Cirrhosis of the liver

Cirrhosis is a type of liver damage in which healthy cells are gradually replaced by scar tissue. As this happens, the liver becomes less able to carry out its vital functions – including metabolism, the production of proteins such as blood clotting factors, and filtering drugs and toxins from the blood.

Many people think that only drinking excessive amounts of alcohol causes cirrhosis, but the liver can be damaged in a number of other ways. Depending on the cause, cirrhosis can develop over months or years. There is no cure, but treatment aims to halt liver damage, manage symptoms and reduce the risk of complications such as diabetes, osteoporosis (brittle bones), liver cancer and liver failure.

Symptoms#

Symptoms depend on the severity of the cirrhosis, but may include:

• appetite loss, nausea and weight loss
• general tiredness and disturbed sleep patterns
• spidery red veins on the skin (spider angiomas) and reddened palms (palmar erythema)
• easily bruised skin and itchy skin
• yellowing of the skin and eyes (jaundice)
• hair loss
• dark-coloured urine
• fluid retention in the abdomen and legs
• internal bleeding, which may show as dark-coloured stools or vomiting blood
• hormone disruptions that can cause a range of problems, including testicular atrophy (shrinking) and impotence in men, or amenorrhoea (no periods) in women
• cognitive problems such as memory loss, confusion or difficulty concentrating

Causes#

Two of the most well-known causes of cirrhosis are long-term excessive alcohol consumption and viral infection. However, a number of other conditions can also lead to liver damage and cirrhosis. Non-alcoholic (‘fatty liver’) disease is now the most common cause of chronic liver disease, and a small proportion of people with fatty liver go on to develop cirrhosis. Hepatitis B virus infection is an important cause of cirrhosis worldwide.

Alcohol#

Excessive and chronic alcohol consumption is the most common cause of cirrhosis, and it can develop over many years. The amount of alcohol that will damage the liver varies from person to person. If a healthy woman drinks the same amount of alcohol as a healthy man, she has a higher risk of cirrhosis. Some people have a genetic predisposition to alcohol-related liver injury, and people with a medical condition – especially one affecting the liver – may have a higher risk of damage from alcohol. If you already have hepatitis B or C, or cirrhosis from any cause, drinking alcohol can make your condition worse.

Hepatitis#

Hepatitis is a general term meaning inflammation of the liver. Viral hepatitis is caused by a virus such as the hepatitis B or C virus. Chronic hepatitis C is a common cause of cirrhosis, and hepatitis B can also cause it. With either condition, drinking alcohol increases your risk of developing cirrhosis.

Fatty liver disease#

Non-alcoholic fatty liver disease (NAFLD) is a condition in which fat builds up in the liver. It is becoming more common, including in children who are overweight or obese, and is associated with conditions such as obesity, type 2 diabetes, and high blood cholesterol and triglycerides. About 20 per cent of people with obesity have fatty liver disease.

NAFLD can lead to inflammation of the liver and the formation of scar tissue, a condition called non-alcoholic steatohepatitis (NASH), which can then lead to cirrhosis. NASH usually occurs in people who are obese, have diabetes, or have high blood cholesterol and triglycerides, so controlling these conditions is recommended. People with NASH have a higher risk of liver damage if they also have hepatitis C. The effect of alcohol is debated, but it is probably best avoided if there is significant liver scarring.

Inherited conditions#

Some inherited conditions damage the liver and lead to the scarring that can contribute to cirrhosis. These include:

• haemochromatosis – the body accumulates iron, which can damage many organs, including the liver
• Wilson disease – the body’s tissues accumulate copper
• galactosaemia – the body is unable to process galactose (a sugar), so it builds up in the blood and can cause liver damage
• cystic fibrosis – mainly affects the lungs, but can also cause scarring of the liver
• alpha-1 antitrypsin deficiency – can cause lung damage and can also affect liver function, leading to cirrhosis and liver failure

Other causes#

A number of other conditions that damage the liver can cause cirrhosis, including:

• autoimmune diseases – certain immune cells attack and damage the liver. These uncommon conditions include autoimmune hepatitis, primary biliary cholangitis and primary sclerosing cholangitis (inflammation and scarring of the bile ducts).
• exposure to poisons – one of the liver’s main roles is to remove toxins from the blood, so prolonged exposure to environmental toxins such as arsenic can damage it and lead to cirrhosis.
• schistosomiasis – a tropical disease (also known as bilharziasis) caused by a parasitic worm, Schistosoma, passed to humans from snails. Chronic infection damages internal organs, including the liver.
• certain medications – such as amiodarone, used to manage heart arrhythmias, which may rarely cause cirrhosis in susceptible people.
• unknown causes – in about one third of cases the cause is unknown (‘cryptogenic cirrhosis’), although some of these are due to non-alcoholic fatty liver disease.

Complications#

Without treatment, cirrhosis can lead to a range of potentially life-threatening complications, including:

• liver failure – the loss of liver cells and the disruption of blood flow through the liver by scar tissue can impair its function
• hepatic encephalopathy – impaired brain function caused by toxins the liver has failed to remove
• primary liver cancer – the most common type caused by cirrhosis is hepatocellular carcinoma
• bleeding from enlarged blood vessels (‘varices’) in the esophagus or stomach
• a build-up of fluid in the abdominal cavity (ascites)
• infection of this fluid (spontaneous bacterial peritonitis)
• osteoporosis (brittle bones)

Diagnosis#

Tests used to diagnose cirrhosis may include:

• a review of your medical history and a physical examination
• blood tests, including liver function tests
• urine tests
• imaging studies, including ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI)
• transient elastography (FibroScan) – an ultrasound-based technique to detect cirrhosis. It is less accurate in people with obesity unless specially designed XL probes are used.
• liver biopsy – obtaining liver tissue for laboratory examination

Treatment#

Cirrhosis is incurable, but in some cases treatment can help reduce the chance of the condition becoming worse. Treatment options include:

• treating the underlying cause of liver damage – for example, treating an underlying hepatitis B or C infection, or removing blood to lower iron levels in haemochromatosis
• making dietary and lifestyle changes – a nutritious, low-fat, high-protein diet and exercise can help people avoid malnutrition
• avoiding alcohol, which damages the liver and harms remaining healthy tissue
• taking certain medications – such as beta-blockers to reduce blood pressure and lower the risk of bleeding, or diuretics to remove excess fluid
• avoiding certain medications that can make symptoms worse, such as non-steroidal anti-inflammatory drugs (NSAIDs), opiates or sedatives
• having regular medical check-ups, including scans to check for liver cancer
• having regular endoscopic procedures to check for varices in the esophagus or stomach
• having a liver transplant, an option that may be considered in severe cases

Key points#

• Many people think that only drinking excessive amounts of alcohol causes cirrhosis.
• Depending on the cause, cirrhosis can develop over months or years.
• Two of the most well-known causes are long-term excessive alcohol consumption and viral infection.
• Non-alcoholic (‘fatty liver’) disease is the most common cause of chronic liver disease.
• Hepatitis B virus infection is an important cause of cirrhosis worldwide.

Where to get help#