What is cirrhosis?
Cirrhosis describes a pattern of damage to the liver usually the result of long-term injury from alcohol, viruses or other conditions. Damaged and dead liver cells are replaced by fibrous tissues which lead to scarring. As a result of this scarring, liver cells regenerate into abnormal clumps or nodules. The scar tissue and regenerative nodules alter the blood flow through the liver which causes some of the serious complications of cirrhosis. This pattern of damage is usually irreversible but removing the cause can slow or halt further damage.
Basic function of the liver includes bile formation and secretion, processing healthy nutrients, eliminating toxins and making products necessary for blood clotting. The liver has an amazing ability to maintain function until damage is extensive. A diagnosis of cirrhosis does not necessarily mean the liver has lost all normal function. Liver functioning can be measured by three blood tests – albumin (protein produced by the liver), INR (measurement of blood clotting) and bilirubin (build up of this substance causes yellowing of the skin). These tests can be affected by other factors but provide a fairly accurate reflection of liver function.
Cirrhosis may be easily diagnosed when a person experiences the typical complications, changes in blood tests and has a known underlying liver disease. At times a liver biopsy is necessary.
Many people may have few or no symptoms with the early stages of cirrhosis. Early symptoms may include fatigue, loss of appetite, reddish and blotchy palms, and spider angiomas (pin head sized red spots with radiating blood vessels on the upper body and arms). As liver failure progresses, symptoms include fluid accumulation in the abdomen (ascites) and legs (edema), loss of muscle bulk, fatigue, jaundice, and loss of body hair.
What are the complications of cirrhosis?
Ascites is fluid accumulation in the abdomen. Fluid build-up in other areas, usually the legs, is called edema. Ascites formation is not completely understood but is probably caused by several factors. One possible explanation is due to the increased scarring, blood flow through the liver is under higher pressure. This high pressure leads to a clear liquid leaking out of the liver into the abdomen. This high pressure, called portal hypertension, also causes a backpressure in other blood vessels and structures. Besides causing ascites, portal hypertension causes other complications and is discussed under the topic of varices.
Ascites may be so minimal that a person is unaware of the fluid or so massive that it is difficult to breathe and eat adequate amounts of food. The most important key to control this fluid accumulation is limiting sodium (salt) to 2 grams (2000mg) per day. Specific diet recommendations are available. There are other means to control this fluid. Diuretics (water pills) are frequently used. Spironolactone (Aldactone) and furosemide (Lasix) are two commonly used medications. If the person remains uncomfortable from the ascites, a procedure can be performed to drain the fluid. This is called a paracentesis. Occasionally these methods are not effective and a shunt is placed in the liver to bypass this high pressure. It is called TIPS (transjugular intrahepatic portosystemic shunts.) This is performed in a radiology department in a hospital.
Spontaneous Bacterial Peritonitis (SBP)
Occasionally, the ascitic fluid may become infected and this is called spontaneous bacterial peritonitis. Symptoms may include fever, chills, abdominal pain, nausea, vomiting, and general malaise. If this occurs, antibiotics may be necessary. Once SBP occurs, patients will need prophylaxis (treatment to prevent recurrence of the infection) with oral antibiotics each week.
Portal hypertension can cause a blood backflow from the liver (portal) blood vessels into other blood flow tributaries. This back pressure can lead to varicose veins in the esophagus (esophageal varices) and stomach (gastric varices). Esophageal and gastric varices can rupture and lead to significant blood loss, possibly even death. Primary biliary cirrhosis and primary sclerosing cholangitis are two chronic liver conditions that tend to have more problems with varices, possibly even before the liver has progressed to cirrhosis. If large varices are detected, banding may be done if indicated. Banding may need to be repeated 2-3 times at 1-2 week intervals until the varices are eliminated. If the varices are not bleeding, they otherwise do not cause symptoms.
An endoscopy is performed on patients with cirrhosis to look for varices. If the endoscopy does not detect varices, it is repeated periodically. If significant esophageal varices are detected, a medication is prescribed to lower the backflow pressure. Propranolol (Inderal) or nadalol (Corgard) are two medications effective to lower this pressure. When taking these medications, your pulse rate is used to determine the correct dose of medication. Your healthcare provider will give you instructions on how to monitor your pulse rate.
If a person vomits red blood or has a bowel movement of red or black stool, these blood vessels could be bleeding. The person should seek medical attention immediately. Endoscopy can be done to stop the bleeding, either by placing rubber bands or injecting medicine.
Splenomegaly and Low Platelets
Portal hypertension usually causes spleen enlargement (splenomegaly). At times the spleen becomes so large it can be felt below the left rib cage. An enlarged spleen traps certain blood cells – white blood cells (infection fighters) and platelets (aids clotting). Occasionally the platelet count is low enough to notice problems with bruising and bleeding.
Patients with cirrhosis are at increased risk for liver cancer (hepatocellular carcinoma). This is a cancer that originates in the liver. There are usually no symptoms. To screen for this cancer, a blood test, alphafetoprotein (AFP), and right upper quadrant ultrasound (or other liver imaging tests) are obtained every six months. If cancer is found early, it can be treated and cured.
Mental Impairment/ Hepatic Encephalopathy
In more advanced cases of cirrhosis, changes in mental capacity can occur. This mental impairment (encephalopathy) can range from forgetfulness and trouble concentrating to coma and death. This condition is not fully understood but probably involves some blood bypassing the liver going directly to the brain and the liver’s decreased capacity to breakdown certain toxins. One of the toxins is ammonia. Measurement of the ammonia blood level is not helpful as almost all people with cirrhosis will have abnormal levels but few have encephalopathy.
Encephalopathy is treated with lactulose, a liquid medication. The correct dose of the medication causes 3-4 soft or loose stools per day. This change in bowel function can be bothersome, but is necessary to clear toxins from your blood. If encephalopathy is present, lactulose should not be discontinued to avoid this problem. Conditions such as dehydration, constipation, infection, surgery and gastrointestinal bleeding can precipitate encephalopathy.
Necessity for liver transplantation is based on the MELD scoring system. This score is calculated on three lab tests: creatinine, INR and bilirubin. Eligibility is limited by a few conditions such as age, other serious health problems and recent history of most cancers. A complete medical evaluation is performed by the transplant center to determine medical fitness for the surgery. If alcohol or drug abuse is present, official listing for transplantation is postponed for 6 months after sobriety is achieved.
- Get vaccinated for hepatitis A and hepatitis B if you are not already immune. Blood tests will be used to determine immunity.
- Salt (sodium) restriction is very important to control fluid retention. Aim for less than 2000mg of sodium per day.
- Follow a balanced diet.
- Even if you are not experiencing symptoms or complications of cirrhosis, office visits every six months are recommended to screen for cancer.
- Alcohol should be avoided.
- Acetaminophen (Tylenol) may be used in doses of 2 – 3 grams (four to six 500 mg tablets) per day.
- Avoid aspirin and non-steroidal anti-inflammatory drugs (ibuprofen and naproxen) because these medications can cause fluid retention or kidney dysfunction.