DescriptionAn in-depth report on the causes, diagnosis, treatment, and prevention of cirrhosis
Alternative NamesAlcoholism; Liver Transportation; Primary Billing Cirrhosis
Cirrhosis is the eleventh leading cause of death by disease in the US, killing more than 25,000 people each year. A damaged liver affects almost every bodily process, including the functions of the digestive, hormonal, and circulatory systems. The most serious complications are those associated with so-called decompensation, which occur when cirrhosis progresses. They include the following:
Liver cancer is also a long-term risk with cirrhosis.
Cirrhosis is irreversible, but the rate of progression can be very slow, depending on its cause and other factors. Five-year survival rates are about 85% and can be lower or higher depending on severity.
Unfortunately, physicians are usually unable to determine when cirrhosis first occurred, which makes it difficult to determine prognosis.
In cirrhosis, liver cell damage slows down blood flow. This causes a backup of blood through the portal vein, a condition called portal hypertension. The effects of portal hypertension can be widespread and serious, including fluid buildup and bleeding.
Ascites and Fluid Buildup. Ascites is fluid buildup in the abdomen. It is uncomfortable and can reduce breathing function and urination. Ascites is usually caused by portal hypertension, but it can result from other conditions. Swelling can also occur in the arms and legs and in the spleen. Although ascites itself is not fatal, it is a marker for severe progression. Once ascites occurs, only half of patients survive after two years. In fact, some experts refer to the phases of cirrhosis as preascitic and ascitic. Some physicians even believe that ascites signals the need for liver transplantation, particularly in alcoholic cirrhosis.
Variceal Bleeding. One of the most serious repercussions of portal hypertension is the development of varices, which are blood vessels that enlarge to provide an alternative pathway for blood diverted from the liver. In about two-thirds of patients they form in esophagus (the "food pipe"). They pose a high risk for rupture and bleeding because of the following characteristics:
Bleeding commonly recurs within two weeks of the first episode, but after six weeks, the risk for recurrence is the same as for patients who have not had a bleeding event.
Factors that predict variceal bleeding in general include the following:
Factors that can increase the danger for a bleeding episode in high-risk individuals include the following:
It is important for patients to be screened for esophageal varices and treated with preventive beta blockers if they show signs of risk. Between 30% and 40% of patients with cirrhosis experience bleeding, which carries a mortality rate of between 20% and 35%. Some experts recommend that all newly diagnosed patients be screened using endoscopy. Screening should also be considered for all previously diagnosed patients who have not been screened but would benefit from preventive treatments.
Gastrointestinal (GI) bleeding can occur from abnormal blood clotting, which can be result of a combination of complications associated with cirrhosis. They include vitamin K deficiencies and thrombocytopenia -- a drop in platelets (the blood cells that normally initiate the clotting process). Some research now suggests that thrombocytopenia itself may be associated with more advanced liver failure.
Bacterial infections are very common in advanced cirrhosis, and may even increase the risk for bleeding. Most bacterial infections, including those in the urinary, respiratory, or gastrointestinal tracts, develop when patients are in the hospital. Abdominal infections are a particular problem in cirrhosis and occur in up to 25% of patients with cirrhosis within a year of diagnosis.
Mental Impairment and Encephalopathy
Mental impairment is a common event in advanced cirrhosis. In severe cases, the disease causes encephalopathy (damage to the brain), with mental symptoms that range from confusion to coma and death. A combination of conditions associated with cirrhosis causes this serious complication:
Encephalopathy is often triggered by certain conditions, including the following:
Alcoholics with cirrhosis are believed to be at higher risk for this complication than with nonalcoholic cirrhosis, but one study suggested that alcoholics simply tend to have more severe cirrhosis.
Symptoms of Encephalopathy. Early symptoms of hepatic encephalopathy include forgetfulness, unresponsiveness, and trouble concentrating. Sudden changes in the patients mental state, including agitation or confusion, may indicate an emergency condition. Other symptoms include bad fruity-smelling breath and tremor. Late stage symptoms of encephalopathy are stupor and eventually coma.
Hepatorenal syndrome occurs if the kidneys drastically reduce their own blood flow in response to the altered blood flow in the liver. It is a life-threatening complication of late-stage liver disease that occurs in patients with ascites. Symptoms include dark colored urine and a reduction in volume, yellowish skin, abdominal swelling, mental changes (delirium, confusion), jerking or coarse muscle movement, nausea, and vomiting.
Cirrhosis greatly increases the risk for liver cancer, regardless of the cause of cirrhosis. Although few studies have been conducted on the risk for liver cancer in patients with primary biliary cirrhosis, one study reported an incidence of 2.3%. About 4% of patients with cirrhosis caused by hepatitis C develop liver cancer. In Asia about 15% of people who have chronic hepatitis B develop liver cancer, but this high rate is not seen in other parts of the world. (One Italian study that followed a group of hepatitis B patients for 11 years found no liver cancer over that period of time.)
About 30% of patients with chronic liver disease develop osteoporosis (loss of bone density), which is twice the usual incidence Primary biliary cirrhosis poses a particularly high risk for osteoporosis. Treating osteoporosis in patients with cirrhosis can be complicated. One study found that calcitriol (a form of vitamin D) is especially helpful in preventing bone loss in patients with cirrhosis.
Nearly all patients with cirrhosis are insulin resistant. Insulin resistance is a primary feature in type 2 diabetes and occurs when the body is unable to use insulin. This hormone is important for delivering blood sugar and amino acids into cells and helps determine whether these nutrients will be burned for energy or stored for future use.
One study reported that nearly a quarter of patients with cirrhosis had gallstones.
They may also face a higher than average risk for certain abnormal heart rhythms. Peptic ulcers, sleep disorders, and respiratory problems are also more common in people with cirrhosis than in the general population.