Cirrhosis


Cirrhosis, also known as liver cirrhosis, hepatic cirrhosis, chronic liver failure, chronic hepatic failure, and end-stage liver disease, is a chronic condition of the liver in which the normal functioning tissue, or parenchyma, is replaced with scar tissue and regenerative nodules as a result of chronic liver disease. Damage to the liver leads to repair of liver tissue and subsequent formation of scar tissue. Over time, scar tissue and nodules of regenerating hepatocytes can replace the parenchyma, causing increased resistance to blood flow in the liver's capillaries—the hepatic sinusoids—and consequently portal hypertension, as well as impairment in other aspects of liver function.
The disease typically develops slowly over months or years. Stages include compensated cirrhosis and decompensated cirrhosis. Early symptoms may include tiredness, weakness, loss of appetite, unexplained weight loss, nausea and vomiting, and discomfort in the right upper quadrant of the abdomen. As the disease worsens, symptoms may include itchiness, swelling in the lower legs, fluid build-up in the abdomen, jaundice, bruising easily, and the development of spider-like blood vessels in the skin. The fluid build-up in the abdomen may develop into spontaneous infections. More serious complications include hepatic encephalopathy, bleeding from dilated veins in the esophagus, stomach, or intestines, and liver cancer.
Cirrhosis is most commonly caused by medical conditions including alcohol-related liver disease, metabolic dysfunction–associated steatohepatitis, heroin abuse, chronic hepatitis B, and chronic hepatitis C. Chronic heavy drinking can cause alcoholic liver disease. Liver damage has also been attributed to heroin usage over an extended period of time as well. MASH has several causes, including obesity, high blood pressure, abnormal levels of cholesterol, type 2 diabetes, and metabolic syndrome. Less common causes of cirrhosis include autoimmune hepatitis, primary biliary cholangitis, and primary sclerosing cholangitis that disrupts bile duct function, genetic disorders such as Wilson's disease and hereditary hemochromatosis, and chronic heart failure with liver congestion.
Diagnosis is based on blood tests, medical imaging, and liver biopsy.
Hepatitis B vaccine can prevent hepatitis B and the development of cirrhosis from it, but no vaccination against hepatitis C is available. No specific treatment for cirrhosis is known, but many of the underlying causes may be treated by medications that may slow or prevent worsening of the condition. Hepatitis B and C may be treatable with antiviral medications. Avoiding alcohol is recommended in all cases. Autoimmune hepatitis may be treated with steroid medications. Ursodiol may be useful if the disease is due to blockage of the bile duct. Other medications may be useful for complications such as abdominal or leg swelling, hepatic encephalopathy, and dilated esophageal veins. If cirrhosis leads to liver failure, a liver transplant may be an option. Biannual screening for liver cancer using abdominal ultrasound, possibly with additional blood tests, is recommended due to the high risk of hepatocellular carcinoma arising from dysplastic nodules.
Cirrhosis affected about 2.8 million people and resulted in 1.3 million deaths in 2015. Of these deaths, alcohol caused 348,000, hepatitis C caused 326,000, and hepatitis B caused 371,000. In the United States, more men die of cirrhosis than women. The first known description of the condition is by Hippocrates in the fifth century BCE. The term "cirrhosis" was derived in 1819 from the Greek word "kirrhos", which describes the yellowish color of a diseased liver.

Signs and symptoms

Cirrhosis can take quite a long time to develop, and symptoms may be slow to emerge. Some early symptoms include tiredness, weakness, loss of appetite, weight loss, and nausea. Early signs may also include redness on the palms known as palmar erythema. People may also feel discomfort in the right upper abdomen around the liver.
As cirrhosis progresses, symptoms may include neurological changes affecting both the peripheral and central nervous systems, disrupting the neurotransmission within the brain and causing neuromuscular fatigue. This can consist of cognitive impairments, confusion, memory loss, sleep disorders, and personality changes. Steatorrhea or presence of undigested fats in stool is also a symptom of cirrhosis.
Worsening cirrhosis can cause a build-up of fluid in different parts of the body, such as the legs and abdomen. Other signs of advancing disease include itchy skin, bruising easily, dark urine, and yellowing of the skin.

Liver dysfunction

These features are a direct consequence of liver cells not functioning:
  • Spider angiomata or spider nevi happen when there is dilatation of vasculature beneath the skin surface. There is a central, red spot with reddish extensions that radiate outward. This creates a visual effect that resembles a spider. It occurs in about one-third of cases. The likely cause is an increase in estrogen. Cirrhosis causes a rise in estrogen due to increased conversion of androgens into estrogen.
  • Palmar erythema, a reddening of the palm below the thumb and little finger, is seen in about 23% of cirrhosis cases, and results from increased circulating estrogen levels.
  • Gynecomastia, or the increase of breast size in men, is caused by increased estradiol. This can occur in up to two-thirds of cases.
  • Hypogonadism signifies a decreased functionality of the gonads. This can result in impotence, infertility, loss of sexual drive, and testicular atrophy. A swollen scrotum may also be evident.
  • Liver size can be enlarged, normal, or shrunken in people with cirrhosis. As the disease progresses, the liver will typically shrink due to the result of scarring.
  • Jaundice is the yellowing of the skin. It can additionally cause yellowing of mucous membranes notably of the white of the eyes. This phenomenon is due to increased levels of bilirubin, which may also cause the urine to be dark-colored.

    Portal hypertension

Liver cirrhosis makes it hard for blood to flow in the portal venous system. This resistance creates a backup of blood and increases pressure. This results in portal hypertension. Effects of portal hypertension include:
Some signs that may be present include changes in the nails. Additional changes may be seen in the hands as well as the skin/bones.

Advanced disease

As the disease progresses, complications may develop. In some people, these may be the first signs of the disease.
Cirrhosis has many possible causes, and more than one cause may be present. History taking is of importance in trying to determine the most likely cause. Globally, 57% of cirrhosis is attributable to either hepatitis B or hepatitis C. Alcohol use disorder is another major cause, accounting for about 20–40% of the cases.

Common causes

  • Alcoholic liver disease develops in 10–20% of individuals who drink heavily for a decade or more. Alcohol seems to injure the liver by blocking the normal metabolism of protein, fats, and carbohydrates. This injury happens through the formation of acetaldehyde from alcohol. Acetaldehyde is reactive and leads to the accumulation of other reactive products in the liver. People with ALD may also have concurrent alcoholic hepatitis. Associated symptoms are fever, hepatomegaly, jaundice, and anorexia. AST and ALT blood levels are both elevated, but at less than 300 IU/liter, with an AST:ALT ratio > 2.0, a value rarely seen in other liver diseases. In the United States, 40% of cirrhosis-related deaths are due to alcohol.
  • In non-alcoholic fatty liver disease, fat builds up in the liver and eventually causes scar tissue. This type of disorder can be caused by obesity, diabetes, malnutrition, coronary artery disease, and steroids. Though similar in signs to alcoholic liver disease, no history of notable alcohol use is found. Blood tests and medical imaging are used to diagnose NAFLD and NASH, and sometimes a liver biopsy is needed.
  • Chronic hepatitis C, an infection with the hepatitis C virus, causes inflammation of the liver and a variable grade of damage to the organ. Over several decades, this inflammation and damage can lead to cirrhosis. Among people with chronic hepatitis C, 20–30% develop cirrhosis. Cirrhosis caused by hepatitis C and alcoholic liver disease are the most common reasons for liver transplant.
  • Chronic hepatitis B causes liver inflammation and injury that, over several decades, can lead to cirrhosis. Hepatitis D is dependent on the presence of hepatitis B and accelerates cirrhosis in co-infection.