Cirrhosis

What does the liver do?

The liver is in the upper right part of the abdomen. It has many functions which include:

• Storing glycogen (fuel for the body) which is made from sugars. When required, glycogen is broken down into glucose which is released into the bloodstream.
• Helping to process fats and proteins from digested food.
• Making proteins that are essential for blood to clot (clotting factors).
• Processing many drugs that you may take.
• Helping to remove or process alcohol, poisons and toxins from the body.
• Making bile which passes from the liver to the gut and helps to digest fats.

What is cirrhosis?

Cirrhosis is a condition where normal liver tissue is replaced by scar tissue (fibrosis). The scarring tends to be a gradual process. The scar tissue affects the normal structure and regrowth of liver cells. Liver cells become damaged and die as scar tissue gradually develops. Therefore, the liver gradually loses its ability to function well. The scar tissue can also affect the blood flow through the liver which can cause 'back pressure' in the blood vessels which bring blood to the liver.

What causes cirrhosis?

There are many causes of cirrhosis. In the UK the most common causes are heavy alcohol drinking and infection with the hepatitis C virus.

Alcoholic cirrhosis
Your liver cells break down alcohol, but too much alcohol can damage the liver cells. As a rule, the heavier you drink, the more your risk of developing cirrhosis. However, alcoholic cirrhosis is not just a condition of 'alcoholics'. People who are 'social' heavy drinkers can also develop cirrhosis.

About 1 in 10 heavy drinkers will eventually develop cirrhosis. It tends to occur after 10 or more years of heavy drinking. It is not clear why some people are more prone for their liver cells to be damaged by alcohol and to develop cirrhosis. Women who drink heavily are more at risk than men.

Hepatitis C and cirrhosis
Chronic (persistent) infection with the hepatitis C virus causes long-term inflammation in the liver. This can eventually lead to liver scarring and cirrhosis. About 1 in 5 people with chronic hepatitis C develop cirrhosis after 20 years.

Other causes of cirrhosis
Less common causes include:

• Chronic infection with the hepatitis B virus. World-wide this is the most common cause of cirrhosis (but alcohol and hepatitis C are the most common causes in the UK).
• Autoimmune hepatitis. The immune system normally makes antibodies to attack bacteria, viruses, and other germs. In people with autoimmune diseases, the immune system makes antibodies against part(s) of the body. Something triggers the immune system to make these auto-antibodies. (The trigger is not known.) In autoimmune hepatitis the immune system makes antibodies against liver cells which can lead to damage and cirrhosis.
• Diseases that cause blockage of the bile ducts can cause back pressure and damage to the liver cells. For example, primary biliary cirrhosis, sclerosing cholangitis, and congenital problems of the bile ducts.
• Nonalcoholic steatohepatitis (NASH). This is a condition which causes fat to build up in the liver. This can lead to scarring and cirrhosis.
• Severe reactions to certain drugs.
• Certain poisons and environmental toxins.
• Certain infections caused by bacteria and parasites which are usually found only in tropical countries.
• Repeated bouts of heart failure which can cause back pressure of blood and congestion in the liver.
• Some rare inherited diseases which can cause damage to liver cells. For example:
  • Haemochromatosis. This is a condition which causes an abnormal build up of iron in the liver and other parts of the body.
  • Wilson's disease. This is a condition which causes an abnormal build up of copper in the liver and other parts of the body.
• Other rare disorders.

What are the symptoms of cirrhosis?

In the early stages of the condition, often there are no symptoms. You can 'get by' with a reduced number of working liver cells. However, as more and more liver cells die, and more and more scar tissue builds up, the liver:

• Fails to make enough proteins such as albumin that help to regulate the fluid composition in the bloodstream and body.
• Fails to make enough chemicals needed for blood clotting.
• Is less able to process waste chemicals in the body such as bilirubin. So, these may build up in the body.
• Is less able to process drugs, toxins, and other chemicals which may then build up in the body.

Therefore, the symptoms that may develop include:

• Tiredness and weakness.
• Fluid which leaks from the bloodstream and builds up in the legs (oedema) and abdomen (ascities).
• Loss of appetite, feeling sick, and vomiting.
• Weight loss (although you may put on weight if you retain a lot of fluid).
• A tendency to bleed and bruise more easily.
• Jaundice ('going yellow') due to a build up of bilirubin.
• Itch - due to a build up of toxins.
• Mental health changes develop in severe cases as toxins build up in the bloodstream and affect the brain. This can cause changes to your personality and behaviour, confusion, forgetfulness, difficulty concentrating. Eventually it can lead to loss of consciousness, and 'hepatic coma'.

Also, the scar tissue restricts the flow of blood through the liver. As the cirrhosis becomes worse this puts 'back pressure' in the portal vein ('portal hypertension'). The portal vein is the vein that takes blood from the gut to the liver - it contains digested foods. Increased pressure in this vein can cause swellings (varices) to develop in the branches of the vein in the lining of the oesophagus (gullet) and stomach. These varices have a tendency to bleed easily into the gut. If a a bleed occurs you may vomit blood, or pass blood with your stools (faeces).

How is cirrhosis diagnosed?

A doctor may suspect that you have cirrhosis from your symptoms, and a physical examination. (For example, a doctor may detect that your liver is enlarged, or that you are retaining fluid.) A doctor may especially think of cirrhosis as a cause of your symptoms if you have a history of heavy alcohol drinking or a previous episode of hepatitis.

Blood tests may show abnormal liver function. (See separate leaflet called 'Liver Function Tests'.) An ultrasound scan may show that you have a damaged liver. To confirm the diagnosis, a biopsy (small sample) of the liver may be taken to be looked at under the microscope. (See separate leaflet called 'Liver Biopsy'.) The scarring of the liver and damage to liver cells can be seen on a biopsy.

If the underlying cause of the cirrhosis is not clear, then further tests may be done to clarify the cause. For example, to check for antibodies to hepatitis viruses, to look in a blood sample for excess iron, copper, etc.

What is the treatment for cirrhosis?

Cirrhosis tends to get progressively worse if the underlying cause persists. In general, once the 'damage is done' the scarring cannot reverse. Therefore, the aim of treatment is, if possible, to prevent further liver scarring, or to slow the progression of the scarring process. Treatments that may be advised include the following.

Stop drinking alcohol
Whatever the cause of cirrhosis, you should stop drinking alcohol completely. Drinking alcohol will increase the rate of progression of cirrhosis from whatever cause.

Be cautious when taking drugs
Always tell your doctor or pharmacist that you have cirrhosis if you take any prescribed or 'over the counter' drug. Some drugs that are processed in the liver may need their dose adjusted if you have liver problems, or even not be used at all.

Treatment for underlying causes
Some underlying causes can be treated which may slow down or halt the progression of cirrhosis. For example:

• Not drinking alcohol if alcohol is the cause.
• Interferon and other medication may be used to treat viral hepatitis.
• Steroid drugs or other immunosuppressant drugs may be used to treat autoimmune diseases causing liver damage.
• Regular removal of a pint or so of blood can remove excess iron which occurs in haemochromatosis.

Treatment to ease symptoms and prevent complications
Various treatments may be advised, depending on the severity of the cirrhosis and the symptoms that develop. For example:

• A low-sodium diet or diuretics ('water tablets') to reduce fluid accumulating in the body.
• Drugs to reduce itch.
• Drugs may help to reduce portal hypertension.

Treatment of bleeding varices
A bleed from varices (described above) is a medical emergency. Seek medical help immediately if you have cirrhosis and you vomit blood, or pass blood in your faeces, or if your faeces become black. Various surgical techniques can be used to stop the bleeding and to help reduce the risk of further bleeds.

Liver transplant
In severe cases where the scarring is extensive, and the liver can barely function, then a liver transplant may be the only option.

The future
Up until recently the scarring process of cirrhosis was thought to be irreversible. However, recent research has led to a greater understanding of the scarring process. Some research suggests that drugs may be able to be developed that can reverse the scarring process. This research continues.

Can cirrhosis be prevented?

Alcohol
The most common cause of cirrhosis is heavy alcohol drinking. The most important way to prevent cirrhosis from developing is to drink within the recommended 'safe' limits. That is:

• Men - no more than 21 units per week (and no more than four units in any one day).
• Women - no more than 14 units per week (and no more than three units in any one day).
• Pregnant women - not known. So, many pregnant women have little, or no, alcohol.

In general, the more you drink above these limits, the more harmful alcohol is likely to be. Also, binge drinking (for example, 10 units twice a week) can be harmful even though the weekly total may not seem too high.

A unit of alcohol is about equal to:

• A half-pint of normal strength beer, cider, or lager.
• A pub measure of spirits (25ml), or of fortified wine such as sherry (50ml).
• A small glass (125ml) of wine containing 8% alcohol by volume.

Note: using the above 'rough guide' it is easy to underestimate how much alcohol that is in a drink. This is because many beers are now strong, and wines are often served in 175ml glasses. Many wines are also stronger than standard (some contain 12-14% alcohol by volume).

But, you should not drink alcohol at all if:

• You have already developed early cirrhosis.
• You have chronic hepatitis or certain other liver problems.

Infectious diseases
Some causes of cirrhosis are due to infectious diseases which can often be prevented. For example, people who inject 'street' drugs are at risk of hepatitis B and C if they use unclean needles or other injection equipment. Hepatitis B can be prevented by immunisation which is offered to those at risk such as health care workers.

What is the outlook (prognosis)?

The outlook depends on factors such as the underlying cause, how early the condition is diagnosed, and how early treatment is given. Many people who have cirrhosis which is not too extensive live a normal life for many years. In some cases, the progression of the cirrhosis can be halted or slowed by treatment.

The outlook is not so good if there is a lot of liver damage, especially if you have alcoholic cirrhosis and do not stop drinking.

Cirrhosis can cause death by bleeding from varices, or by going into a coma from liver failure. People with cirrhosis are also more at risk of developing serious infections. In the UK over 4,000 people die from cirrhosis each year, two thirds of them being under the age of 65.

Further help and information

British Liver Trust
2 Southampton Road Ringwood BH24 1HY
Tel: 0870 770 8028   Web: www.britishlivertrust.org.uk

© EMIS and PIP 2006   Updated: May 2006

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