Cirrhosis

Cirrhosis is an often irreversible scarring of the liver. This is usually the result of various problems that damage liver cells over time. Eventually, damage becomes so severe that the normal structure of the liver is changed and it stops funtioning correctly.

The disease process often takes the following path:

Scarring. The main damage in cirrhosis is triggered by scarring (fibrosis) that occurs from injuries due to alcohol, viruses, fatty liver disease (NASH) or other problems. Eventually, the liver is taken over by scar tissue and becomes a series of nodules which do not allow chemicals to flow through and the liver stops functioning. The scar tissue and nodules act like small dams and alter the flow of blood and bile in and out of the liver.

Altered Blood and Bile Flow. The changes in blood and bile flow have significant consequences, with both the liver and other organs responding to the altered flow.

Changes in Liver Size. The liver enlarges in the first phases of the disease. In advanced stages, the liver sometimes shrinks, this is cirrhosis.

How serious is cirrhosis?

Cirrhosis is the seventh leading cause of death by disease in the U.S., 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 means that the liver can not keep up with the body's demands. 90% of the liver must be non-functioning for this to occur. Therefore, patients can live for years, sometimes decades with few symptoms or problems related to cirrhosis.

Signs of "decompensation" include the following: Bleeding from the GI tract

  • From Esophageal (swallowing tube) or gastric (stomach) varices
  • From Portal Hypertensive Gastropathy (swelling of the stomach lining)

Fluid buildup in the belly (ascites)

  • Infection of the fluid can be life-threatening
  • Fluid can leak into lungs and cause shortness of breath

Medical confusion (encephalopathy). Impaired brain function occurs when the liver cannot detoxify harmful substances.

  • Can lead to coma

Liver Cancer

Cirrhosis is often 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.

  • For example, for alcoholics with cirrhosis who stop drinking, a survival rate of five years or more can be as high as 85%. For those who continue drinking, the chance for living beyond five years is no higher than 60%.
  • In patients with hepatitis B or C, the five-year survival rate after a diagnosis of cirrhosis ranges between 71% to 85%.
  • About two-thirds of patients with primary biliary cirrhosis never develop symptoms and can have a normal life span. Once symptoms of liver damage, such as jaundice, occur, the average survival time declines. In one study of women diagnosed with primary biliary cirrhosis, about 36% developed symptoms over an 11-year period, and 11% either died or required liver transplantation.

Unfortunately, physicians are ususally unable to determine when cirrhosis first occurred, which makes it difficult to determine prognosis.

How does cirrhosis shorten your life?

  1. Variceal bleeding or stomach/esophagus bleeding which can occur without warning
  2. Ascites or fluid build-up on your belly which can become infected
  3. Encephalopathy or medical confusion which can result in a coma
  4. Liver cancers and tumors

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.

Lab Tests

Certain blood tests are used to determine liver function. They include the following:

  • Serum albumin concentration. Albumin is a protein the liver normally makes. Low levels show decreased liver function.
  • Prothrombin time (PT)/INR. The PT/INR test measures in seconds the time it takes for blood clots to form. The liver makes blood clotting factors. Higher INR means thinner blood and worse liver function.
  • Bilirubin. Indicative of liver damage, bilirubin, a red-yellow pigment is normally metabolized in the liver and then excreted in the urine. In patients with hepatitis, the liver cannot process bilirubin, and blood levels of this substance rise, sometimes causing jaundice.

The results of these tests along with the presence of specific complications (ascites and encephalopathy) are used for calculating the severity of cirrhosis.

The MELD score to determine where a patient is on the transplant list uses the INR, Total Bilirubin and Creatnine (a measure of kidney function).

Other Tests Used to Detect Complications of Cirrhosis

Paracentesis. If ascites is present, paracentesis is performed to determine its cause. This procedure involves using a thin needle to withdraw fluid from the abdomen.

  • Bacteria cultures and white blood cell counts. (These are used to determine the persence of infection.)
  • Protein levels. Low levels of protein in the fluid plus a low white blood cell count suggest that cirrhosis is the cause of ascites.

Screening for Liver Cancer. Patients with cirrhosis are usually screened for liver cancer using ultrasound and tests for a substance called alpha-fetoprotein (AFP). Screening is not necessary in patients without cirrhosis.

What are the symptoms of cirrhosis?

Early cirrhosis often has NO symptoms.

However, symptoms can include the following:

  • Fatigue and loss of energy
  • Loss of appetite and nausea

Patients in later stages may develop the following symptoms:

  • Jaundice. This is a yellowish cast to the skin and eyes, which occurs because the liver cannot process bilirubin for elimination from the body.
  • The palms of the hands may be reddish or blotchy (palmar erythema).
  • Loss of body hair
  • Abnormalities in hormone-affected organs. In men with alcoholic cirrhosis, the testicles may shrink and their breasts may become swollen, sometimes painfully.
  • Ascites. A swollen belly is a sign of ascites, the most common major complication of cirrhosis, which occurs when fluid accumulates in the abdomen. Fever, abdominal pain, and tenderness when the belly is pressed indicate that the fluid is infected, but infection can occur without any symptoms.
  • Fluid buildup and swelling (edema) in legs
  • Confusion or changes in sleep-wake cycle (awake during night, sleepy during the day)

What lifestyle factors can help manage cirrhosis?

A healthy lifestyle is particularly important for people with cirrhosis.

Dietary Factors

If Ascites is present: Salt restriction is the most important lifestyle change.

Sodium/Salt  Less than 2000mg per day. Salt is in EVERYTHING. From soda to soup. Tips to avoid extra sodium - NEVER use the salt shaker or salt substitute. NEVER eat canned vegetables, canned soup, crackers, chips, sausage, bacon, sandwich meat, processed cheeses, frozen meals. Read ALL labels.

  • Do NOT use salt substitutes!! These contain potassium chloride instead of sodium chloride and may make a person's potassium to high and put them at risk for sudden cardiac death!

Healthy Foods.  Because important antioxidant vitamins are depleted in the cirrhotic liver, cirrhosis patients should maintain a diet rich in fresh fruits, vegetables, and whole grains.

Antioxidant Supplements. There is some preliminary laboratory evidence that various antioxidant supplements including vitamin E, selenium, and S-adenosylmethionine (SAMe) may help protect against liver damage and cirrhosis. Supplements, however, are not recommended for people with liver disease except with the advice of a physician. A multi-vitamin without iron is usually recommended (Centrum Silver type). Some vitamins, such as vitamins D and A, are metabolized in the liver and can be toxic.

Iron Restrictions. Elevated iron levels have been associatedwith cirrhosis from many causes. Patients should avoid iron-rich foods, such as red meats, liver, spinach and iron-fortified cereals and should avoid cooking with iron-coated cookware and utensils.

Supplemental Nutritional Products. Supplemental nutritional beverages may be helpful, particularly for patients with both alcoholism and cirrhosis. In one study, patients with both alcoholism and cirrhosis drank Ensure® every day as a supplement to their regular diet. After six months they showed significant improvement in many signs of overall health compared to those who didn't consume the beverage.

Pain Medicine

  • It is okay to use Tylenol (acetaminophen) as long as a person is not drinking. However, you must be very careful not to use more than 2 grams in 24 hours (regular strength 325mg = 1 tablet every 4 hours or extra strength 500mg = a total of 4 tablets in 24 hours).
  • Do not use ibuprophen, Advil®, Aleve®, naprsyn/nuprin or anything with similar ingredients as this may cause stomach bleeding, worse ascites (fluid on the belly) and kidney problems.
  • Avoid narcotics as much as possible as they may cause confusion. If they must be used, use the smallest dose as far apart as possible, because a cirrhotic liver will not "use up" the drugs as fast as a normal liver.

Limiting Fluids

Fluid restriction is not usually necessary, but patients with severe ascites should discuss limiting fluid with their physicians.

Vaccinations

  • Get annual Flu shots
  • Ask your physician about vaccinations against hepatitis A & B

Warnings on alternative and so-called natural remedies

It should be strongly noted that alternative or natural remedies are not regulated and their quality is not publicly controlled. In addition, any substance that can affect the body's chemistry can, like any drug, produce side effects that may be harmful. Even if studies report positive benefits from herbal remedies, the compounds used in such studies are, in most cases, not what are being marketing to the public.

There have been a number of reported cases of serious and even lethal side effects from herbal products. In addition, some so-called natural remedies were found to contain standard prescription medication.

The following warnings are of particular importance for people with liver disease:

  • Kava kava (an herb used for anxiety and tension) can be toxic to the liver and cause severe hepatitis and even liver failure if taken excessively.
  • Black licorice (not red) can increase blood pressure and may be harmful in people with hypertension.

ConsumerLab.com® is building a database of natural remedy brands that it tests and rates. Not all are available yet.

The Food and Drug Administration has a program called MedWatch for people to report adverse reactions to untested substances, such as herbal remedies and vitamins (call 800-332-1088).


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