhosis from the patient’s medical history and physical examination. In addition, certain blood tests and scans or ultrasound (sonography) can provide helpful information. To make a definite diagnosis, however, a liver biopsy (tissue sample) is required. This is performed by anesthetizing the skin of the right-lower chest and inserting a thin, needle into the liver. A core or specimen of tissue is removed and examined under a microscope.
What Is the Course of Cirrhosis?
When cirrhosis is diagnosed, the patient and physician begin a plan of action designed to preserve the remaining liver cells and correct the complications mentioned above. By following this plan, many patients can lead long, productive lives.
Perhaps 90 percent of cirrhosis is caused by excessive alcohol consumption or hepatitis viruses. Of course, alcohol can be avoided. Alcohol consumption should always be limited to no more than 1 or 2 drinks per day. Hepatitis B now has an effective vaccine against it. Vaccination against hepatitis B virus is safe and inexpensive. It should be taken especially by certain high-risk groups: all health care professionals, persons traveling to Third World countries, and other high risk individuals.
Often, the only required treatment for cirrhosis is removing the offending cause:
- The alcoholic patient must permanently stop consuming alcohol.
- When iron is being retained in the body, chronic removal of blood by vein eliminates large amounts of iron.
- Cortisone medicine helps treat autoimmune hepatitis and cirrhosis.
- Restricting salt and using fluid pills (diuretics) reduce edema and abdominal swelling.
- Toxins and injurious drugs must be avoided.
- Decreasing dietary protein and using certain laxatives generally can prevent changes in mental function.
- Bleeding veins in the esophagus can be closed with small rubber bands. Occasionally, surgery is necessary to prevent recurrent massive bleeding.
- Ursodiol (Actigall) and other drugs have been helpful in treating primary biliary cirrhosis and primary sclerosing cholangitis.
- Treating the metabolic syndrome with dietary changes, sustained weight loss, and medications can minimize or even reverse the progression of NAFLD.
Liver transplantation has progressed to the stage where it can now be considered as standard treatment for selected patients with advanced cirrhosis.
Cirrhosis of the liver is a common disorder that has many causes. With early diagnosis, much can be done to prevent serious complications. Various treatments are available, depending on the cause of the liver injury and its complications. Ongoing medical research promises major advances in treating cirrhosis in the future.
