Cirrhosis

Cirrhosis refers to scarring of the liver. The liver is a vital organ located in the right upper quadrant of the abdomen, whose function is to detoxify metabolites, synthesize proteins, hormones, bile, and biochemicals needed for digestion, growth, and metabolism. When the liver suffers an injury due to any cause, it tries to heal itself, resulting in fibrosis and scarring. Recurrent injuries ultimately result in massive liver scarring, replacing the normal functional tissue with the non-functional scarred tissue. The liver loses its ability to execute its functions, resulting in loss of appetite,  tiredness, weakness, nausea, vomiting, unexplained weight loss. With the progression of the disease, symptoms may include jaundice, itchiness, easy bruising, swelling in the lower legs, and building of fluid in the abdomen.  

Alcoholic liver disease, chronic hepatitis C, chronic hepatitis B, chronic non-alcoholic fatty liver disease, autoimmune hepatitis, Wilson's disease, chronic heart failure are among the most typical causes of liver cirrhosis. Treatment of liver cirrhosis depends upon the cause and the extent of the damage. The scarring is irreversible; however, early detection, prevention, and treatment can limit the progression of the disease.

Many different liver diseases may cause injury to the liver. After an injury, the healing process occurs, which involves excess deposition of extracellular substances (collagen, proteoglycans, glycoproteins), which replaces the normal functioning tissue of the liver.

Following are the most common chronic liver diseases leading to cirrhosis.

• Alcoholic liver disease
• Hepatitis C
• Hepatitis B
• Non-alcoholic fatty liver disease
• Autoimmune hepatitis
• Hemochromatosis
• Primary sclerosing cholangitis
• Alpha-1 antitrypsin deficiency
• Chronic right-sided heart failure
• Type IV glycogen storage disease
• Granulomatous disease - Eg, sarcoidosis
• Wilson disease
• Primary biliary cholangitis

Cirrhosis is prevalent worldwide, resulting in serious morbidity and mortality. Alcoholic liver disease is more common in the west, and the age for the presentation depends upon the years of alcohol usage.

Chronic viral hepatitis C and B are among the second most common cause. They are found worldwide, and cases are now increasing in the united states. It is more prevalent in the Eastern Mediterranean region and Europe. There is no age or sex predilection. 

Following are the risk factors that may increase your chances of having the disease.

• Excessive alcohol consumption.
• Being obese
• Being infected with viral hepatitis C and B
• Family history of having autoimmune diseases
• Using certain medicines like methotrexate, amiodarone, alpha methyldopa. 

The signs and symptoms are developed slowly over several days or even years. The initial symptoms are due to hepatic insufficiency; however, later, the symptoms are a result of complications of cirrhosis which are portal hypertension and ascites.

Portal hypertension refers to increased pressure in the liver’s blood supply, which causes back pooling of blood in the digestive tract and anastomosis between inside and outside of the body at multiple sites.

Ascites are the building up of fluid in your abdomen due to leakage from the blood vessels because of portal hypertension and decreased production of some proteins by the diseased liver.

Signs and symptoms are as follows;

• Tiredness and weakness
• Loss of appetite
• Easy bleeding or bruising
• Nausea
• Swelling in your lower legs and feet, called edema
• Weight loss
• Jaundice
• Itchy skin
• Redness in the palms of the hands
• Fluid accumulation in your abdomen (ascites)

Your doctor may ask you questions about your symptoms, check the physical signs, and order the following investigations.

• Blood tests: complete blood picture to assess for anemia, number of blood cells, liver function tests to determine the inflammation of the liver, coagulation profile, electrolytes and renal profile, tests for hepatitis C and B viruses, etc.
• Imaging: ultrasound, CT, and MRI scans can be used to assess the degree of fibrosis. The latest imaging test to determine the elasticity of the liver has been used lately called Magnetic resonance elastography (MRE).
• Biopsy: a sample of your liver tissue is taken out to check the fibrosis’s extent and severity in the laboratory. It is not usually done unless needed. 

Cirrhosis is the end-stage disease of multiple chronic liver diseases. Some other conditions may mimic the presentation of cirrhosis;

• Liver cancer
• Bacterial liver abscess
• Amoebic liver abscess
• Glycogen storage diseases
• Syphilis of the liver
• Cystic diseases of the liver
• Tuberculosis of the liver
• Trematode or other parasitic diseases.
• Tropical liver

Treatment is directed towards the specific cause of cirrhosis, preventing the progression of the disease and the symptomatic treatment of the symptoms.

Medications: Medicines are given for the respective causes like:

• Steroids like prednisone and azathioprine for autoimmune hepatitis,
• Phlebotomy for hemochromatosis,
• Interferon, and other antiviral agents for hepatitis B and C,
• Trientine and zinc for Wilson disease.
• Zinc sulfate is given For appetite improvement. It can also improve muscle cramps.
• Antihistamines can help mild itching
• Cholestyramine is used for specific itching due to liver disease

Liver transplant: In this procedure, your diseased liver is replaced by a new one. The liver tissue is taken from the deceased person or a living donor. Extensive investigations and medicines are ordered before the transplant to exclude the possibility of tissue rejection. 

Cirrhosis is an incurable disease. Once the damage is done, it cannot be reversed. The course of progression of cirrhosis to end-stage liver disease is variable in every individual. Some people with significant fibrosis may not show symptoms; however,  after a period of compensated liver disease, all will progress to decompensated liver disease with serious risks to health and life. After the diagnosis of cirrhosis is made, it takes up to 10 years to develop cirrhosis complications, the most common of which is ascites. After that, the patient will continue to deteriorate unless liver transplantation is done.

Following lifestyle changes can be adopted to prevent cirrhosis.

• Avoid drinking alcohol
• Consuming a healthy diet rich in vitamins, minerals, omega 3 fatty acids, antioxidants and avoiding fatty and fried food
• Bodyweight should be maintained according to BMI by taking a balanced diet and regular exercise.
• Avoid unprotected sex and sharing needles to prevent the risk of getting hepatitis B, and C.
• Get vaccinated for hepatitis B and hepatitis C.
• Employ regular exercises to improve inactivity and muscle cramps, and wasting.