Liver Cirrhosis

What is liver cirrhosis?

Liver cirrhosis refers to a shrunken, scarred and hardened liver with failure of liver function. The condition results from chronic (long-term) damage to the liver from various causes such as chronic viral hepatitis infection (chronic hepatitis B or C), fatty liver disease, excessive alcohol intake, and autoimmune liver disease.

Liver cirrhosis is a serious condition because once the liver becomes cirrhotic, the damage to the liver is irreversible and can lead to complications of liver cirrhosis, liver cancer and eventual death.

What are the symptoms of liver cirrhosis?

Patients with early liver cirrhosis often have no detectable symptoms or signs of disease. Such patients may feel completely well and healthy and are often diagnosed based on abnormal blood tests or liver scans. This condition is known as compensated cirrhosis, which is associated with a favorable median survival of more than 10 years. Patients with early, compensated cirrhosis are often diagnosed on regular ultrasound screening during follow-up for chronic liver disease (e.g. chronic viral hepatitis or fatty liver disease).

Patients with more advanced liver cirrhosis may develop the following signs and symptoms:

• Ascites (swelling of the abdomen due to accumulation of fluid)
• Pedal edema (swelling of the ankles and feet)
• Spider naevi (dilated blood vessels on the upper chest and arms)
• Splenomegaly (enlarged spleen). Hepatic encephalopathy (drowsiness or confusion due to inability of the liver to break down toxins in the blood). Varices (swollen veins in the esophagus and stomach that develop due to obstruction of blood flow in the liver)

Portal hypertension is a common complication of liver cirrhosis. It refers to increased blood pressure in the blood vessels supplying the liver (the portal vein). The hardened liver obstructs blood flow from the portal vein, leading to elevated pressures in the portal vein. This results in enlargement of the spleen (splenomegaly), development of swollen veins in the stomach and esophagus (varices) and accumulation of fluid in the abdomen (ascites).

Most of the symptoms and signs of liver cirrhosis are a result of the development of portal hypertension.

When should you see a doctor?

You should seek medical attention if you have a history of chronic liver disease, heavy alcohol use or hepatitis infection, even if you are not experiencing symptoms. Early detection of liver cirrhosis can help manage the condition before complications arise.

Additionally, if you notice any unusual changes in your overall health, such as persistent fatigue, unexplained weight loss or jaundice (yellowing of the skin or eyes), it is important to consult a doctor. Regular check-ups are also crucial for individuals at risk of developing these conditions to prevent disease progression.

How is liver cirrhosis prevented?

Preventing liver cirrhosis involves taking steps to protect liver health and reduce the risk of conditions that lead to these complications. Here are key preventive measures:

• Limit alcohol intake: Avoid excessive alcohol consumption as chronic alcohol abuse is a leading cause of liver cirrhosis.
• Vaccination and safe practices: Get vaccinated against hepatitis B and practise safe behaviours to avoid hepatitis B and C infections, such as using clean needles and practising safe sex.
• Maintain a healthy weight: Reducing the risk of non-alcoholic fatty liver disease by maintaining a healthy weight through a balanced diet and regular exercise can prevent cirrhosis.
• Manage chronic conditions: Properly managing conditions such as diabetes and high cholesterol can help reduce the risk of liver damage.
• Avoid exposure to toxins: Limit exposure to harmful chemicals and toxins that can cause liver damage.
• Regular medical check-ups: If you have a liver condition or are at risk, regular monitoring through medical check-ups and liver function tests can help detect issues early before they progress to cirrhosis.

What causes liver cirrhosis?

Liver cirrhosis is primarily caused by chronic liver damage from various conditions that directly affect liver tissue and its function. These causes include:

1. Toxin exposure: Long-term exposure to environmental toxins or harmful chemicals, such as industrial solvents or arsenic, can lead to liver damage and cirrhosis over time.
2. Chronic biliary obstruction: Prolonged blockages in the bile ducts from gallstones or tumours can cause pressure build-up, leading to inflammation and cirrhosis.
3. Chronic drug use: The long-term use of certain medications, including methotrexate and isoniazid, can cause liver damage that progresses to cirrhosis.
4. Chronic inflammation: Frequent liver infections or persistent inflammation, even from non-viral sources, may cause scarring and cirrhosis over time.

What are the risk factors for liver cirrhosis?

You may be at risk of liver cirrhosis if you have one of the following conditions:

• Chronic hepatitis B
• Chronic hepatitis C
• Chronic excessive alcohol intake
• Fatty liver disease (non-alcoholic steatohepatitis)
• Autoimmune liver disease (autoimmune hepatitis, primary biliary cirrhosis or primary sclerosing cholangitis
• Wilson disease, hemochromatosis and other rare inherited liver diseases.

How is liver cirrhosis diagnosed?

Liver cirrhosis is diagnosed via the following modalities:

• Liver imaging (ultrasound, CT or MRI of the liver)
• Liver stiffness measurement using Fibroscan®
• Liver biopsy (removal of a small sample of liver tissue for histological analysis)

The doctor may suspect liver cirrhosis in people with risk factors for cirrhosis who have abnormal blood tests, abnormal liver imaging or one of the signs and symptoms listed above.

Liver imaging is highly specific for the diagnosis of liver cirrhosis in which the liver has a shrunken and nodular appearance. Early cirrhosis is more difficult to diagnose as these patients may show a normal liver image during the scan. Early cirrhosis is often diagnosed by liver stiffness measurement (Fibroscan®). Sometimes a liver biopsy is required to confirm the diagnosis of early cirrhosis.

How are liver cirrhosis and portal hypertension treated?

Patients with liver cirrhosis will benefit from the following treatment which include:

Treatment of the underlying cause of liver cirrhosis

• Patients with alcoholic liver cirrhosis must stop all intake of alcohol
• Patients with chronic hepatitis B and C should be started on antiviral treatment if there are no contraindications
• Patients with autoimmune hepatitis may require treatment with steroids

Treatment of portal hypertension to reduce risk of variceal bleeding by:

• Non-selective beta blocker medication (e.g. propranolol) for lowering of portal pressure to reduce risk of variceal bleeding
• Endoscopic ligation (banding) of esophageal varices to treat acute bleeding or prevent future variceal bleeding
• Endoscopic sclerotherapy (histoacryl injection) of gastric varices to treat acute bleeding

Treatment and prevention of ascites include:

• Maintenance of a strict low salt diet
  
• Maintenance diuretic medication (e.g. spironolactone or furosemide) to remove excess fluid from the body
• Patients who have persistent ascites that do not respond to medications may require paracentesis, Transjugular Intrahepatic Portosystemic Shunt (TIPS) or liver transplant.

Treatment and prevention of hepatic encephalopathy include:

• Regular bowel clearance in order to reduce build-up of toxins in the bloodstream that may precipitate encephalopathy
• Avoidance of sedatives that may worsen encephalopathy

Surveillance for liver cancer

• Patients with cirrhosis should undergo regular abdominal ultrasound and alfa-fetoprotein (AFP) blood tests at least once every six months Diseases Gastroenterology

Treatment of cirrhosis-related infections

• Cirrhotics need to be closely monitored for infections (e.g. spontaneous bacterial peritonitis) and should be referred for early treatment with antibiotics

Early assessment for liver transplant

• Cirrhotic patients who develop decompensation events should be referred for liver transplant