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Cirrhosis of the Liver

A chronic hepatic disease, cirrhosis is characterized by diffuse destruction and fibrotic regeneration of hepatic cells.As necrotic tissue yields to fibrosis, cirrhosis alters liver structure and normal vasculature, impairs blood and lymph flow and ultimately, causes hepatic insufficiency. Cirrhosis is a serious, irreversible disease that's the 11th largest cause of death in the United 'States. The prognosis is better in noncirrhotic forms of hepatic fibrosis, which cause minimal hepatic dysfunction and don't destroy liver cells.

Causes

Cirrhosis can be caused by many things, some known and others unknown:

• Alcohol -- Using alcohol in excess is the most common cause of cirrhosis in the United States.
• Chronic Viral Hepatitis -- Type B and Type C hepatitis, and perhaps other viruses, can infect and damage the liver over a prolonged time and eventually cause cirrhosis.
• Chronic Bile Duct Blockage -- This condition can occur at birth (biliary atresia) or develop later in life (primary biliary cirrhosis). The cause of the latter remains unknown. When the bile ducts outside the liver become narrowed and blocked, the condition is called primary sclerosing cholangitis. This condition is often associated with chronic ulceration of the colon (colitis).
• Drugs and Toxins -- Prolonged exposure to certain chemicals or drugs can scar the liver.

Signs and symptoms

You may not have signs and symptoms of cirrhosis in the early stages of the disease. But as more scar tissue replaces healthy tissue and liver function declines, you may experience some of the following:

• Lack of appetite
• Weight loss
• Nausea
• Small, red spider veins under your skin or easy bruising
• Weakness
• Fatigue
• Yellowing of your skin and eyes and dark, cola-colored urine
• Bleeding from engorged veins in your esophagus or intestines
• Loss of interest in sex
• Fluid in your abdominal cavity (ascites)
• Itching on your hands and feet and eventually on your entire body
• Swelling of your legs and feet from retained fluid (edema)
• Mental confusion, such as forgetfulness or trouble concentrating (encephalopathy)

Diagnosis

The doctor often can diagnose cirrhosis from the patient's symptoms and from laboratory tests. During a physical exam, for instance, the doctor could notice a change in how your liver feels or how large it is. If the doctor suspects cirrhosis, you will be given blood tests. The purpose of these tests is to find out if liver disease is present. In some cases, other tests that take pictures of the liver are performed such as the computerized axial tomography (CAT) scan, ultrasound, and the radioisotope liver/spleen scan.

The doctor may decide to confirm the diagnosis by putting a needle through the skin (biopsy) to take a sample of tissue from the liver. In some cases, cirrhosis is diagnosed during surgery when the doctor is able to see the entire liver. The liver also can be inspected through a laparoscope, a viewing device that is inserted through a tiny incision in the abdomen.

Treatment

Dietary measures

The patient may benefit from a high calorie and moderate- to high-protein diet, but developing hepatic encephalopathy mandates restricted protein intake. In addition, sodium is usually restricted to 400 to 800 mg/day, fluids to 1,000 to 1,500 ml/day.

If the patient's condition continues to deteriorate, he may need tube feedings or hyperalimentation. Other supportive measures include supplemental vitamins - A, B complex, D, and K - to compensate for the liver's inability to store them and vitamin B, folic acid, and thiamine for deficiency anemia. Rest, moderate exercise, and avoidance of exposure to infections and toxic agents are essential.

Drug therapy

In cirrhosis, drug therapy requires special caution because the cirrhotic liver can't detoxify harmful substances efficiently. Alcohol is prohibited; sedatives should be avoided or prescribed with great care. Acetaminophen (Tylenol) is especially hepatotoxic, particularly when combined with alcohol.

When absolutely necessary, antiemetics, such as trimethobenzamide or benzquinamide, may be given for nausea; vasopressin, for esophageal varices; and diuretics, such as furosemide or spironolactone, for edema. However, diuretics require careful monitoring; fluid and electrolyte imbalance may precipitate hepatic encephalopathy.

Vitamin K may be given for bleeding tendencies due to hypoprothrombinemia. Transfusion of blood and fresh frozen plasma may also be necessary.

Beta blockers may be given to decrease pressure from varices.

Lactulose may be given orally or rectally for high ammonia levels.

Other treatment

Paracentesis and infusions of salt-poor albumin may alleviate ascites. Surgical procedures include ligation of varices, splenectomy, esophagogastric resection, and splenorenal or portacaval anastomosis to relieve portal hypertension.

CLINICAL TIP Transjugular intrahepatic portosystemic shunt is an alternative to surgical shunting in patients with variceal bleeding refractory to standard therapy. It's helpful in severe ascites. The technique involves insertion of an expandable metal shunt between a branch of the hepatic vein and portal vein over a catheter inserted via the jugular vein. This is usually a bridging mechanism to control variceal bleeding or ascites until liver transplantation can be performed.

Hepatorenal and hepatopulmonary syndromes may occur. Treatment is ineffective except in patients who are acceptable candidates for liver transplantation.

Prevention

The best way to avoid cirrhosis is to avoid the underlying conditions that cause it.

• Avoid risky behaviors such as alcohol abuse, IV drug use, and unprotected sexual intercourse.
• Develop healthy habits. Avoid using tobacco. Eat a healthy diet, get plenty of physical activity and rest, and maintain your weight in a healthy range.
• Alcohol is a toxin that must be filtered by your liver. In the process, liver cells become damaged. Unfortunately, you may not recognize that you have a problem with alcohol before serious liver damage has occurred. Knowing and recognizing a family history of alcoholism for you or others is an important step in seeking treatment.
• Avoid contact with toxic chemicals at work.
• Foods to be avoided are Processed foods, Soy sauce, pickled products, gravies, alcohol, caffeine, tobacco, chocolate and refined sugar and flour.