Liver Cirrhosis 2024 | Causes, Symptoms, and Treatment Methods
What is liver cirrhosis?
Liver cirrhosis occurs when healthy liver tissue becomes scarred and does not function well. Cirrhosis is the first stage of liver scarring. Some cases of cirrhosis can be reversible. Liver scarring happens on a spectrum of different degrees. Some of these degrees can be treated and reversed.
However, medications and lifestyle changes can help prevent further deterioration of cirrhosis.
What are the stages of liver cirrhosis?
There are several different metrics to determine the stages of cirrhosis, where the doctor identifies the degree of liver damage.
This can be achieved through a variety of methods such as blood tests, imaging tests, and a liver biopsy where tissue samples may be examined under a microscope (histopathology).
First, the doctor needs to diagnose any chronic liver diseases, such as fatty liver disease or hepatitis. This can help identify the underlying causes of inflammation leading to cirrhosis and guide better treatment. While determining the stages of cirrhosis can help in understanding the extent of liver damage, identifying the underlying cause is more important than focusing on a specific stage.
Another scoring system based on histology is the Batts and Ludwig system, which classifies cirrhosis on a scale from grade 1 to grade 4, with grade 4 being the most severe.
The International Association for the Study of the Liver (IASL) also has an anatomical scoring system with four categories:
- Simple chronic hepatitis
- Mild chronic hepatitis
- Moderate chronic hepatitis
- Severe chronic hepatitis
The determination of cirrhosis stages may rely on tests other than liver biopsy and histology. For example, a doctor may confirm cirrhosis with a blood test measuring fibrosis 4 (Fib4) in the blood.
Additionally, imaging tests can confirm the staging of cirrhosis. The size and shape of the liver are examined, as well as excess fat, masses, or shrinkage. Possible imaging techniques include:
- Abdominal ultrasound
- Abdominal CT scan
- MRI (Magnetic Resonance Imaging)
- Elastography, combined with either ultrasound or MRI
What are the symptoms of liver cirrhosis?
Doctors often do not diagnose liver cirrhosis in its mild to moderate stages because cirrhosis typically does not cause symptoms until a significant portion of the liver is damaged.
As liver disease progresses, the person may experience symptoms such as:
- Loss of appetite
- Difficulty thinking clearly
- Fluid accumulation in the legs or abdomen
- Jaundice (yellowing of the skin and eyes)
- Nausea
- Unexplained weight loss
- Weakness
What causes liver cirrhosis?
Liver cirrhosis occurs after the liver has been exposed to injury or inflammation. Liver cells initiate the wound healing process, and during this healing, excess proteins like collagen and glycoproteins accumulate in the liver.
Eventually, after many repair processes, liver cells (hepatocytes) become unable to repair themselves. Excess proteins form scar tissue or fibrosis.
Several types of liver diseases can cause cirrhosis. These include:
- Autoimmune hepatitis
- Biliary duct obstruction
- Hemochromatosis
- Non-alcoholic fatty liver disease (NAFLD), which includes non-alcoholic fatty liver (NAFL) and non-alcoholic steatohepatitis (NASH)
- Viral hepatitis B and C
Alcoholic liver disease
The most common cause of liver cirrhosis is non-alcoholic fatty liver disease (NAFLD), followed by alcoholic liver disease due to long-term excessive drinking.
Diagnosing liver cirrhosis
Liver biopsy
Traditionally, doctors considered a liver biopsy the “gold standard” for testing cirrhosis. This surgical procedure involves taking a tissue sample, which a pathologist examines for scarring or fibrosis.
Elastography
Another option is a test known as transient elastography, which measures the stiffness of the liver. In cirrhosis, scar tissue makes the liver stiffer.
This test uses low-frequency sound waves to measure liver stiffness, but false positives may occur, where the tissue appears stiff, but the biopsy does not show scarring.
Non-surgical tests
Physicians can use other non-invasive tests to determine the likelihood of cirrhosis. Examples include serum hyaluronate, matrix metalloproteinase-1 (MMP), and tissue inhibitor of metalloproteinase-1 (TIMP-1).
Doctors may also use calculations like the aspartate aminotransferase to platelet ratio index (APRI) or a blood test called FibroSURE, which measures six different markers of liver function and incorporates them into an algorithm before determining a score. However, doctors usually cannot stage cirrhosis based on these tests alone.
Treating liver cirrhosis
Treatment options for cirrhosis usually depend on the underlying cause. The doctor will treat the root disease, if possible, to reduce the effects of liver disease.
For example, if a person drinks alcohol excessively, the doctor may recommend a treatment program to help them stop drinking. If the person has non-alcoholic fatty liver disease (NAFLD), the doctor may recommend dietary changes to lose weight and prescribe medications to improve blood sugar control.
Exercise and weight loss can also help slow disease progression.
Specific treatments for cirrhosis include:
- Chronic liver disease: ACE inhibitors such as benazepril, lisinopril, and ramipril.
- Hepatitis C virus: Direct-acting antivirals like Epclusa, Harvoni, and Mavyret.
- Non-alcoholic steatohepatitis (NASH): PPAR-alpha agonists.
- Autoimmune hepatitis: Immunosuppressive therapy.
- Alcoholic liver disease: Abstinence from alcohol.
Doctors may also recommend antifibrotic medications that help reduce the likelihood of permanent liver cirrhosis (cirrhosis). Depending on the drug, antifibrotic medications are classified as:
- Anti-inflammatory agents: Examples include belapectin, cenicriviroc, and liraglutide.
- Hepatocyte apoptosis inhibitors: These include emricasan, pentoxifylline, and selonsertib.
- Oxidative stress inhibitors: Options include methyl ferulate and losartan.
- Hepatic stellate cell (HSC) inhibitors: These drugs target cytokines that may activate HSCs and contribute to fibrosis.
However, antifibrotic treatments have limitations. While some drugs are approved for other uses, such as high blood pressure and vascular diseases, not all have been approved for cirrhosis treatment. Animal studies show promise, but clinical trials in humans are limited.
If cirrhosis progresses to the point where the liver is filled with scars and no longer functions, the only definitive treatment may be a liver transplant. However, the waiting list for transplants is long, and not everyone qualifies for surgery.
Complications of cirrhosis
The most severe complication of cirrhosis can be liver cirrhosis or extensive scarring, which renders the liver so damaged that the person becomes critically ill. This usually takes years to develop, often over a decade or two.
The liver is vital for survival, as it is responsible for filtering harmful substances in the blood and performing many other essential bodily functions.
If cirrhosis progresses to cirrhosis and liver failure, complications may include:
- Ascites (severe fluid accumulation in the abdomen).
- Hepatic encephalopathy.
- Hepatorenal syndrome.
- Portal hypertension.
- Bleeding.
Each of these conditions can be life-threatening for someone with liver disease.
Prognosis
Liver cirrhosis is one of the leading causes of death worldwide. Therefore, it is crucial for individuals to be diagnosed and treated for cirrhosis as early as possible before it progresses to cirrhosis.
Because cirrhosis does not always cause symptoms, this can be challenging. Sometimes doctors must consider risk factors, such as obesity or excessive alcohol consumption, in diagnosing cirrhosis and recommending treatments.
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