Cirrhosis of the liver

Basic facts about the liver

The liver is one of the most important organs in the human body. It is located in the upper right part of the abdomen, under the ribs and weighs approximately 1.5 kg. A normal liver is smooth and elastic. It is connected directly to the intestine via the bile duct, which transports the bile that is produced in the liver to the small intestine, where it is used in the digestion. The liver works like a big chemical factory. Almost all the blood that comes out of the stomach and intestine passes through the liver. Among the many functions that the liver carries out are the following:

• The production of bile and other digestive enzymes (proteins).
• The control of infections.
• The production of proteins that help blood coagulation.
• The metabolization of cholesterol.
• The storage of glycogen that serves as fuel for the muscles.
• The maintenance and regulation of hormone levels
• The metabolization of medicines, alcohol and other drugs.

Considering all the functions of the liver, it is not surprising that hepatic illnesses alter all the other functions of the body. One of the most important liver diseases is cirrhosis.

What is cirrhosis?

Cirrhosis is the consequence of progressive liver damage, usually over a period of various years that is characterized by the accumulation of fibrosis (“scars”) on the hepatic tissue and the reduction of functional hepatic tissue. These changes interfere with the liver’s structure and normal function, causing serious complications to the flow of  blood through the liver and its functions.

What are the causes of cirrhosis?

There exist numerous causes that can set off cirrhosis, among the principle causes are:

• Hepatitis B, hepatitis C and hepatitis D viruses.
• Excessive alcohol consumption.
• Non-alcoholic fatty liver (also known as non-alcoholic steatohepatitis); a condition common in the general population, associated with diabetes and obesity.
• Autoimmune disease: autoimmune hepatitis and primary bile cirrhosis.
• Hereditary or congenital illnesses such as:
• Hemochromatosis, in which iron accumulates in the liver damaging the tissue.
• Wilson’s disease, which is caused by a disorder in the transport of copper, which accumulates in the liver and other tissues.
• The prolonged obstruction of the bile duct, such as sclerosing cholangitis.
• Absence of specific proteins or enzymes for the metabolization of different substances in the liver, such as alpha1-antitrypsin deficiency.
• Certain heart diseases (heart failure).
• Severe reaction to drugs or medicines.
• Prolonged exposure to toxic agents in the environment.

Can the causes of cirrhosis be identified?

Yes. Most of the time the causes of cirrhosis can be identified:

• In the case of alcoholic cirrhosis: previous history of regular or excessive alcohol consumption, physical or behavioural changes and a hepatic biopsy.
• In the case of hepatitis: Blood tests to detect the virus or other specific markers of the disease, images and hepatic biopsy among others. A hepatic biopsy is a sample of the liver which is obtained under local anaesthesia.

Can excessive drinking lead to a person developing cirrhosis?

Many people who consume excessive amounts of alcohol develop a certain degree of liver damage, but this does not necessarily lead to hepatic cirrhosis. Among those individuals who consume between 200 and 400 ml of alcohol per day for a period of 15 years or more, approximately a third develop fatty liver and the rest will have minor hepatic problems. In general, the more someone drinks and the more frequently and regularly they do it, the greater the possibility of developing hepatic cirrhosis. Alcohol on its own in excessive quantities is a toxin that can cause cirrhosis.

Can a person who drinks socially develop cirrhosis?

Yes. People who drink alcohol socially can also develop cirrhosis. The contributory factors that contribute to the development of the disease are:

• Quantity of alcohol consumed.
• Frequency of alcohol consumption.
• Genetic and hereditary factors.
• Physical and nutritional condition.

It is not known why certain people are more prone than others to the effects of alcohol. Women have a lower tolerance to alcohol than men. Many investigators believe that it is because men have a greater ability than women to metabolize and eliminate alcohol. Investigations indicate that women, even when they consume less alcohol than men, develop cirrhosis more frequently than men.

Does hepatitis always result in cirrhosis?

Some patients with chronic viral hepatitis develop cirrhosis. There are 5 known types of virus that cause hepatitis.

• Acute hepatitis type A and hepatitis E don’t lead to chronic hepatitis (exceptional cases of chronic hepatitis E have been described in immunosuppressed patients, but this is very rare).
• Acute hepatitis B leads to chronic infection in 5% of adult patients. In a minority of these patients, chronic hepatitis leads to cirrhosis.
• Hepatitis D affects only people previously infected with hepatitis B.
• Hepatitis C becomes chronic in approximately 80% of infected adults. A minority of these patients (20-30%) will later develop cirrhosis of the liver in a period of various years (10-30 years).

What are the signs and symptoms of cirrhosis?

The onset of cirrhosis is generally silent owing to its very few symptoms. As liver damage accumulates, the following symptoms may appear:

• Loss of appetite.
• General discomfort.
• Nausea and vomiting.
• Loss of weight.
• Increase in size of the liver.
• Jaundice, which is the yellow pigmentation of the skin and the whites of the eyes, due to the accumulation of blood when the liver is incapable of eliminating bile.
• Itching.
• Ascites, which is the accumulation of liquid in the abdomen.
• Vomiting blood, due to vein rupture (varicose veins) in the lower part of the oesophagus.
• Encephalopathy or changes in the state of consciousness, which can be subtle (confusion) or profound (coma).

The diagnosis of cirrhosis may be unexpected. A person may go to the doctor with symptoms that don’t appear to be those of cirrhosis and after a physical examination and some blood tests discover he or she has cirrhosis.

How is cirrhosis treated?

The treatment of cirrhosis depends on the type of cirrhosis that the person suffers, the time they have had the disease, and the level of permanent damage that the liver has suffered. In some cases the liver damage suffered can be reversed if the specific cause of the cirrhosis is found and the appropriate treatment given.

• In the case of alcoholic cirrhosis, total abstention and a balanced diet are important parts of the treatment.
• In the case of secondary cirrhosis from viral hepatitis, medication, such as interferon,   is used to increase the response of the immune system to the virus.
• In cases of cirrhosis caused by autoimmune hepatitis, corticososteroids used on their own or combined with azathioprine can be an effective treatment.
• In cirrhosis patients with jaundice, supplementary treatment with fat-soluble vitamins may help them.
• In the case of Wilson’s disease, the excessive amounts of copper are eliminated from the organism using medications.
• In the case of hemochromatosis, the excess of iron is eliminated using phlebotomy (bloodletting).
• Many types of cirrhosis require a liver transplant when liver failure is advanced.

What are the complications of cirrhosis?

The complications of cirrhosis include ascites, encephalopathy and haemorrhaging due to the rupture of esophagic varicose veins.

• Ascites is treated by reducing the intake of salt and the administration of diuretics. In some cases the direct removal of large quantities of liquid from the abdomen using a catheter via the wall of the stomach, also known as paracentesis, is necessary.
• The treatment of hepatic coma or first signs of coma (hepatic encephalopathy) require specific medication, avoiding the excessive intake of proteins and the control of the digestive haemorrhage.
• The treatment of haemorrhages of esophagic varicose veins includes endoscopic treatment such as the banding or sclerotherapy (the direct injection of a chemical substance that destroys the varicose vein from the inside) and other treatments such as medication that reduce the bleeding tendency, the compression of a bleeding vein by way of special inflatable balls and a procedure called transjugular intrahepatic portoystemic shunt (TIPS).

How can cirrhosis affect other diseases that I suffer and their treatment?

The responsibility of the liver for the adequate functioning of the whole organism is so big that chronic liver disease may modify the responses of the organism to a variety of diseases. The abnormal functioning of the liver with cirrhosis may:

• Affect the dosage of medication requires for the treatment of other diseases.
• Modify the treatment of diabetes.
• Affect the response of the organism to infections.
• Affect tolerance to surgical procedures.

Patients with cirrhosis are prone to develop bacterial infections, kidney function disorders, stomach ulcers, gall stones, certain types of diabetes and liver cancer.

What are the expectations of having reasonable health and survival with treatment?

The treatment at this stage with an adequate adherence to the doctor’s recommendations may lead to an improvement of the symptoms, with which the patient can lead a normal life and carry out normal activities. When the cirrhosis isn’t discovered in time, the prognosis may be less favourable with respect to an improvement, and complications such as ascites and haemorrhage are more frequent.

How can I avoid cirrhosis?

• Don’t drink in excess. Avoid alcoholic drinks. Alcohol destroys  liver cells.
• Follow a balanced diet, maintain an adequate weight and do physical exercise regularly.
• Seek medical help. Stay under medical supervision if you develop viral hepatitis until an improvement in your health is assured.

The liver is a large organ, with a big functional reserve, capable of carrying out its functions even when it is damaged. It also has the capacity to repair itself to a certain extent. The cells that die can be replaced by other new ones. If the cause of the cirrhosis can be eliminated or controlled, this capacity of the liver allows for a certain improvement and the carrying out of a normal life.