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Liver cirrhosis

Overview

Cirrhosis is characterised by the progressive replacement of healthy liver tissue with the scar tissue (fibrosis), which disrupts key liver functions, such as detoxification, bile secretion, clotting factor production, and nutrient storage in addition to impairing normal blood flow to the liver, ultimately resulting in life-threatening complications. Importantly, the regeneration capacity of the liver is also compromised by the scar tissue formed in cirrhosis; therefore, in advanced stages of the disease, the liver is unable to regenerate and start functioning properly, i.e., permanent loss of function. Thus, cirrhosis is the final stage of chronic liver disease. Cirrhosis can be attributed to various factors, including persistent inflammation of the liver, fatty liver disease (N/AFLD), viral hepatitis, and certain inherited conditions.

Cirrhosis can be attributed to the following factors:

  • Excessive and prolonged (chronic) alcohol consumption
  • Hepatitis:
    • Chronic viral hepatitis: Viral infections result in significant liver damage as viral clearance involves killing of the cells harbouring the virus. Especially, Hepatitis B and C viruses can cause more liver damage (compared to other Hepatitis viruses) as they are more persistent (chronic), causing chronic liver inflammation that progressively leads to scarring, eventually culminating in cirrhosis.
    • Autoimmune hepatitis: Killing of self-liver cells by the immune surveillance machinery causes chronic inflammation (a hepatitis hallmark), which then progresses to scarring (fibrosis), and eventually cirrhosis.
  • Fatty liver: Accumulation of fat in the liver results in inflammation, which over time induces scarring, and ultimately leads to cirrhosis.
  • Genetic disorders: Certain inherited conditions can lead to cirrhosis; these include:
    • Wilson’s disease (copper overload)
    • Haemochromatosis (iron overload)
    • Alpha-1 antitrypsin deficiency (a disorder that can cause liver damage).
  • Biliary diseases: Diseases of the biliary system, such as primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) cause bile duct damage, resulting in bile buildup in the liver, which causes inflammation that ultimately culminates in scarring and cirrhosis.
  • Medications and toxins: Long-term use of certain medications (e.g., methotrexate, isoniazid) and exposure to industrial toxins or chemicals can cause liver damage and cirrhosis.
  • Chronic heart failure: Severe, long-standing heart failure can cause liver congestion, a condition where blood pools in the liver and associated blood vessels, this causes liver tissues to become stressed due to lack of oxygen and bile acid accumulation, ultimately leading to liver damage and cirrhosis (cardiac cirrhosis).
  • Other causes: Conditions like gallstones and hepatocellular carcinoma (liver cancer) can also contribute to cirrhosis.

Cirrhosis, in its early stages may be asymptomatic (no obvious symptoms); however, as it progresses, the symptoms become more pronounced and may include:

  • Fatigue
  • Jaundice
  • Abdominal pain
  • Swelling (oedema
  • Nausea and loss of appetite
  • Easy bruising or bleeding
  • Spider angiomas: These are small, red, spider-like blood vessels visible under the skin, often on the chest and upper body.
  • Hepatic encephalopathy: The buildup of toxins like ammonia in the blood owing to the impaired detoxification function of the liver might result in hepatic encephalopathy, which manifests as confusion, altered mental status, forgetfulness, and even coma.
  • Pruritus (itching)
  • Dark urine and pale stools
  • Impaired clotting

  • Physical examination: Cirrhosis can be diagnosed by looking for signs, such as jaundice, ascites, an enlarged liver (hepatomegaly), or an enlarged spleen (splenomegaly) in clinical examination.
  • Blood tests:
    • Liver function tests: To evaluate the levels of liver enzymes (ALT, AST), bilirubin, and albumin, and determine the prothrombin time (clotting function)
    • Complete blood count (CBC): To check for anaemia, low platelet counts, or signs of bleeding
    • Ammonia level assessment: To detect hepatic encephalopathy
  • Imaging:
    • Ultrasound: To detect liver size and shape, and signs of cirrhosis, such as nodularity and ascites
    • CT: To detect complications like liver cancer
    • MRI: To assess liver fibrosis and portal hypertension
  • Elastography (FibroScan): To assess the degree of fibrosis based on measurement of liver stiffness
  • Liver biopsy: This may be performed to assess the degree of fibrosis and confirm cirrhosis. However, liver biopsy is usually reserved for cases where other diagnostic methods are inconclusive.

The treatment of cirrhosis is aimed at managing symptoms, preventing complications, and addressing the underlying cause. While cirrhosis is not reversible, interventions can slow the progression and improve quality of life.

  • Treating the underlying cause:
    • Alcohol abstinence: In case of alcohol abuse-induced cirrhosis, stopping alcohol consumption is crucial in preventing further liver damage.
    • Antiviral therapy: In case of viral hepatitis-induced cirrhosis, antiviral medications can reduce viral load and prevent further liver damage.
    • Weight management: For patients with NAFLD or NASH, weight loss through diet and exercise is important for managing liver fat and improving liver function.
    • Medications:
      1. Antiviral medications: These are used to manage viral hepatitis.
      2. Immunosuppressive drugs: These are used to manage autoimmune hepatitis.
  • Managing complicated cirrhosis:
    • Beta-blockers: These medications (e.g., propranolol, nadolol) reduce portal pressure, thereby helping manage portal hypertension-associated complicated cirrhosis.
    • Transjugular intrahepatic portosystemic shunt (TIPS): It is generally used for complicated cases of cirrhosis where portal hypertension and associated complications are difficult to manage. TIPS involves creating a shunt between the portal and hepatic veins, which diverts blood flow from the portal circulation to systemic (whole body) circulation, thereby reducing the pressure in the portal system. Thus, TIPS can provide relief for portal hypertension-associated complications of cirrhosis.
  • Managing symptoms:
    • Medications:
      1. Diuretics: These are used to decrease fluid accumulation in tissues (ascites).
      2. Lactulose: It is used to manage hepatic encephalopathy by reducing the ammonia levels.
  • Liver transplant: This might be necessary in cases of advanced cirrhosis with liver failure.

  • Avoiding excessive alcohol consumption.
  • Vaccination against hepatitis B and C
  • Employing safe practices to prevent hepatitis transmission (e.g., avoid sharing needles)
  • Weight management and exercise to prevent fatty liver disease
  • Regular screenings for individuals with chronic liver disease or a family history of liver conditions
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