Section 10. Liver and Gallbladder Disorders

Chapter 136. Fatty Liver, Cirrhosis, and Related Disorders

Topics: Introduction | Fatty Liver | Cirrhosis | Primary Biliary Cirrhosis | Primary Sclerosing Cholangitis | Alpha1-Antitrypsin Deficiency

Cirrhosis

Cirrhosis is the destruction of normal liver tissue that leaves nonfunctioning scar tissue surrounding areas of functioning liver tissue.

Most of the common causes of liver injury, when repeated or sustained over a long time, can result in cirrhosis. In the United States, the most common cause of cirrhosis is alcohol abuse--continued excessive intake of alcohol over a prolonged period. In many parts of Asia and Africa, chronic hepatitis is a major cause of cirrhosis.

Cirrhosis is the third most common cause of death after heart disease and cancer among people aged 45 to 65. The scar tissue that forms impairs the liver's ability to function and obstructs the flow of blood through the portal vein (the vein that carries blood from the intestines to the liver). As a result of this obstruction, high blood pressure (portal hypertension (see Section 10, Chapter 135)) occurs.

Symptoms and Complications

Many people with mild cirrhosis have no symptoms and appear to be well for years. Others are weak, have a poor appetite, feel sick, and lose weight. If the flow of bile (the greenish yellow digestive fluid produced by the liver) is chronically obstructed, the person develops jaundice (see Section 10, Chapter 135), overall itchiness, and small yellow skin nodules, especially around the eyelids. The reduced production of bile salts by the damaged liver means that the absorption of fats and fat-soluble vitamins is impaired. Malnutrition commonly results from the impaired absorption of vitamins and from the loss of appetite.

Other effects of cirrhosis (which are also found in other causes of severe liver failure) include the wasting away of muscle (atrophy), redness of the palms (palmar erythema), a curling up of the fingers (Dupuytren's contracture), small spiderlike veins in the skin, salivary gland enlargement in the cheeks, axillary hair loss, abnormal nerve function (peripheral neuropathy), and, in men, breast enlargement (gynecomastia) and shrinking of the testes (testicular atrophy) due to a failure of the damaged liver to break down estrogens.

Some complications of cirrhosis result from the high blood pressure. High blood pressure can cause dilated, twisted veins to form at the lower end of the esophagus (esophageal varices (see Section 10, Chapter 135)). A person may vomit large amounts of blood because of bleeding from esophageal varices. High blood pressure in the portal vein along with poor liver function may also lead to fluid accumulation in the abdomen (ascites (see Section 10, Chapter 135)). Other complications of cirrhosis include kidney failure (see Section 11, Chapter 143) and a deterioration of brain function due to liver failure (liver encephalopathy (see Section 10, Chapter 135)).

Liver cancer (hepatoma) is another complication of cirrhosis, particularly when the cirrhosis is due to chronic hepatitis B or hepatitis C infection, iron overload (hemochromatosis), or glycogen storage diseases. Liver cancer may result from cirrhosis due to alcohol abuse.

See the sidebar Alcohol's Toll on the Liver.

Diagnosis

The diagnosis of cirrhosis is generally made on the basis of the symptoms and physical examination, together with a history of risk factors such as alcohol abuse. On physical examination, a doctor may feel a small, firm liver; occasionally, small lumps (nodules) on the surface of the liver are felt as well.

Liver function tests often are normal because of the tremendous reserve of the liver and the relative insensitivity of these biochemical tests. The liver can carry out essential functions even when its total activity is 85% below normal. An ultrasound or computed tomography scan (CT) may show that the liver is shrunken or abnormally patterned, suggesting cirrhosis. A liver scan using a radioactive isotope creates an image showing which areas of the liver are functioning and which are scarred. The diagnosis can be confirmed by a liver biopsy (removal of a tissue sample for examination under a microscope).

Prognosis and Treatment

Cirrhosis is usually progressive. If someone with early-stage cirrhosis stops drinking alcohol, the process of further liver scarring may stop, but scar tissue, once formed, remains indefinitely. In general, the prognosis is poorer if serious complications--such as vomiting of blood, accumulation of fluid in the abdominal cavity, or deterioration in brain function--have occurred.

No cure exists for cirrhosis. Thus, it is a disorder that should be prevented or arrested at its earliest stages. Treatment includes withdrawing toxic agents such as alcohol and treating complications as they arise. If the person needs to take drugs that are processed (metabolized) by the liver, much smaller doses must be given to avoid overdosage. Attention is given to proper nutrition, which usually involves carefully controlling protein and sodium intake and taking supplemental vitamins.

Liver transplantation can be lifesaving for a person with advanced cirrhosis. If the person continues to abuse alcohol, or if another underlying cause cannot be altered, a transplanted liver will also eventually develop cirrhosis, and liver transplantation is not usually done.