“I was a teetotaller till the age of 19. In today’s day and age, when alcoholism is fad, I found myself gleaming with pride when I had low spirits. But this didn’t last long. I finally gave into persuasion and like my peers, started drinking. As I got older, I found myself maintaining a mini bar at home and my glass of wine became my constant companion. My capacity increased and so did my liking for stronger spirits. Even when I knew I was going over board, I silenced that voice inside me that asked me to stop. Repercussions came soon after, with the first signs being extreme exhaustion and pain in the gut. Little did I know that I was on my way to developing a dreaded liver disease.”
Does this sound like your story? A lot of people today have a similar tale to tell. It is therefore no surprise that the World Health Report lists liver cirrhosis as one of the leading causes of mortality in the world, with reported 27,000 deaths every year. While research is yet to find a permanent cure, a deeper understanding will help better manage the condition.
What Is Liver Cirrhosis?
Clinically, it is defined as the permanent damage to the liver wherein; healthy tissue is replaced by non-functional scar tissue. Scarring is a gradual process and its extent directly relates to the seriousness of the condition and thereby quality of liver function. The most common cause for degeneration of the liver is alcoholism. However, in the United States, chronic hepatitis is recognised as another cause.
Understanding The Importance Of The Liver
Liver is the seat of all metabolic functions in our body and it is impossible to survive without this organ. This multifunctional organ is responsible for:
- Controlling infections, processing alcohol and removing bacteria and toxins from the blood
- Storing glycogen and converting it to glucose when our bodies require energy
- Producing bile that digests fats, including cholesterol and fat-soluble vitamins
- Making proteins responsible for blood clotting
- Helping to process fats and proteins from digested food
- Processing many medicines that we take
Fortunately, liver is the only organ that has the capacity to self-repair. But serious damage to this organ as in the case of cirrhosis would bring important metabolic functions to a grinding halt, eventually causing death.
Alcohol and Liver
Blood from the gut always first goes through the liver before it is circulated in the rest of the body. Alcohol too is absorbed from the gut and taken directly to the liver for further metabolism before being released. In the liver, this is converted to toxic chemicals, which in turn trigger an immune reaction causing the release of powerful compounds called cytokines. These compounds in large amounts are known to cause inflammation and damage to the liver tissue.
A damaged liver tissue cannot break down fatty acids leading to a build up of fat. This further hinders oxygen absorption by the liver and accelerates scarring. In the initial phase of tissue damage, fat-laden liver becomes greatly enlarged, but later shrinks, increases scarring and develops cirrhosis.
Although the liver’s capacity to process alcohol differs from individual to individual, it can process only a fixed amount per hour. So, drinking more than what your liver can deal with leads to an increase in alcohol levels in your blood stream.
Other Causes Of Cirrhosis
Another common cause of cirrhosis is chronic hepatitis (B or C). Hepatitis C is the more serious one with around 20-30% of patients developing cirrhosis in 20 years. Factors causing hepatitis give rise to similar conditions leading to inflammation of the liver and eventual scarring.
Autoimmune hepatitis also leads to cirrhosis with the body’s immune system attacking its own liver cells causing inflammation and damage.
Non-alcoholic steatohepatitis (NASH) is a condition where-in fat builds up in the liver as a consequence of obesity, diabetes, protein malnutrition and coronary artery disease.
Certain conditions cause damage to bile ducts leading to backing up of bile in the liver and causing cirrhosis. This is often termed ‘primary biliary cirrhosis’ when bile ducts become inflamed and ultimately disappear. Another condition termed’ secondary biliary cirrhosis’ occurs when bile ducts are accidently tied off or injured during a gallbladder surgery.
Certain inherited diseases like Wilson’s disease, hemochromatosis and glycogen storage diseases interfere with metabolic functions of the liver and cause cirrhosis.
Drug reactions, prolonged exposure to toxins and infections coupled with liver congestion are known to cause cirrhosis.
Symptoms Of Liver Cirrhosis
Manifestation of symptoms is often a direct correlation to the extent of damage. This is the reason why most patients don’t experience any discomfort until liver function deteriorates greatly.
To start with, most people experience fatigue and exhaustion, loss of appetite coupled with nausea and weight loss. Further decline in liver function leads to lesser production of proteins. Decreased production of albumin causes water retention in the abdomen and legs, a condition termed ‘ascites’. Similarly, decreased production of blood clotting proteins makes the individual to bleed profusely even with a minor injury.
As the disease progresses, the following symptoms are seen:
- Itching
- Spider like blood vessels on skin
- Greasy and foul smelling stools
- Abdominal pain
- Gall stones, caused by hardening of bile that doesn’t flow out of the liver
- Blockage of bile may also lead to jaundice
- Sensitivity to medications
- Hair fall
- Discoloration of nails
Complications Of Cirrhosis
Liver is the only organ with the capacity to regenerate. Therefore, in some cirrhotic patients, symptoms are first noticed only with extensive liver damage and associated complications.
a) Portal Hypertension
The largest vein in the liver is the portal vein, which transfers all the processed blood from the liver to the rest of the body. In cirrhotic patients, scarring causes increased resistance to blood flow through portal vein leading to hypertension.
b) Esophageal And Gastric Varices
As a consequence of portal hypertension, collateral vessels develop which connect portal vessels to general circulation by bypassing the liver. Due to increased pressure, these varices are prone to bursting in the stomach or esophagus, often leading to fatal outcomes.
c) Splenomegaly
With portal hypertension, spleen enlarges and holds back platelets and white blood cells without releasing them into the blood stream. This further increases risk of bleeding.
d) Hepatic Encephalopathy
A damaged liver fails to remove toxins from blood, causing their accumulation in the brain. This decreases brain function with signs including confusion, memory loss, personality changes and change in sleep habits. More serious cases can lead to a coma.
e) Liver Cancer
Also called ‘hepatocellular carcinoma’, this starts in the liver tissue itself and has high mortality rates.
f) Hepatorenal Syndrome
Kidney failure characterised by a decrease in the blood flow in the kidneys in response to changed blood flow in the liver. This is seen in the late stage of liver disease and its symptoms include dark urine, reduction in urine volume, nausea and vomiting.
Diagnosis
Assessing alcohol intake and checking for other risk factors like obesity form the ground for cirrhosis. Thorough physical examination (liver might feel enlarged) along with blood tests and imaging (CT scan, ultrasound or liver scan) can confirm diagnosis. Sometimes, liver biopsy is done to check liver tissue under a microscope for scarring.
Treatment Options
Cirrhosis is a progressive disease. Treatment plans available today can only prevent further disease progression and treat complications, but cannot undo the damage already done.
To start with, cirrhotic patients are advised complete abstinence from alcohol as even small amounts can have devastating effects. A healthy diet is recommended to overcome malnutrition often seen in patients and promotes regeneration of healthy liver cells. Patients are asked to notify their doctors about any medication they take as it can affect liver function.
Beta-blockers are prescribed to relieve portal hypertension and diuretics to treat ascites.For gastrointestinal bleeding, band-ligation is performed to compress varices and stop bleeding. Patients with loss of brain function are given laxatives to cleanse their bowels and asked to reduce protein intake in food.
In patients with more than 80% damage, a liver transplant is performed. This has proved to be life saving in most cases only if proper care and alcohol consumption is avoided.
Conclusion
Owing to its slow progression and lack of obvious symptoms in its early stages, liver cirrhosis today is considered the ‘lesser-known silent killer’. Women are more susceptible to liver impairment, with as little as 2/3rd ounce of pure alcohol a day (as against 2 ounces for men) sufficient to cause damage.
Most of us are still living in denial about the amount of alcohol we consume. But remember, there is still no cure for this dreaded disease and the only way to save yourself is by keeping the liver’s biggest enemy at bay!
Article by Snigdha Taduri for Biomed-ME