Lloydspharmacy.com Health - Cirrhosis of the liver

Reviewed by Dr Alan Ogilvie, gastroenterologist

What is cirrhosis of the liver?

Cirrhosis is scarring of the liver that involves the formation of fibrous (scar) tissue associated with the destruction of the normal architecture of the organ. It is the result of long-standing injury most commonly due to alcohol in excess but there are a number of other important causes (see below).

The destruction of the normal architecture and the loss of liver cells prevents the liver from functioning normally. It plays an important part in digestion of food but it also has a major role in metabolising drugs and making proteins, including those that help the blood to clot.

Cirrhosis is a serious condition. Only 30 per cent of patients with this problem will survive five years after diagnosis and the outlook is worse if the cause is alcohol and the patient continues to drink.

What are the causes of the inflammation that leads to cirrhosis of the liver?

Alcohol excess: the rate of cirrhosis in a country is directly related to the average alcohol consumption in that country. Half of all cases of cirrhosis are due to alcohol excess.
Chronic viral hepatitis: the two important viruses are hepatitis B and hepatitis C. Cirrhosis due to hepatitis B is common in Africa and Asia. Hepatitis C is increasing in importance both in Europe and the US. Hepatitis A (infectious hepatitis) does not cause cirrhosis.
Primary biliary cirrhosis: this is an uncommon disease mainly affecting women. It is not due to alcohol. For some reason the body mounts an attack on the liver in patients with primary biliary cirrhosis.
Autoimmune chronic active hepatitis: another uncommon condition that results in the body's immune system attacking and destroying liver cells.
Drugs and chemicals: a number of drugs and chemicals can cause liver damage but few cause cirrhosis. Certain specialised drugs need monitoring for their effect on the liver.
Metabolic and inherited disorders: These are a number of uncommon conditions that allow the accumulation of toxins in the liver. The commonest is haemochromatosis, which causes excess deposits of iron in the liver.

What are the symptoms of liver cirrhosis?

The symptoms will depend on how much damage has occurred to the liver.

In the early stages there may be no symptoms at all and the disease may be discovered as a result of an investigation for another illness.

As the disease progresses, tiredness, weakness, lack of energy, loss of appetite, nausea and weight loss may develop.

In the later stages the liver is struggling to perform all its functions and any or all of the following symptoms may be present.

Jaundice: this is the yellowing of the skin (jaundice) and the eyes due to the failure of the liver to remove a substance called bilirubin from the blood.
Nail changes: the shape and appearance of the nails may change. They may be more curved (clubbing) and they may be white rather than pink.
Skin changes: about a quarter of patients will have darkening of the skin.
Fluid retention: this is common at some stage in cirrhosis. An important function of the liver is to rid the body of excess fluid through the kidneys and when it fails, fluid gathers in the legs (oedema) or in the abdomen (ascites).
Abnormal blood vessels: the commonest abnormality is a spider naevus, which is a spot surrounded by fine blood vessels. A red face is also common.
Easy bruising: nosebleeds and easy bruising occur as a result of abnormal blood vessels and delayed clotting because the liver does not make enough clotting proteins.
Enlargement of breasts in men: the liver destroys the female sex hormones and in cirrhosis these accumulate and cause enlargement of the breasts and shrinking of the testes in men.

In the very late stages of the disease, serious complications may occur. These include vomiting of blood, either from ulcers in the stomach or from leaking varicose veins in the lower end of the oesophagus (gullet). This is serious and requires hospital treatment.

The liver is responsible for removing poisonous substances from the blood. In cirrhosis, the blood may bypass the liver and these poisonous substances pass to the brain where they may result in alteration in brain function, causing confusion, drowsiness and finally coma. This is called hepatic encephalopathy. This is also serious and requires hospital treatment.

Who is at risk?

The more alcohol a person drinks, the more likely they are to develop cirrhosis. Women seem to be more susceptible than men. It is therefore advisable to restrict alcohol consumption to 28 units a week for men and 21 units a week for women (a unit of alcohol is a single measure of spirits, a half pint of ordinary beer or lager or a standard size glass of wine).
Patients who have ongoing infection with hepatitis B or hepatitis C virus.
Patients with primary biliary cirrhosis or autoimmune chronic active hepatitis.
Patients with metabolic or inherited disorders.

How can cirrhosis of the liver be prevented?

Limit the intake of alcohol (see above).
Alcoholics should seek help.
Precautions should be taken to avoid getting hepatitis and if it is contracted it is important that it is treated.
Avoid contact with toxic chemicals at work.

How is cirrhosis of the liver diagnosed?

If a clinical examination creates a suspicion of cirrhosis of the liver, the diagnosis may be supported by the analysis of blood samples. Although it may be confirmed by an ultrasound examination, it may be necessary to perform a liver biopsy to obtain tissue samples from the liver. This may also give information on the underlying cause of the cirrhosis.

Good advice

If alcohol excess and dependence is the cause, you must stop drinking alcohol immediately. Once alcohol has damaged the liver, then the liver cells are vulnerable to even small amounts of alcohol.

Seek help from friends, family and any of the organisations that specialise in helping people with alcohol problems. Your doctor will be able to help.

Activity

Try to lead an active life. This may be difficult because of the tiredness and weakness but it is worth persevering.

If your legs are swollen, it may be helpful to raise them while you are resting.

Food

Avoid all alcohol intake.
Eat a well-balanced, high-protein diet (only in consultation with your doctor).
Avoid adding salt to meals. Salt may be used in small amounts in cooking.
In the later stages, the amount of protein you eat may be reduced from time to time (on the advice of your doctor).
Vitamin and mineral supplements may be necessary.

Possible complications

Impotence in men. This is a combination of the effects of alcohol and cirrhosis.
Severe internal bleeding from ruptured varicose veins in the stomach or oesophagus. This is serious and requires hospital treatment.
Liver cancer, which occurs at a late stage in a number of patients with cirrhosis.
Blood poisoning, due to infection of the excess fluid in the abdomen (ascites).

Future prospects

The gradual destruction of the liver can be stopped by removing the cause. This underlies the advice on alcohol. Treatment is available for chronic hepatitis B virus infection and also for chronic hepatitis C virus infection. Iron overload can be treated by removing blood on a regular basis. Autoimmune chronic active hepatitis can be treated with steroids to suppress the immune system and prevent it attacking the liver cells.

Although the damage may not be repaired, the symptoms can be relieved and controlled. If treatment is started early, the sufferer may be able to lead an almost normal life. If the cause is not removed, however, the formation of scar tissue and destruction of the liver structure will continue, ultimately resulting in liver failure and death.

How is cirrhosis of the liver treated?

Apart from removing the cause, cirrhosis of the liver cannot be treated. The emphasis is therefore on dealing with and reducing the complications of the disease.

The following approaches are used:

water tablets (diuretics) for the treatment of fluid retention in the legs (oedema) or abdomen (ascites).
vitamins and mineral supplements.
calorie supplements (usually sugar-based drinks) to maintain nutrition.
laxatives (usually a syrupy solution called lactulose) to prevent constipation and to reduce the chances of the poisonous substances from the bowel bypassing the liver and reaching the brain, causing drowsiness, confusion and coma (hepatic encephalopathy).
some patients who have had bleeding from ruptured varicose veins in the lower oesophagus may be put onto a drug called propranolol, which reduces the pressure in those veins and lowers the chances of them bleeding again.
finally, liver transplantation may be considered in patients with end-stage cirrhosis.

Based on a text by Dr Carl J. Brandt, GP and Professor Ove Schaffalitzky de Muckadell, consultant

Last updated 04.01.2005