Cirrhosis of the Liver
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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.
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.
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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.
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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.
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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.
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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.
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American Liver
Foundation (ALF)
Hepatitis Foundation International
United Network for Organ Sharing
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