CIRRHOSIS - A Patient's Guide
Dr Geoff Green - Physician

What is it?

Cirrhosis is a liver condition characterised by scar formation in the liver, accompanied by regeneration (new growth) of tissue. These changes in the liver is the result of repetitive damage to the liver, usually over a prolonged period of time. As a result, the liver becomes hardened, nodular, and may shrink. At a later stage the functioning of the liver may decline.

The most important causes are:

1. Alcohol (prolonged and excessive use)

2. Viral hepatitis -hepatitis B, hepatitis C, other viruses.

3. Inherited diseases - Wilson's disease, Haemochromatosis(iron overload), Alpha1-antitrypsin deficiency.

4. Drugs and Toxins - methotrexate, isoniazid, methlydopa, arsenic.

5. Biliary cirrhosis.

6. Chronic heart failure (cardiac cirrhosis).

What are the consequences?

Cirrhosis can lead to:

1. Liver failure with jaundice and confusion (hepatic encephelopathy)

2. Portal hypertension (increases pressure in the vessels that drain the liver). This can cause severe bleeding, particularly from dilated veins (varices) in the oesophagus. It may also cause an enlarged spleen.

3. Ascites (fluid in the abdominal cavity). This results from decreases protein production by the liver, as well as portal hypertension.

4. Bleeding due to decreased production by the liver of clotting factors.

5. Spontaneous bacterial peritonitis - this is an infection in the ascites, which can be very serious.

6. Renal failure (hepato-renal syndrome)

7. Liver cancer (hepatoma)

Diagnosis:

Diagnosis requires a careful history, particularly relating to alcohol intake, as well as a clinical examination. Blood tests can usually identify abnormalities in liver function, as well as identify the different viruses which cause hepatitis. Radiological scanning (ultrasound, CT or MRI) of the liver shows evidence of scarring. In some cases a biopsy of the liver is required, so that a piece of tissue can be examined under the microscope.

What can be done about it?

The ideal is to prevent cirrhosis, by avoiding excessive alcohol intake and vaccination(against Hepatitis B). Once diagnosed, it is important to stop all alcohol consumption, and avoid drugs that damage the liver, if possible.

Interferon, given by subcutaneous injection, can slow the progression to cirrhosis in patients with chronic viral hepatitis, although it is best used before cirrhosis ensues. A number of other antiviral drugs are useful, including Lamivudin, which can be used in Hepatitis B cases with cirrhosis, and Ribavirin, used in Hepatitis C.

Where ascites occurs, diuretics, particularly spirinolactone can be used. A low salt diet is recommended. Spontaneous bacterial peritonitis requires aspiration of the ascitic fluid to determine the offending organism, and specific antibiotic therapy.

In patients with portal hypertension, drugs called Beta-blockers can reduce the risk of bleeding from oesophageal varices. When bleeding does occur (usually manifesting as vomiting blood), urgent hospital treatment is required.

When hepatic encephelopathy occurs(leading to a confused mental state), patients require treatment with antibiotics to reduce bowel bacteria, as well as treatment with lactulose, which decreases ammonia absorption. Ammonia is an important cause of the confusion that occurs in hepatic failure. Blood replacement and clotting products is often needed, and frequently intensive care treatment is needed.

Transplantation remains an option in cases of severe cirrhosis. Evaluation by a specialist unit is required. Not all patients are able to have a transplant.