Cirrhosis is a disease that can be life threatening and occurs when fibrosis develops. Fibrotic tissue replaces healthy liver tissue and prevents it from functioning normally. Cirrhosis occurs after many years of liver tissue inflammation. As the cirrhosis develops, fibrotic tissue surrounds the normal liver cells, causing nodular aspect. Nodular liver tissue can block or inflame the bile ducts, causing bile reflux in the liver and bloodstream. Fibrotic tissue can also block bloodstream from the intestines to the liver, causing increased pressure in the portal venous system. This complication, called portal hypertension, leads to ascites fluid accumulation in the abdominal cavity, the bleeding of enlarged vessels in the digestive tract and further serious complications.
Cirrhosis can have many causes. Some people suffer from cirrhosis without an obvious cause, a condition called cryptogenic cirrhosis (no known etiology). Most frequent causes of cirrhosis are excessive intake of alcohol for an extended period of time and infection with hepatitis B or C.
- Alcoholic cirrhosis. This can occur in men who consume large amounts of alcohol daily for 10-15 years. Women develop alcoholic cirrhosis by a lower consumption of alcohol daily for the same period of time. At least 10-15% of chronic users eventually develop alcoholic cirrhosis. Every year over 26,000 people die due to cirrhosis, at least 40% having a history of chronic alcohol consumption.
- Cirrhosis caused by the infection with hepatitis viruses. This occurs in approximately 40% of people suffering from chronic viral hepatitis. Cirrhosis occurs slowly, requiring 20 years or more until its appearance. However, in patients with chronic viral hepatitis who drink too much alcohol, cirrhosis is installed much faster than in patients with chronic viral hepatitis that don’t consume alcoholic drinks.
- Cirrhosis caused by NASH (Non-alcoholic Steatohepatitis). NASH is a disease caused by the accumulation of fat in the liver. The disease becomes increasingly common and can cause multiple types of cirrhosis, currently classified as cirrhosis of unknown etiology (idiopathic).
- Primary biliary cirrhosis is a type of cirrhosis that occurs when the bile ducts from the liver to the duodenum are inflamed and blocked. The exact cause is unknown, but it appears to be related to the immune system.
Autoimmune hepatitis. In some people, the immune system attacks the liver causing cirrhosis.
- Hereditary diseases. Sometimes, cirrhosis may be caused by a congenital disease such as Wilson’s disease, cystic fibrosis or hereditary hemochromatosis. Other causes of cirrhosis that are less common include severe reactions to drugs, prolonged exposure to environmental pollutants, the disease called alpha-1-antitrypsin deficiency (AAT) (extremely rare cause) or a biliary tract disease with prolonged evolution, such as primary sclerosing cholangitis.
Some people suffering from cirrhosis have no symptoms until damage caused is already severe. Symptoms of cirrhosis and its complications include:
- Lower limb edema (swelling of legs) and ascites fluid (liquid accumulated in the abdomen);
- Jaundice (yellowing of the skin and whites);
- Generalized pruritus (itching);
- Nosebleeds (epistaxis);
- Mottled hands (red colored palms) – palmar erythrosis;
- Bruising from minor trauma;
- Weight loss and muscle weakness;
- Abdominal pain;
- Frequent infections.
Cirrhosis is a potentially life-threatening condition that occurs when the inflammation of the fibrotic tissue affects the liver. Physical examination and medical history to assess symptoms are first performed to investigate whether liver damage is severe enough to cause signs of cirrhosis and to determine the cause of liver disease.
A combination of tests can be used for diagnostic when physical examination and medical history suggests signs of cirrhosis. Blood tests can evaluate and determine the cause of the liver cirrhosis and reveal liver inflammation. Other tests that provide images of the liver are used to detect tumors and obstructed (blocked) bile ducts and to assess the size of the liver and intrahepatic blood flow.
Blood tests that can reveal the presence of an active liver inflammation include:
- Aspartate aminotransferase (AST) – A high AST level (also called SGOT) may indicate liver damage and the “death” of liver cells;
- Alanine aminotransferase (ALT) – High levels of ALT (also called SGPT) may also indicate liver damage and the “death” of liver cells;
- Lactate dehydrogenase (LDH) – High levels of LDH may indicate liver damage and the possible “death” of blood cells;
- Alkaline phosphatase (ALP) – High levels of ALP may indicate bile duct obstruction;
- Gamma-glutamyl transpeptidase (GGT) – An increased level of GGT reveals that the liver inflammation is caused by consumption of alcohol or bile duct obstruction; the level of GGT may also indicate the use of certain drugs, such as Phenobarbital and Dilantin. However, GGT can be increased without the presence of an inflammation.
Blood tests that evaluate liver function. Measuring levels of certain substances synthesized by the liver may be helpful in assessing the liver function. These tests include:
- Albumin and total serum proteins – Albumin is a type of protein. Cirrhosis can lead to decreased serum protein levels;
- Partial thromboplastin time (PTT), prothrombin time (PT) or international normalized ratio (INR). These tests measure the factors synthesized by the liver which have the role of coagulation;
- Bilirubin. It is produced by the liver by breaking down hemoglobin, which is a component of red blood cells with oxygen carrier role. Cirrhosis may increase blood levels of bilirubin, the clinical manifestation being jaundice (yellowing of the skin and the whites of the eyes).
Blood tests that can diagnose the cause of cirrhosis include:
- Anti-nuclear antibodies (ANA). ANA testing and Anti-smooth muscle antibodies (ASMA) can help detect chronic autoimmune hepatitis;
- Anti-mitochondrial antibodies (AMA) can help determine a primary biliary cirrhosis;
- Ferritin and serum iron can help diagnose hemochromatosis;
- Hepatitis B and hepatitis C antibodies or genetic material tests of liver viruses (RNA or DNA) can help diagnose a viral hepatitis infection;
- Blood alcohol level can help detect alcohol consumption, which can cause alcoholic cirrhosis;
- Analysis of serum ceruloplasmin help diagnose Wilson’s disease;
- The level of Alpha-1-antitrypsin can diagnose the alpha-1-antitrypsin deficiency (ATT), a rare cause of cirrhosis.
Imaging tests check for tumors and biliary obstruction and evaluate liver size and hepatic blood flow. These tests include:
- Abdominal ultrasound (ultrasonography);
- Abdominal Computed tomography (CT);
- Abdominal MRI;
- Liver and spleen scintigraphy (rarely used).
Other tests used to confirm the diagnosis of cirrhosis and assessment of possible complications include:
- Liver biopsy, the only test that can directly confirm the diagnosis of cirrhosis. Examination of liver tissue may also reveal signs of inflammation. Liver biopsy is done by inserting a long needle through the two lower ribs, extracting a tissue sample that will be microscopically analyzed;
- Paracentesis helps diagnose fluid accumulation in the abdominal cavity (ascites) or to detect the infection of the accumulated fluid (spontaneous bacterial peritonitis). Paracentesis is a procedure whereby a needle is inserted into the abdominal cavity to extract the liquid accumulated, which is to be analyzed;
- Upper gastrointestinal endoscopy is performed to detect varicose veins in the digestive tract that may cause variceal bleeding. Endoscopy allows your doctor to look inside the digestive organs, body cavities and channels, using a thin, flexible and light instrument called an endoscope;
- Blood levels of Alpha-fetoprotein (AFP) is a screening test for hepatocellular carcinoma;
- The ammonia test detects high levels of ammonium in the blood which can cause hepatic encephalopathy.
There is currenly no treatment or cure for cirrhosis, nor is there a treatment that can heal the liver damage done.
However, treatment can sometimes prevent or delay further liver damage.
The main components of treatment include:
- Treating the cause of cirrhosis, if possible, to prevent further deterioration;
- Avoid substances that can aggravate liver damage, especially alcohol and NSAIDs (Non-steroidal anti-inflammatory drugs);
- Preventing and treating symptoms and complications or cirrhosis;
- Liver transplant, if severe liver damage and if the patient is included on the transplant waiting list and a compatible donor is found.