The liver is located at the upper abdomen and is the largest and one of the most vital internal organs in the body. Currently, there are no methods to compensate for the absence of liver. The liver has a large range of functions, from hormone production to glycogen storage and bile production, performing both regulatory and metabolic roles.
Cirrhosis is the extensive scarring of the liver due to chronic, irreversible liver inflammation and damage. It was René Laennec in 1826 who introduced the term cirrhosis, which is derived from the greek term "kirrhos" (meaning tawny). It is characterized by diffuse fibrotic bands of connective tissue that distorts the liver's normal architecture. As cirrhosis develops, the tissue becomes nodular that can block the bile ducts and normal blood flow throughout the liver. Although cirrhosis can develop due to many different factors, in the United States chronic alcoholism continues to be the main cause of this condition. It is the 12th leading cause of death by disease with a total of 27,000 related deaths in the United States.
- Chronic Hepatitis (B, D and autoimmune)
- Cystic fibrosis
- Fatty liver (steatohepatitis) - due to obesity and diabetes
- Primary biliary cirrhosis
- Primary sclerosing cholangitis
- Hemochromatosis – excess of iron in the liver
- Parasite infection
- Wilson's disease
- Alpha-1 antitrypsin deficiency
- Prescription drugs and toxins
- Cardiovascular disease - vascular cirrhosis is associated with a severe right sided heart failure
In early cirrhosis, the symptoms are vague and nonspecific, and this may lead to difficulties in developing patient awareness and diagnosis.
The symptoms of cirrhosis include:
- Change in weight - loss or gain
- Bleeding and bruising easily
- Nausea and vomiting
- Edema of the extremities - swelling on legs
- Water retention in the abdomen (ascites)
- Confusion or disorientation
- Clay colored stools
- Spider angiomas
- Vomiting blood
- Blood in stool
Diagnosis starts as with many other conditions with a medical interview and a complete physical assessment. This is important to guide the next steps during diagnosis and treatment. Initial suspicion of liver problems may be confirmed by laboratory tests (including blood tests) to check for abnormalities in liver markers. These abnormalities are very common in liver disease, but may be due to diverse etiology.
Ultrasound of the liver is often the first imaging assessment used in the differential diagnosis, since it allows scanning for abnormalities in the shape of the liver and may detect an array of conditions. Abdominal computerized tomography (CT) and magnetic resonance imaging (MRI) may also be applied to visualize the liver.
Liver biopsy is also very useful to determine the extent of the disease and the exact pathology. However, the procedure is associated with some risks and is not performed when the previous analyses are conclusive.
Disease severity is normally classified with the Child-Pugh score which takes into account bilirubin, albumin, the prothrombin time, presence and degree of ascites and encephalopathy. Under this scale there are three classes: A, B or C. Prognosis worsens and risk of death increases from A to C. Currently there are other scores (Model for End-Stage Liver Disease and Pediatric End-Stage Liver Disease) that measure severity and need for liver transplant.
Independently of the exact etiology of the disease, it is very important to prevent any further damage to the liver by stopping any drinking of alcohol, taking medication that causes hepatic damage (such as paracetamol) or consuming drugs. Cirrhosis is irreversible and has no cure, however, there are treatments available that can avoid complications and provide comfort measures. A low sodium diet should be followed in order to control fluid accumulations in the abdomen and edema. Refractory ascites and variceal bleeding may be managed non-surgically by transjugular intrahepatic portosystemic shunt (TIPS). In cases of complete or near-complete liver failure, liver transplantation is necessary.
Medications are very important in the clinical management of the disease:
Diuretics help to reduce fluid retention and prevent edema.
Lactulose promote excretion of ammonia in the stool and is effective in treating hepatic encephalopathy.
Antibiotics are used to fight any ongoing bacterial infections.
Hemodialisis and drugs to facilitate blood circulation through kidneys for patients with hepatorenal failure.
Vitamin K to address ongoing coagulopathy.
Antiviral or steroids to stop viral infections and control liver cell damage due to viral hepatitis.
Milk thistle is an herbal treatment that helps in alleviating liver disorders and helps in management of cirrhosis. Institution of diet therapy is important for cirrhotic patients. The objective is not to overwhelm the injured liver with large amounts of food. Small frequent meals are better than eating large portions.
Cirrhosis is a serious and irreversible disease. The prognosis of cirrhosis depends on the extent of the liver damage. If the condition of the liver is still manageable, the prognosis is fair under the appropriate treatment and surveillance. However, if there is the occurrence of liver failure, the patient may need a liver transplant in order to live.
People living with cirrhosis should have a healthy lifestyle. They must stop drinking alcoholic beverages, eat a healthy diet and avoid high sodium foods. Always take your medications and follow proper usage of the drug. If you developed hepatorenal failure, you will need to go to a dialysis center frequently to detoxify your blood.
Research aims to develop new therapeutic tools for serious complications from cirrhosis, such as an increase in portal hypertension and hepatorenal syndrome. Evaluation of risk factors and improvement in diagnostics through the use of new markers is another area of current development. In an exciting new field of research, investigators are attempting to design and create artificial liver support systems.