In cirrhosis of the liver, progressive scarring (fibrosis) of the liver causes scar tissue to replace normal liver tissue. The scar tissue damages the normal structure of the liver which affects the normal flow of blood through the liver. The liver itself becomes distorted, hardened and lumpy. Without a good blood flow the liver can’t work as it should and its normal functions are impaired.
The liver is the largest organ in the body and is a very important organ to keep the body functioning properly. It is involved in the processing of nutrients and fats, poisons or toxins that find their way into the body, hormones and medications. It controls blood clotting and produces proteins. So, cirrhosis of the liver can affect the functioning of the entire body.
What happens in cirrhosis?
Cirrhosis happens when there are repeated episodes of inflammation and attempted healing in the liver. The initial damage can be caused by toxins, viruses, auto-immune inflammation or disorders of the body’s normal metabolic processes. Although many people associate liver cirrhosis with alcoholism, it can have many other origins, all of which lead to the same characteristic damage.
What causes it?
Cirrhosis of the liver has a number of different causes.
- Long-term heavy drinking of alcohol. It usually takes about 10 years of heavy drinking of alcohol for cirrhosis to develop. Women can develop cirrhosis with a daily intake of 2-3 alcoholic drinks a day, which might not be considered by some to be ‘heavy’. Similarly, men who have 3-4 alcoholic drinks a day can also develop cirrhosis.
- Chronic viral hepatitis types B, C and D. These hepatitis viruses cause inflammation of the liver and liver damage that after a few decades can cause cirrhosis.
- Wilson’s disease. This is a rare inherited disorder where excessive amounts of copper are absorbed in body tissues, particularly the liver.
- Haemochromatosis. One of the most common inherited disorders in Australia, where too much iron is absorbed by the body and the excess is deposited in the liver and other organs.
- Other inherited metabolic disorders, such as cystic fibrosis. Certain disorders that interfere with the body’s metabolism and how the liver stores substances can result in cirrhosis.
- Autoimmune hepatitis. This is hepatitis caused by a problem in the body’s immune system. The immune system doesn’t recognise its own cells and tissues as ‘self’ and attacks them thinking they are ‘foreign’, like invading bacteria.
- Blocked bile ducts. Bile is made in the liver and then the bile ducts carry the bile out of the liver to the gallbladder where it is stored. If the bile ducts become blocked due to scarring or inflammation, bile backs up in the liver and damages the liver tissues causing cirrhosis. Primary biliary cirrhosis is a disease of adults where the bile ducts become damaged. Biliary atresia is a condition of babies in which they are born without bile ducts or the bile ducts are damaged causing build-up of bile in the liver.
- Toxic hepatitis. This is rare and is caused by severe reactions to medications or environmental toxins.
- Chronic congestive heart failure with liver congestion. Repeated episodes of congestive heart failure with liver congestion can cause cirrhosis of the liver.
- Non-alcoholic fatty liver disease. In this condition, fat accumulates in the liver, which can cause inflammation and cirrhosis. This disorder is increasingly common, and is associated with obesity and diabetes.
- Cryptogenic cirrhosis. In about 10 per cent of cases, no cause for cirrhosis is found — this type of cirrhosis is called cryptogenic cirrhosis.
What are the initial symptoms of cirrhosis?
Often, especially in the early stages of liver cirrhosis, there may be no symptoms at all or some people may notice only minor changes in their body.
Symptoms of early cirrhosis include:
- loss of appetite;
- weight loss;
- tiredness and weakness; and
Later symptoms and problems
Later on, as the cirrhosis progresses and liver function gets poorer, other symptoms can develop including the following.
- Ascites. Ascites is a build-up of fluid in the abdominal cavity. This occurs in cirrhosis of the liver because less protein than normal is made by the cirrhosed liver, which leads to water building up. Raised pressure in the veins taking blood from the intestine also causes fluid to leak into the abdominal cavity. Fluid can also build up in the legs, where it is known as oedema.
- Bruising and bleeding. You may bruise more easily (due to a decrease in proteins needed for blood clotting).
- Intense itching. You may experience intense itching. This is due to bile products being deposited in the skin.
- Jaundice. Because bilirubin is not secreted so easily from the liver cells in cirrhosed livers, it builds up in the blood, leading to jaundice, with its typical yellow colour of the skin and whites of the eyes.
- Spider naevi. These are dilated blood vessels in the skin with a spidery appearance. They can often be seen on the face and chest of people with cirrhosis.
- Gallstones. Gallstones can occur in cirrhosis because not enough bile is being secreted from the liver and so not enough bile reaches the gallbladder.
- Reddening of the palms of the hands.
- Enlarged breast tissue in men (doctors call this gynaecomastia). This is because oestrogen is not broken down as normal in the liver cells and so builds up.
- Mental disturbances. If your liver is cirrhosed it no longer filters out toxins effectively. This causes the toxins to build up in the blood, which can cause mental impairment. At first this may be mild, such as poor concentration, forgetfulness or not being able to complete simple tasks, but may progress to personality changes, even coma.
- Sensitivity to medicines. Most medicines that are taken by mouth are absorbed in the digestive tract and then into the bloodstream. They then pass through the liver. When the liver is cirrhosed, it does not filter medications as effectively as normal, which may lead to the build-up of medications in the body which may increase the side effects of the medication.
- Varices. These are enlarged veins that can form in the oesophagus (gullet) due to high venous blood pressure in the liver. Blood from the intestines and spleen is normally pumped to the liver in the portal vein. If cirrhosis has damaged the liver, reducing venous blood flow through the liver, then the pressure in the portal vein rises and causes the blood to flow through other veins to return to the heart. The new blood vessels can become large and they have thin walls. Because the blood pressure inside them is high, if they break there will be a serious bleeding problem. Swelling of the spleen and haemorrhoids are 2 other consequences of raised portal venous pressure.
How is cirrhosis diagnosed?
Your doctor can usually diagnose cirrhosis quite easily by physically examining you and taking a history of any symptoms you may have. The doctor will be able to feel whether your liver is enlarged by gently pushing on your abdomen. Usually if cirrhosis is suspected, other tests such as blood tests, ultrasounds or a liver biopsy are done to confirm the diagnosis, assess the severity and identify the cause.
What is the treatment for cirrhosis?
Because cirrhosis is irreversible, treatment aims to stop the disease from getting any worse. The treatment you are offered will depend on the cause of your cirrhosis.
If you are a heavy drinker, you must stop consuming alcohol. Your doctor will be able to provide you with a comprehensive plan to help you to do so. The outlook for your disease is not good if you continue to drink — whereas the benefits of stopping are enormous. You will halt the progression of the disease from day one and will also feel much better. Talk to your doctor today. There are many methods available to help you.
If your cirrhosis is caused by viral hepatitis, you may be treated with anti-viral drugs to reduce permanent damage. Treatment of hepatitis B and C in the early stages is increasingly successful at preventing cirrhosis. Autoimmune hepatitis may be treated with steroids or other medicines that supress the immune system.
Cirrhosis caused by Wilson’s disease is treated with medications to remove the excess copper from the body. Similarly, cirrhosis caused by haemochromatosis is treated by letting blood every so often to use up the excess iron in the body.
Some symptoms of cirrhosis can be helped by medications. Ascites and fluid retention can be treated with medicines known as diuretics that help remove excess fluid. A low-sodium diet and restricting fluid intake can also help with these problems.
Medications may be given to help reduced mental functioning and your doctor may advise making changes to your diet to assist this process. Meals that are high in protein can often precipitate confusion — known as hepatic encephalopathy — in people with liver failure. Also, if itching is a symptom, your doctor will probably be able to prescribe something to help stop or reduce the itching.
If cirrhosis is very severe and the liver stops working, liver transplantation is the only option. It is often recommended when symptoms become difficult to control by other methods. Transplants are not usually given to people with cirrhosis who are actively using alcohol or drugs, although people who have cirrhosis as a result of heavy drinking, and who can show that they have stopped, may be good candidates for transplantation.
In all cases of cirrhosis of the liver a healthy balanced diet and avoidance of alcohol are essential.