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The liver, the largest organ in the body, is essential in
keeping the body functioning properly. It removes or neutralizes
poisons from the blood, produces immune agents to control
infection, and removes germs and bacteria from the blood.
It makes proteins that regulate blood clotting and produces
bile to help absorb fats and fat-soluble vitamins. You cannot
live without a functioning liver.
In cirrhosis of the liver, scar tissue replaces normal,
healthy tissue, blocking the flow of blood through the organ
and preventing it from working as it should. Cirrhosis is
the twelfth leading cause of death by disease, killing about
26,000 people each year. Also, the cost of cirrhosis in terms
of human suffering, hospital costs, and lost productivity
is high.
Causes
Cirrhosis has many causes. In the United States, chronic
alcoholism and hepatitis C are the most common ones.
Alcoholic liver disease. To many people,
cirrhosis of the liver is synonymous with chronic alcoholism,
but in fact, alcoholism is only one of the causes. Alcoholic
cirrhosis usually develops after more than a decade of heavy
drinking. The amount of alcohol that can injure the liver
varies greatly from person to person. In women, as few as
two to three drinks per day have been linked with cirrhosis
and in men, as few as three to four drinks per day. Alcohol
seems to injure the liver by blocking the normal metabolism
of protein, fats, and carbohydrates.
Chronic hepatitis C. The hepatitis C virus
ranks with alcohol as a major cause of chronic liver disease
and cirrhosis in the United States. Infection with this virus
causes inflammation of and low grade damage to the liver
that over several decades can lead to cirrhosis.
Chronic hepatitis B and D. The hepatitis
B virus is probably the most common cause of cirrhosis worldwide,
but it is less common in the United States and the Western
world. Hepatitis B, like hepatitis C, causes liver inflammation
and injury that over several decades can lead to cirrhosis.
Hepatitis D is another virus that infects the liver, but
only in people who already have hepatitis B.
Autoimmune hepatitis. This disease appears
to be caused by the immune system attacking the liver and
causing inflammation, damage, and eventually scarring and
cirrhosis.
Inherited diseases. Alpha-1 antitrypsin
deficiency, hemochromatosis, Wilson's disease, galactosemia,
and glycogen storage diseases are among the inherited diseases
that interfere with the way the liver produces, processes,
and stores enzymes, proteins, metals, and other substances
the body needs to function properly.
Nonalcoholic steatohepatitis (NASH). In
NASH, fat builds up in the liver and eventually causes scar
tissue. This type of hepatitis appears to be associated with
diabetes, protein malnutrition, obesity, coronary artery
disease, and treatment with corticosteroid medications.
Blocked bile ducts. When the ducts that
carry bile out of the liver are blocked, bile backs up and
damages liver tissue. In babies, blocked bile ducts are most
commonly caused by biliary atresia, a disease in which the
bile ducts are absent or injured. In adults, the most common
cause is primary biliary cirrhosis, a disease in which the
ducts become inflamed, blocked, and scarred. Secondary biliary
cirrhosis can happen after gallbladder surgery if the ducts
are inadvertently tied off or injured.
Drugs, toxins, and infections. Severe reactions
to prescription drugs, prolonged exposure to environmental
toxins, the parasitic infection schistosomiasis, and repeated
bouts of heart failure with liver congestion can all lead
to cirrhosis.
Symptoms
Many people with cirrhosis have no symptoms in the early
stages of the disease. However, as scar tissue replaces healthy
cells, liver function starts to fail and a person may experience
the following symptoms:
- exhaustion
- fatigue
- loss of appetite
- nausea
- weakness
- weight loss
- abdominal pain
- spider-like blood vessels (spider angiomas) that develop
on the skin
As the disease progresses, complications may develop. In
some people, these may be the first signs of the disease.
Complications of Cirrhosis
Loss of liver function affects the body in many ways. Following
are the common problems, or complications, caused by cirrhosis.
Edema and ascites. When the liver loses
its ability to make the protein albumin, water accumulates
in the legs (edema) and abdomen (ascites).
Bruising and bleeding. When the liver slows
or stops production of the proteins needed for blood clotting,
a person will bruise or bleed easily. The palms of the hands
may be reddish and blotchy with palmar erythema.
Jaundice. Jaundice is a yellowing of the
skin and eyes that occurs when the diseased liver does not
absorb enough bilirubin.
Itching. Bile products deposited in the
skin may cause intense itching.
Gallstones. If cirrhosis prevents bile
from reaching the gallbladder, gallstones may develop.
Toxins in the blood or brain. A damaged
liver cannot remove toxins from the blood, causing them to
accumulate in the blood and eventually the brain. There,
toxins can dull mental functioning and cause personality
changes, coma, and even death. Signs of the buildup of toxins
in the brain include neglect of personal appearance, unresponsiveness,
forgetfulness, trouble concentrating, or changes in sleep
habits.
Sensitivity to medication. Cirrhosis slows
the liver's ability to filter medications from the blood.
Because the liver does not remove drugs from the blood at
the usual rate, they act longer than expected and build up
in the body. This causes a person to be more sensitive to
medications and their side effects.
Portal hypertension. Normally, blood from
the intestines and spleen is carried to the liver through
the portal vein. But cirrhosis slows the normal flow of blood
through the portal vein, which increases the pressure inside
it. This condition is called portal hypertension.
Varices. When blood flow through the portal
vein slows, blood from the intestines and spleen backs up
into blood vessels in the stomach and esophagus. These blood
vessels may become enlarged because they are not meant to
carry this much blood. The enlarged blood vessels, called
varices, have thin walls and carry high pressure, and thus
are more likely to burst. If they do burst, the result is
a serious bleeding problem in the upper stomach or esophagus
that requires immediate medical attention.
Insulin resistance and type 2 diabetes.
Cirrhosis causes resistance to insulin. This hormone, produced
by the pancreas, enables blood glucose to be used as energy
by the cells of the body. If you have insulin resistance,
your muscle, fat, and liver cells do not use insulin properly.
The pancreas tries to keep up with the demand for insulin
by producing more. Eventually, the pancreas cannot keep up
with the body's need for insulin, and type 2 diabetes develops
as excess glucose builds up in the bloodstream.
Liver cancer. Hepatocellular carcinoma,
a type of liver cancer commonly caused by cirrhosis, starts
in the liver tissue itself. It has a high mortality rate.
Problems in other organs. Cirrhosis can
cause immune system dysfunction, leading to infection. Fluid
in the abdomen (ascites) may become infected with bacteria
normally present in the intestines. Cirrhosis can also lead
to impotence, kidney dysfunction and failure, and osteoporosis.
Diagnosis
The doctor may diagnose cirrhosis on the basis of symptoms,
laboratory tests, the medical history, and a physical examination.
For example, during a physical examination, the doctor may
notice that the liver feels harder or larger than usual and
order blood tests that can show whether liver disease is
present.
If looking at the liver is necessary to check for signs
of disease, the doctor might order a computerized axial tomography
(CAT) scan, ultrasound, magnetic resonance imaging (MRI),
or a scan of the liver using a radioisotope (a harmless radioactive
substance that highlights the liver). Or the doctor might
look at the liver using a laparoscope, an instrument that
is inserted through the abdomen and relays pictures back
to a computer screen.
A liver biopsy will confirm the diagnosis. For a biopsy,
the doctor uses a needle to take a tiny sample of liver tissue,
then examines it under the microscope for scarring or other
signs of disease.
Treatment
Liver damage from cirrhosis cannot be reversed, but treatment
can stop or delay further progression and reduce complications.
Treatment depends on the cause of cirrhosis and any complications
a person is experiencing. For example, cirrhosis caused by
alcohol abuse is treated by abstaining from alcohol. Treatment
for hepatitis-related cirrhosis involves medications used
to treat the different types of hepatitis, such as interferon
for viral hepatitis and corticosteroids for autoimmune hepatitis.
Cirrhosis caused by Wilson's disease, in which copper builds
up in organs, is treated with medications to remove the copper.
These are just a few examples—treatment for cirrhosis
resulting from other diseases depends on the underlying cause.
In all cases, regardless of the cause, following a healthy
diet and avoiding alcohol are essential because the body
needs all the nutrients it can get, and alcohol will only
lead to more liver damage. Light physical activity can help
stop or delay cirrhosis as well.
Treatment will also include remedies for complications.
For example, for ascites and edema, the doctor may recommend
a low-sodium diet or the use of diuretics, which are drugs
that remove fluid from the body. Antibiotics will be prescribed
for infections, and various medications can help with itching.
Protein causes toxins to form in the digestive tract, so
eating less protein will help decrease the buildup of toxins
in the blood and brain. The doctor may also prescribe laxatives
to help absorb the toxins and remove them from the intestines.
For portal hypertension, the doctor may prescribe a blood
pressure medication such as a beta-blocker. If varices bleed,
the doctor may either inject them with a clotting agent or
perform a so-called rubber-band ligation, which uses a special
device to compress the varices and stop the bleeding.
When complications cannot be controlled or when the liver
becomes so damaged from scarring that it completely stops
functioning, a liver transplant is necessary. In liver transplantation
surgery, a diseased liver is removed and replaced with a
healthy one from an organ donor. About 80 to 90 percent of
patients survive liver transplantation. Survival rates have
improved over the past several years because of drugs such
as cyclosporine and tacrolimus, which suppress the immune
system and keep it from attacking and damaging the new liver.
To read the rest of this article and related
materials from The National Digestive Diseases Information
Clearinghouse (NDDIC), please click here: http://digestive.niddk.nih.gov/ddiseases/pubs/cirrhosis/
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