Cirrhosis

Cirrhosis is when the liver becomes scarred by chronic inflammation, which can be caused by a variety of conditions, such as viral hepatitis, chronic alcoholism, or fatty liver disease. When the liver is injured, it will try to repair itself. With chronic or repeated injury, the repair process forms scar tissue, and the accumulation of scarring results in cirrhosis of the liver impairing its function. Advanced cirrhosis is a life-threatening condition with the patient at risk of liver cancer (hepatocellular carcinoma).

Cirrhosis of the liver cannot be reversed, but if it is diagnosed early and treated properly, further damage can be prevented. 

Symptoms
A person with cirrhosis usually appears to have no outward signs or symptoms until the liver has been severely damaged; some of the signs and symptoms are as follow: 

• Weakness
• Prone to bleeding / bruising
• Loss of appetite
• Nausea
• Swollen legs, feet, or ankles 
• Weight loss
• Itchiness of the skin
• Jaundice
• Accumulation of intra-abdominal fluid (ascites)
• Spider-like blood vessels that are visible in the skin
• Redness of the palms
• For women, cessation of period unrelated to menopause
• For men, loss of sex drive, testicular atrophy, or enlarged breasts
• Confusion, drowsiness, or slurred speech 

When to see a physician
The patient should make an appointment with the doctor if they have the aforementioned symptoms.

Causes

• Excessive alcohol consumption
• Chronic viral hepatitis(such as type B, C, and D)
• Non-alcoholic fatty liver disease
• Hemochromatosis
• Cystic fibrosis
• Wilson's disease
• Biliary atresia
• Alpha-1 antitrypsin deficiency
• Galactosemia and glycogen storage disease
• Autoimmune liver disease, such as autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC)

Risk factors that can increase the chance of developing cirrhosis

• Excessive alcohol consumption – Drinking too much alcohol is one of the factors that could increase the risk of developing cirrhosis.
• Obesity - Being overweight can increase the risk of developing many conditions that may lead to cirrhosis, such as non-alcoholic fatty liver disease and non-alcoholic steatohepatitis.
• Viral hepatitis – A leading cause of liver disease worldwide.  

Complications caused by cirrhosis

• Portal hypertension – This is when high blood pressure occurs in the portal veins that flow into the liver. Cirrhosis increases pressure in the portal venous system leading to complications such as legs edema, ascites, splenomegaly, and bleeding from a collateral vein.
• Infections – Cirrhotic patients have poor immunity, making them at-risk for severe infection.  
• Malnourishment – The disease makes it hard for the body to absorb nutrients, leading to weight loss and fatigue.
• Hepatic encephalopathy – Severe cirrhotic liver is unable to detoxify toxins from the body, leading to toxin accumulation. It could result in mental confusion and even progression to coma.
• Jaundice – This is the yellowing of the skin and eyes, and darkening of urine because the liver cells are unable to remove bilirubin from the blood.  
• Bone disease – Cirrhosis can decrease bone density and strength, thereby making the patient at higher risk of bone fractures.  
• Higher risk of developing liver cancer
• Acute-on-chronic liver failure – This is a condition when multi-organ failure occurs in patients with chronic liver disease, precipitated by multiple etiologies, especially infections.

How to prevent cirrhosis

• Stop alcohol consumption when you have cirrhosis
• Maintain a healthy diet. Consume a balanced diet of all five food groups, increasing the proportions of fruits, vegetables, whole grain, and lean protein. Reduce consumption of fatty foods. 
• Maintain a healthy BMI – High body fat can damage the liver; consult your doctor about a weight reduction plan if you are overweight. 
• Reduce the risk of hepatitis – Avoid sharing needles and having unprotected sex as it can increase the risk of developing viral hepatitis B and C.

Diagnosis
Early-stage cirrhosis rarely produces any symptoms. Cirrhosis is often detected via blood tests or health checkups. 

The doctor may order one of these tests if the doctor suspects that the patient may have a liver problem such as: 

• Laboratory test – Doctor may order blood tests to evaluate your liver function, such as a high level of bilirubin and other liver enzymes. All patients are usually screened for viral hepatitis. The doctor will also check the patient's international normalized ratio (INR; blood clotting ability), and albumin level to evaluate the liver’s synthetic function. 

The result from the blood test will help the doctor determine the underlying cause of cirrhosis and the severity of the condition. 

• Imaging studies – Ultrasound with or without elastography, computed tomography, and magnetic resonance imaging are used to evaluate liver morphology, stage, and complications of cirrhosis.
• Fibroscan – Used to evaluate the stiffness of the tissues, which reflect the amount of fibrosis in your liver. This tool can detect cirrhosis early. It can also measure percentage of fat in the liver.  
• Liver biopsy – Is rarely used nowadays due to very effective non-invasive tests such as blood test and fibroscan. However, in certain situations, a liver biopsy may be required to determine the etiology of cirrhosis.

Regular follow-up is recommended to monitor for disease progression or complications, especially enlarged veins in the esophagus (varices) and liver cancer. 

Treatment
Treatment for cirrhosis depends on the cause and severity of liver damage. The treatment aims to slow the progression of cirrhosis and treat complications resulting from cirrhosis. Hospitalization is needed when the patient has a severely damaged liver. 

There is a possibility that damage could be minimized if the underlying cause of cirrhosis is treated at an early stage as follow:  

• Treatment for alcohol addiction – People with cirrhosis due to excessive alcohol consumption are advised to stop drinking. The doctor may recommend a treatment program for the addiction. 
• Treatment for non-alcoholic fatty liver disease - People with cirrhosis resulting from the non-alcoholic fatty liver disease will be advised to lose weight and maintain their blood sugar levels.
• Use medications to treat viral hepatitis – The antiviral could help limit further damage to the liver due to hepatitis B or C.
• Medications to lessen other symptoms of cirrhosis - These medications may help slow down some types of liver cirrhosis. Patients with primary biliary cirrhosis or autoimmune hepatitis diagnosed early could be treated with medication.

Other medications can help lessen some symptoms, such as itching, weakness, and pain. Nutritional supplements may be prescribed to treat malnutrition related to cirrhosis and to prevent osteoporosis.

The treatments for complications of cirrhosis are as follow: 

• For excess fluid in the body – The doctor may advise the patient to consume a low-sodium diet and medication to prevent extra fluid in the body to control edema. However, in severe cases, drainage may be required.  
• Portal hypertension – Medication used to control portal pressure can also help prevent severe bleeding. The doctor will perform an upper GI endoscopy to look for enlarged veins in the esophagus or stomach.

If there are varices present, the patient will need to take medication to prevent bleeding. The patient may also need endoscopic band ligation to stop the bleeding or prevent future bleeding.

• Infections – Doctor may prescribe antibiotics or other treatments to treat infections. You may also need to get vaccinations for influenza, pneumonia, and hepatitis A and B.
• Increased risk of developing liver cancer – Regular tumor marker check and liver ultrasound every 6 months for liver cancer surveillance.
• Hepatic encephalopathy – Doctor may prescribe medications to help relieve the accumulation of toxins in the blood. 

Liver transplantation
Liver transplantation may be the only option for severe cases of cirrhosis, replacing the patient’s liver with a healthy liver from a donor. Those who require liver transplants must undergo various testing to determine if they are suitable for the surgery. 

Conventionally, patients with alcoholic cirrhosis are not candidates for liver transplant if they are evaluated as at high-risk for resuming alcohol consumption after transplantation. However, studies have found that survival rates of selected patients with severe alcoholic cirrhosis are similar to those who undergo liver transplants for other liver disease conditions. 

For alcoholic cirrhosis, liver transplant surgery is a treatment option; however, the patient will need to:

• Qualify for the program that works with people with alcoholic cirrhosis and to meet requirements of the program such as lifelong commitment to alcohol abstinence and other requirements. 

Lifestyle changes

• Quit drinking alcohol – even if you don’t have alcoholic cirrhosis.
• Consume a low-sodium diet – Too much salt may cause the body to retain fluids, resulting in swelling in the abdomen and legs. Use food seasonings instead of salt. Choose low sodium foods.
• Eat healthy – Malnutrition is one of the complications of cirrhosis. Consume a healthy and balanced diet, comprised of the five food groups including fruits, vegetables, lean protein, legumes, poultry, or fish. Avoid consuming raw seafood.  
• Avoid infections – Cirrhotic patients are immunocompromised, so they should wash their hands frequently and avoid people who are sick. Vaccination for hepatitis A and B, influenza, and pneumonia is recommended.
• Be cautious when using over-the-counter medicine – Always consult a physician before deciding to take any medication.

Preparing for the doctor's appointment
If your doctor suspects you may have cirrhosis, the doctor may refer you to a gastroenterologist or a hepatologist. 

These are tips on how to prepare for the doctor's appointment and what the patient can expect.

 How to prepare for the appointment 

• Be fully aware of any restrictions before the appointment, inquire about what you may need to prepare before the appointment, such as the type of diet. 
• Note down all symptoms, including any symptoms that may seem unrelated to cirrhosis.
• Note down personal information, including any stressors or life changes.
• Note down information about your medical conditions, as well as other health conditions.
• Bring your own medical record results such as CT, MRI, or ultrasound images, and liver biopsy slides to the doctor. 
• Write down all medications, vitamins, or supplements that you are currently taking.
• Come to the appointment with a family or a friend to help you remember information from the doctor. 
• Note down questions to ask the doctor.

Possible questions to ask the doctor

• What could be causing cirrhosis?
• Is there a way to slow down liver damage?
• What treatment options do I have?
• What kind of medicine or supplements could harm my liver?
• What complication signs should I look for?
• How can I manage cirrhosis if I also have other health conditions? 

The doctor may ask the following questions: 

• When did the symptoms first begin?
• Are these symptoms occasional or continuous?
• What is the severity of these symptoms? 
• Is there anything that improves the symptoms?
• Is there anything that worsens the symptoms? 
• Do you drink alcohol, and how often?
• Have you been exposed to toxic substances?
• In your family history, is there liver disease, hemochromatosis, or obesity?
• Have you ever experienced jaundice?
• Did you ever get a blood transfusion?
• Have you ever used injection drugs?
• Do you have any tattoos on the body?
• Have you ever been sick from viral hepatitis?