Chronic Liver Disease / Liver Cirrhosis

What is chronic liver disease / liver cirrhosis?

Cirrhosis of the liver refers to scarring of the liver which results in abnormal liver function as a consequence of chronic (long-term) liver injury. According to the latest WHO data published in 2018, liver disease deaths in Philippines reached 7,491 or 1.23% of total deaths, with chronic hepatitis B infection as the most common etiology of cirrhosis. In its advanced stages, cirrhosis is usually irreversible, so treatment may involve liver transplant. In its earlier stages, cirrhosis may be reversible if the underlying cause is treated.

What causes liver cirrhosis?

Cirrhosis of the liver is a consequence of long-term liver injury of many types. While excess alcohol use and chronic infection with hepatitis viruses (such as hepatitis B and hepatitis C) are the most common causes of cirrhosis in the United States, cirrhosis can be caused by many conditions including fatty liver disease, inherited disorders, drug-induced injury, bile duct disorders and autoimmune diseases. Some patients may have more than one cause for cirrhosis (such as alcohol excess and viral hepatitis occurring together).

A large portion of patients (up to 20%) do not have an identifiable cause for cirrhosis. This is known as cryptogenic cirrhosis.

What are the signs and symptoms of liver cirrhosis?

The liver is a large organ that is located in the right upper abdomen beneath the rib cage. It is responsible for many complex metabolic functions essential to life. Blood leaving the digestive system (stomach, intestines) passes through the liver on its way back to the heart. Essential functions of the liver include:

• Extraction and processing of nutrients absorbed by digestive system
• Produces bile, which is delivered to the digestive system to help absorb fat and certain vitamins.
• Removes medications and toxic waste-products from the blood and excretes them into bile.
• Produces blood proteins, including the proteins involved in normal blood clotting function.

Malfunction of the liver as a consequence of scarring impairs these essential functions of the liver and produce symptoms that can be attributed to the underlying liver problem. People with early liver cirrhosis sometimes are asymptomatic, but the disease can cause possible signs and symptoms that can occur together once the damage is significant.

Some of the more common symptoms include:

• Loss of appetite
• Weight loss
• Weakness or fatigue
• Jaundice (yellowing of the skin or eyes)
• Pruritus or itching of the skin
• Swelling of the abdomen (caused by ascites which is fluid build up in the abdominal cavity)
• Abnormal sleep patterns, confusion, or mood changes (symptoms of hepatic encephalopathy)
• Muscle cramps
• Absent or irregular menstrual bleeding (in women)
• Erectile dysfunction, infertility, or loss of sex drive (in men)
• Breast development in men (known as gynecomastia)
• Reddening of the palms
• Signs of portal hypertension (which is blood pressure build-up inside the portal vein which is brought about by the obstruction of blood flow through the scarred liver. As the pressure builds up, blood backs up into the nearby veins of the esophagus, stomach and intestines which may rupture and cause gastrointestinal bleeding manifesting as vomiting of blood, bloody/black stools. Portal hypertension may also be evident as prominent visible veins in the abdomen)

What are the risk factors of liver cirrhosis?

There are several known risk factors for developing cirrhosis. The most common risk factors are:

• Excess alcohol use – regular consumption of more than 1-2 alcoholic beverage a day for women or 2-3 alcoholic beverages a day for men over a long period of time can lead to liver cirrhosis. Patients with other risk factors for liver disease may develop cirrhosis with even less regular alcohol use.
• Infection with viral hepatitis – while not all patients who have chronic infection with the hepatitis B virus (HBV) or the hepatitis C virus (HCV) will develop cirrhosis, chronic viral hepatitis is one of the leading causes of liver disease in the world.
• Obesity and Diabetes – obesity and diabetes are both risk factors for a form of liver injury known as non-alcoholic steatohepatitis (NASH). Over time NASH can lead to significant liver injury and cirrhosis. Not all patients with obesity or diabetes will develop NASH, but given the obesity epidemic in the

How is liver cirrhosis diagnosed?

If your doctor suspects that you have liver cirrhosis based on your clinical history and physical examination findings, an imaging test of the abdomen is requested, most often an ultrasound. A liver biopsy may not be necessary if the symptoms, blood tests, and imaging tests all point to cirrhosis.

An alternative method for diagnosing liver cirrhosis is a test called liver elastography or more commonly known as Fibroscan, which uses ultrasound to measure liver stiffness.

This measurement can be used to estimate how much scarring there is in the liver and to determine if cirrhosis has developed.

How is liver cirrhosis treated?

The goals of treatment in patients with cirrhosis are the following:

• Slow or reverse the causes of the liver disease. Identification of the underlying cause of liver injury is the first step to treatment. Patients with cirrhosis due to alcoholism should be advised to abstain from drinking. Patients diagnosed with chronic viral hepatitis, either hepatitis B or C should be evaluated of their status and be treated accordingly. Patients diagnosed with nonalcoholic steatohepatitis should be advised to c ontrol the conditions associated with the disease such as obesity, diabetes, and hyperlipidemia.
• Prevent, identify, and treat the complications of cirrhosis. Cirrhosis can lead to many complications, some of which happen because the liver no longer functions normally and because the blood flow through the liver is disrupted. Portal hypertension can lead to rupture and hemorrhage of the esophageal varices causing life-threatening bleeding which can be controlled through an upper gastrointestinal endoscopy with rubber band ligation or injection of histoacryl (tissue adhesive). Portal hypertension can also be medically treated using diuretics and beta-blockers with strict monitoring of blood pressure and blood electrolytes. They are recommended to reduce the amount of sodium they consume.

In extreme cases that the portal hypertension is not controlled, a procedure known as intrahepatic portosystemic shunt or TIPS allows blood to bypass the liver through a tube inserted through the vein relieving the pressure in the portal vein. Cirrhotic patients also are prone to develop ascites or fluid in abdominal cavity due to portal hypertension and low blood protein levels. Ascitic fluid sometimes develop infection, known as spontaneous bacterial peritonitis which may not cause symptoms, but if they do, they present with abdominal pain and tenderness, fever, and confusion. This condition is diagnosed by draining the fluid through the abdomen using a technique called paracentesis and is managed using appropriate antibiotics against identified microbes. Advanced stages of cirrhosis can adversely affect brain function by build up of toxins in the blood when the liver is malfunctioning. This condition is known as hepatic encephalopathy and manifests as sleep disturbances, mood or personality changes, trouble concentrating, shaking, slurred speech, confusion, or coma at the end of the line. Treatment involves controlling underlying stressors such as infection, bleeding, and taking certain medications such as lactulose to induce bowel movement. Lastly, patients with liver cirrhosis are at increased risk of developing liver cancer. Given this risk, patients should be screened using ultrasound and blood tests every six months to check for signs of cancer.

• Manage symptoms and blood abnormalities. Patients with cirrhosis are prone to develop electrolyte derangements especially low blood levels of sodium (hyponatremia) which may manifest with weakness or changes in sensorium. Unfortunately, restoring normal sodium levels in cirrhotic patients is difficult to do and often herald need for a liver transplant. The blood clotting mechanism among cirrhotic patients is also impaired since the liver is responsible in producing the proteins necessary for clot formation. This problem puts patients further at risk of bleeding from esophageal or gastric varices.

This is usually corrected medically by giving Vitamin K which aids in blood coagulation or blood transfusion of platelets or fresh frozen plasma if required.

• Determine if and when a liver transplant is needed. The definitive treatment for people with advanced cirrhosis is replacing the diseased liver with a healthy liver. However, not everyone with advanced cirrhosis is a good candidate for a transplant. Certain conditions such as liver cancer that has spread outside the liver, or significant heart or lung disease are not good candidates for the complicated, major surgery. Also, a good candidate must wait from long list for a compatible liver to be available. More than 80% if people will be alive once year after a successful liver transplant, and the majority of these will be alive five year after the transplant. This is compared with a high death rate in patients with very advanced cirrhosis who do not receive a liver transplant. The prognosis, however, depends in part on the cause of the liver disease (hepatitis C may develop/recur). Other major concerns following a transplant are the risks of side effects from anti-rejection drugs used to suppress the immune system, and the risk of rejection of the transplanted organ.

Can liver cirrhosis be prevented?

You can reduce your risk of developing cirrhosis by getting professional help if you have alcohol drinking problems, prevention of contracting viral hepatitis by vaccination against hepatitis B and A if not yet received, practicing safe sex, and lastly, lifestyle modification adapting healthy eating habits and exercise to prevent obesity, diabetes, and hyperlipidemia which are risks to developing fatty liver disease that can progress to liver cirrhosis in the long run.

For more information of liver cirrhosis, consult your physician.