Cirrhosis

Cirrhosis is a chronic liver disease where the healthy liver tissue is damaged and is replaced by scar tissue.

A progressive scarring of the liver that prevents the liver from working properly causes the liver cirrhosis.

Cirrhosis often leads to:

• The diminished ability of the liver to detoxify toxic substances (liver failure).
• Bleeding disorders (coagulopathy).
• Increased pressure within the portal vein (portal hypertension). Portal hypertension produces an abnormal build-up of fluid in the abdomen (ascites), in addition to enlarged veins on the lining of the esophagus (esophageal varices). If these veins break open, it can lead to severe gastrointestinal bleeding.
• Altered brain function with drowsiness and disorientation due to the accumulation of toxins, like ammonia, in the bloodstream (hepatic encephalopathy).

The main causes of cirrhosis are (most common ones highlighted in bold):

1. Drug or toxicant-induced liver damage:
   1. Alcohol: Most cases of cirrhosis are due to alcoholism
   2. Medication: Amiodarone, methotrexate, oral contraceptives
   3. Other substances that may cause liver toxicity: Arsenic
2. Infection
1. Viral hepatitis (Hepatitis B and Hepatitis C)
2. Brucellosis
3. Parasitic infections: Capillariasis, echinococcosis, toxoplasmosis, schistosomiasis
3. Metabolic disorders
   1. Hemochromatosis: A disorder that causes an increased absorption of iron that leads to iron overload in the liver.
   2. Wilson's disease: A disorder that causes increased copper absorption, and the accumulation of copper in the liver.
   3. Other less common conditions: Fanconi syndrome, alpha-1 antitrypsin deficiency, biliary atresia, Alagille syndrome, glycogenosis
4. Other causes:
   1. Bile duct obstruction (caused by bile duct defects) and primary biliary cirrhosis
   2. Primary sclerosing cholangitis
   3. Other less common causes: Cystic fibrosis, non-alcoholic fatty liver disease, sarcoidosis, Graft versus host disease.

Many patients remain asymptomatic for years, making it difficult to diagnose the disease.

Common symptoms linked to cirrhosis are:

• Constitutional symptoms: Lack of appetite, fatigue, and weight loss.
• Nausea and vomiting. The vomit may contain blood in case of esophageal varices and/or coagulopathies.
• Jaundice (yellowing of the skin and mucosa due to excess amount of bilirubin).
• Abdominal swelling when there is ascites.
• Menstrual disorders in women.
• Impotence and enlargement breast in men.
• Spider veins: Red blood vessels in the skin, making spider-like figures.

To diagnose cirrhosis, the following tests and procedures are performed:

• Physical examination: Abdominal palpation may detect a hard liver or bulky liver, sometimes enlarged (hepatomegaly), and small in other cases. If portal hypertension is present, fluid will be found in the abdomen (ascites). An enlarged spleen may also be palpated (splenomegaly).
• Blood test: There is a decrease in red blood cell count (anemia), blood clotting disorders (elevated prothrombin time), and decreased albumin in the bloodstream (hypoalbuminemia). There may be an increase in bilirubin levels (hyperbilirubinemia) and liver enzymes (elevated transaminase with a GOT/GPT ratio>1). Ammonia is usually found in the blood when encephalopathy is present. Cirrhosis may alter many other laboratory tests.
• Imaging and radiology:
• Plain abdominal X-ray: May shows an altered liver shape
• Abdominal ultrasound: A specific test to show the destruction of the liver and the enlarged spleen.
• Contrast X-ray can confirm esophageal varices.
They are pain-free procedures.
• Endoscopy: If there are esophageal varices, they will be seen through endoscopy.
• Liver biopsy: It may be necessary to confirm the diagnosis of cirrhosis through a liver biopsy, where the altered architecture of the liver is confirmed. This can be an uncomfortable medical procedure.

Common complications that derive from cirrhosis are:

• Bleeding from esophageal varices.
• Bleeding disorders not related with esophageal varices.
• Ascites (build-up of fluid in the abdomen).
• Confusion and coma.

Cirrhosis can be managed using supportive measures and/or specific treatments.

1. General principles:
   1. Abstinence from alcohol
   2. Low-sodium diet, with vitamin B supplements, and many proteins (except in cases of encephalopathy).
2. Treatment for complications of cirrhosis:
   1. Ascites: Treated with sodium restriction (low-sodium diet) and diuretics. Sometimes it may be necessary to remove excess fluid from the peritoneal cavity through the abdominal wall.
   2. Esophageal varices: Dilated veins are treated by sclerotherapy using a chemical substance. This prevents the veins from breaking open and bleeding. Elastic bands are another treatment option. They can also be treated with surgery.
   3. Blood clotting disorder: It is treated with vitamin K injections or blood transfusions.
   4. Encephalopathy: To prevent the production of ammonia from digestion of proteins from the gut bacteria, protein intake is restricted. Oral antibiotics may kill the bacteria in the intestine. Constipation should be avoided with mild laxatives (lactulose).

The prognosis is much better when the consumption of alcohol is completely discontinued.

Advanced cirrhosis has a poor prognosis, with a 2-year survival rate of only 50%.