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Liver Cirrhosis

Cirrhoses Hepatic

Cirrhosis represents the final common histologic pathway for a wide variety of chronic liver diseases. It is characterized by fibrosis and the conversion of normal liver architecture into structurally abnormal nodules. Cirrhosis is irreversible, but the progression can be very slow, depending on its cause and other factors.


Presentation

Easy Bruising
  • There may be also easy bruising. There also may be heavy internal bleeding from the food pipe which may be fatal.[symptoma.com]
  • Kidney disease or failure Easy bruising and severe bleeding. This happens when the liver stops making proteins that are needed for your blood to clot. Type 2 diabetes.[hopkinsmedicine.org]
  • When symptoms do appear, they include, bleeding or easy bruising, swelling, fatigue, and a yellow coloring to the skin and whites of the eyes.[emedicinehealth.com]
  • Cirrhosis can lead to Easy bruising or bleeding, or nosebleeds Swelling of the abdomen or legs Extra sensitivity to medicines High blood pressure in the vein entering the liver Enlarged veins called varices in the esophagus and stomach.[medlineplus.gov]
  • Cirrhosis can cause weakness , loss of appetite , easy bruising , yellowing of the skin ( jaundice ), itching , and fatigue .[medicinenet.com]
Splenomegaly
  • Esophageal varices and splenomegaly regressed after 3 and 8 years of sustained virologic responses in cases 1 and 2, respectively.[ncbi.nlm.nih.gov]
  • The SBLS is more feasible and effective than ALS in patients with massive splenomegaly ( 30 cm) secondary to portal hypertension and liver cirrhosis.[ncbi.nlm.nih.gov]
  • The serum thrombopoietin levels, the distribution of splenomegaly grades, and liver stiffness did not differ between the two LC groups to a statistically significant extent. As the splenomegaly grade increased, the platelet count decreased.[ncbi.nlm.nih.gov]
  • Quantitative CTTA features may increase the accuracy of diagnosing causes of splenomegaly.[ncbi.nlm.nih.gov]
  • Splenic infiltration of lymphoma cells may cause splenomegaly in many cases. However, splenomegaly is caused not only by tumor involvement but also by non-tumorous disorders.[ncbi.nlm.nih.gov]
Fatigue
  • We report here the case of a 58-year-old male presented with atypical chest pain, dyspnea and fatigue, with a medical history of liver cirrhosis and undergoing treatment with beta-blocker. The clinical exam was normal.[ncbi.nlm.nih.gov]
  • A 40-year-old man with severe alcoholic liver cirrhosis with a 2-day history of fatigue and abdominal pain was admitted. He reported eating sushi and sliced raw chicken a few days previously. His abdomen was distended, with shifting dullness.[ncbi.nlm.nih.gov]
  • In the presented case, the authors describe an obese middle-aged man that presented to the emergency department for persistent oedema, scleral icterus and fatigue.[ncbi.nlm.nih.gov]
  • Symptoms & Causes Cirrhosis has many signs and symptoms, such as fatigue and severe itchy skin. They may not appear until the liver is badly damaged.[niddk.nih.gov]
  • Symptoms: Some people may have no symptoms while others may be very sick with yellowing of the eyes, swelling of the legs and body, fatigue and decreased appetite. There may be also easy bruising.[symptoma.com]
Weight Loss
  • As such, weight loss may be beneficial in these patients.[ncbi.nlm.nih.gov]
  • Currently, there are no proven therapies except diet and weight loss, which is hard to sustain.[reuters.com]
  • As the disease worsens, symptoms may include: Loss of appetite Lack of energy (fatigue) Weight loss or sudden weight gain Bruises Yellowing of skin or the whites of eyes (jaundice) Itchy skin Fluid retention ( edema ) and swelling in the ankles, legs,[my.clevelandclinic.org]
  • Cirrhosis may make it more difficult for your body to process nutrients, leading to weakness and weight loss. Buildup of toxins in the brain (hepatic encephalopathy).[mayoclinic.org]
  • Weight loss (although you may put on weight if you retain a lot of fluid). A tendency to bleed and bruise more easily. Yellowing of the skin or of the whites of the eyes (jaundice) due to a build-up of bilirubin. Itch due to a build-up of toxins.[patient.info]
Anemia
  • Glycated hemoglobin (HbA1c) is a widely used marker of glycemic control but can be affected by hemolytic anemia. Glycated albumin (GA) is also affected in patients with liver cirrhosis.[ncbi.nlm.nih.gov]
  • In cirrhotic patients, lipoprotein impairment is associated with several complications: infections, malnutrition, adrenal function, and spur cell anemia. Alterations of liver function are associated with modifications of circulating lipids.[ncbi.nlm.nih.gov]
  • […] an abnormal systemic immunological response, including rheumatoid factor (RF) and cryo- and non-cryoprecipitable immune complexes, as well as clinical manifestations, comprising dermatitis, polyarthralgias and arthritis, pulmonary disease, aplastic anemia[ncbi.nlm.nih.gov]
  • FastStats Homepage Diseases and Conditions Anemia or Iron Deficiency Arthritis and Bone Arthritis Osteoporosis Cancer Cardiovascular Cerebrovascular Disease or Stroke Cholesterol Heart Disease Hypertension Dementia and Mental Health Alzheimer’s Disease[cdc.gov]
  • Anemia can cause weakness, leucopenia can lead to infections, and thrombocytopenia can impair the clotting of blood and result in prolonged bleeding.[rxlist.com]
Leg Edema
  • A 65-year-old male with liver cirrhosis of alcoholic etiology was admitted to hospital with bilateral leg edema, ascites, and marked weakness. At admission, his blood pressure was 82/52 mmHg and he had sinus tachycardia of 130/min.[ncbi.nlm.nih.gov]
  • As liver function decreases, fewer proteins such as albumin are produced resulting in fluid accumulation in the legs (edema) or abdomen (ascites).[liver.ca]
  • Portal hypertension can cause fluid to accumulate in the legs (edema) and in the abdomen (ascites). Edema and ascites also may result from the inability of the liver to make enough of certain blood proteins, such as albumin.[mayoclinic.org]
  • From deposition in the skin of products of the breakdown of bile Abdominal pain - From enlargement of the liver or formation of gallstones Abdominal swelling or bloating - From fluid retention Weight gain - From fluid retention Swelling in ankles and legs[emedicinehealth.com]
  • (edema) impotence gynecomastia (when males start to develop breast tissue) A diagnosis of cirrhosis begins with a detailed history and physical exam.[healthline.com]
Leg Swelling
  • Swollen stomach and legs Swelling in your abdomen is known as ascites. The swelling is caused by fluid building up in the lining around your abdomen.[britishlivertrust.org.uk]
  • swelling, hepatic encephalopathy , and dilated esophageal veins. [1] In severe cirrhosis, a liver transplant may be an option. [1] Cirrhosis affected about 2.8 million people and resulted in 1.3 million deaths in 2015. [3] [4] Of these, alcohol caused[en.wikipedia.org]
Loss of Appetite
  • The clinical manifestations may be generalised and non-specific, such as malaise, and loss of appetite.[symptoma.com]
  • As the disease worsens, symptoms may include: Loss of appetite Lack of energy (fatigue) Weight loss or sudden weight gain Bruises Yellowing of skin or the whites of eyes (jaundice) Itchy skin Fluid retention ( edema ) and swelling in the ankles, legs,[my.clevelandclinic.org]
  • Some people who drink heavily develop alcoholic hepatitis, an inflammation of the liver that can last a week or two, producing symptoms of nausea, fever, loss of appetite, jaundice, and confusion. Over time, the condition can also lead to cirrhosis.[webmd.com]
  • Symptoms may include: Fluid buildup in the belly (ascites) Vomiting blood, often from bleeding in the blood vessels in the food pipe (esophagus) Gallstones Itching Yellowing of the skin and eyes (jaundice) Kidney failure Muscle loss Loss of appetite Easy[hopkinsmedicine.org]
Hematemesis
  • The child presented with complaints of malena, hematemesis and variceal bleed. The examination revealed a child with respiratory distress, irritability, tachycardia, clubbing and abdominal distention.[ncbi.nlm.nih.gov]
  • Gastrointestinal hemorrhaging can result in hematemesis (vomiting of blood), melena (tarry stools), or hematochezia (bloody stools).[ssa.gov]
Cyanosis
  • Clinical manifestations usually include dyspnea, orthodeoxia (increasing hypoxemia with erect position), platypnea (improvement of dyspnea with flat position), cyanosis, and clubbing.[ssa.gov]
Jaundice
  • The patient also presented with acute encephalopathy, jaundice, right upper quadrant abdominal pain and hyperbilirubinaemia (total bilirubin of 8.1 mg/dL with direct bilirubin of 3.0 mg/dL).[ncbi.nlm.nih.gov]
  • Liver decompensation with intractable ascites and jaundice occurred 4 months later. The reformed images of the venous phase of enhanced CT images with Max IP and Min IP showed middle hepatic vein thrombosis.[ncbi.nlm.nih.gov]
  • An 18-year-old male presented with a history of abdominal distension and jaundice for 2 months. He had abdominal tenderness but no rebounding pain. Moreover, his dullness was felt over the liver and the spleen was palpable 8 cm below the ribs.[ncbi.nlm.nih.gov]
  • More specific symptoms include symptoms suggestive of decompensation such as jaundice, ascites, and upper gastrointestinal bleeds (variceal) and confusion (hepatic encephalopathy).[symptoma.com]
  • When symptoms such as jaundice become apparent, the disorder will have already reached an advanced stage. When liver function declines, your body will feel sluggish; you will feel tired and lose your appetite.[otsuka.co.jp]
Hepatomegaly
  • Cardinal symptoms include fasting hypoglycemia, lactic acidosis and hepatomegaly as well as neutropenia.[ncbi.nlm.nih.gov]
  • Liver enlargement is usually an indicator of liver disease, although there are usually no symptoms associated with a slightly enlarged liver (hepatomegaly). Symptoms of a grossly enlarged liver include abdominal discomfort or "feeling full."[stanfordchildrens.org]
  • Patients may be asymptomatic or have fatigue, pruritus , and non-jaundice skin hyperpigmentation with hepatomegaly.[en.wikipedia.org]
Scleral Icterus
  • In the presented case, the authors describe an obese middle-aged man that presented to the emergency department for persistent oedema, scleral icterus and fatigue.[ncbi.nlm.nih.gov]
Palmar Erythema
  • erythema) itchy skin hair loss dark coloured urine fluid retention in the abdomen and legs internal bleeding presenting as dark-coloured stools or vomiting blood hormone disruptions that could cause a range of problems, including testicular atrophy ([betterhealth.vic.gov.au]
  • Patients cannot reproduce simple designs (e.g. a star of David) Drowsiness and confusion Parotid gland enlargement Spider angiomas Icterus Bilateral parotid swelling ( Credit ) Diminished axillary hair Spider angioma Gynecomastia in a male Asterixis Palmar[stanfordmedicine25.stanford.edu]
  • Abnormal findings suggestive of cirrhosis include: Jaundice Spider angiomata Palmar erythema Caput medusa Palpable left lobe of the liver Splenomegaly Ascites Clubbing Asterixis Gynecomastia Testicular atrophy Temporal wasting Hypertrophic osteoarthropathy[hiv.va.gov]
  • One study found that spider angiomata occur in about 1/3 of cases. [10] Palmar erythema is a reddening of palms at the thenar and hypothenar eminences also as a result of increased estrogen. [11] Gynecomastia , or increase in breast gland size in men[en.wikipedia.org]
  • Patients with alcohol-related cirrhosis can present with the same findings as patient with cirrhosis from other causes including jaundice, ascites, edema, hepatic encephalopathy, weakness and muscle wasting, spider nevi, and palmar erythema.[clinicaladvisor.com]
Muscle Cramp
  • cramps nosebleeds pain in the right shoulder breathlessness stools become black and tarry, or very pale. urine becomes darker. vomiting blood problems with walking and mobility The liver tissue is replaced by fibrous scar tissue.[medicalnewstoday.com]
  • Is taurine effective for treatment of painful muscle cramps in liver cirrhosis? [letter]. Am J Gastroenterol. 1993;88:1466 - 1467. Okita M, Watanabe A, Nagashima H. A vegetable protein-rich diet for the treatment of liver cirrhosis.[cancercarewny.com]
  • cramps right shoulder pain in men: enlarged breasts and shrunken testes in women: irregular or lack of menstrual periods impotence and loss of sexual desire dizziness and extreme fatigue (anaemia) shortness of breath very rapid heartbeat (tachycardia[britishlivertrust.org.uk]
Confusion
  • More specific symptoms include symptoms suggestive of decompensation such as jaundice, ascites, and upper gastrointestinal bleeds (variceal) and confusion (hepatic encephalopathy).[symptoma.com]
  • Confused thinking and other mental changes (hepatic encephalopathy). Hepatic encephalopathy most often occurs when the patient has had cirrhosis for a long time.[my.clevelandclinic.org]
  • The classification of liver cirrhosis is determined according to the appearance of symptoms: liver cirrhosis resulting in obvious symptoms such as jaundice, ascites (accumulation of fluid in the abdomen), and hepatic encephalopathy (confusion and coma[otsuka.co.jp]
  • Memory loss and confusion (Encephalopathy) Confusion, short-term memory problems and even loss of consciousness can result if your liver is not working properly. You might feel sleepy, experience tremors and have difficulty performing simple tasks.[britishlivertrust.org.uk]
Tremor
  • Liver cirrhosis in the index patient was complicated by hyperamonemia, hepatic encephalopathy and flapping tremor.[ncbi.nlm.nih.gov]
  • […] liver Enlarged spleen Appearance of thin, purplish-red, spidery looking blood vessels on the skin, especially around the navel Water retention and swelling in the legs and abdomen Vomiting blood Itching Abdominal infections Forgetfulness or confusion Tremors[chp.edu]
  • It can also feature problems in movement (called ataxia) and speech, slurring of words, tremor and a particular symptom of fl apping hands when you extend your arms (called asterixis).[britishlivertrust.org.uk]
  • […] may include: Impaired consciousness Changes in logical thinking, personality, and behavior Mood changes Impaired judgment Drowsiness Confusion Sluggish speech and movement Disorientation Loss of consciousness Coma Seizures (rare) Muscle stiffness or tremors[stanfordchildrens.org]
  • The physical exam can show signs such as: pale skin yellow eyes (jaundice) reddened palms hand tremors an enlarged liver or spleen small testicles excess breast tissue (in men) decreased alertness Tests can reveal how damaged the liver has become.[healthline.com]
Insomnia
  • The following signs and symptoms may occur: blood capillaries become visible on the skin on the upper abdomen. fatigue insomnia itchy skin loss of appetite loss of bodyweight nausea pain or tenderness in the area where the liver is located red or blotchy[medicalnewstoday.com]
  • […] variceal bleed, the combination of nonselective beta-blockers and endoscopic variceal ligation are recommended to decrease the risk of another bleed Hepatic Encephalopathy Overview: Variable abnormalities of neurological and psychiatric function, including insomnia[hiv.va.gov]
  • Examples include pregabalin (Lyrica) for pain or antidepressants and antipsychotics used to treat anxiety or insomnia. Furthermore, it may be difficult to eat a balanced, nutritious diet.[crohnsdisease.com]
  • Adverse effects may include: Anemia (ribavirin‑induced hemolysis), neutropenia, thrombocytopenia, fever, cough, fatigue, myalgia, arthralgia, nausea, loss of appetite, pruritis, and insomnia. Behavioral side effects may also occur.[ssa.gov]

Workup

The gold standard for diagnosis is to view the liver architecture, this can only be done on autopsy or on a removed liver during transplantation. The next best test would be a biopsy. The sample may be obtained percutaneous, transjugular, or by a laparoscopic approach. The sensitivity is usually very good if done appropriately.

Other tests that may be asked for to access the liver function include, INR (international normalized ratio), protein, albumin levels and liver enzyme levels. The INR increases with advance disease, while albumin and protein level decrease with advancing disease. Other examinations include tests to look for infective causes as listed above and autoimmune diseases [6].

Imaging 

Ultrasonography is a reliable tool that can be used to access the liver non-invasively. It can also access the nodularity and size of the liver and suspicious nodules (malignant), may be seen. It can also be used to access the portal pressures [7] [8]. Computed tomography may be used to diagnose hepatocellular carcinoma with specialized sequences.

Albumin Decreased
  • Common complications of alcoholic hepatitis Malnutrition Usually present Low serum albumin, decreased muscle strength, decreased lymphocyte count Infections Can occur during treatment.[clinicaladvisor.com]
Prothrombin Time Increased
  • Albumin – levels fall as the synthetic function of the liver declines with worsening cirrhosis, since albumin is exclusively synthesized in the liver Prothrombin timeincreases, since the liver synthesizes clotting factors.[en.wikipedia.org]
Trichophyton Rubrum
  • It was identified as Trichophyton rubrum by morphology and further conformed by sequencing of internal transcribed spacers of ribosomal DNA. The patient died quickly before the identification was available.[ncbi.nlm.nih.gov]
Vibrio Vulnificus
  • Local cultures following debridement revealed Vibrio vulnificus, and subsequent history revealed consumption of raw oysters 48 h before presentation.[ncbi.nlm.nih.gov]

Treatment

The treatment is to find the underlying cause and remove or treat it. As cirrhosis is the end stage, most of the injury is non-reversible and transplantation is the only option left. Some modalities which are mostly supportive may help slow the symptomology, for example laxatives [9].

Prognosis

Many patients with liver cirrhosis will eventually decompensate and the treatment is liver transplantation. Without transplantation the options for decompensated liver cirrhosis are only supportive. Despite the dramatic improvements in survival in liver transplant patients, donor organs are rare and difficult to come by. Overall without transplantation, outlook is poor [4].

Etiology

Alcohol is considered to be one of the major causes of cirrhosis, but other diseases such as hepatitis B and C are also common causes. The etiology may be divided into the following categories:

Infective

Ingestion

  • Alcohol
  • Methotrexate

Genetic

Autoimmune

Epidemiology

Many causes of chronic injury to the liver can lead to cirrhosis. In most cases of cirrhosis the cause may be found (80-90%). Previously alcohol was thought to be the commonest cause of liver cirrhosis, but infective causes are immerging, particularly hepatitis C has become the leading cause in the United States of America. It is in the top cause of cirrhosis currently.

Sex distribution
Age distribution

Pathophysiology

The occurrence of fibrosis is due to an imbalance between the laying down of collagen within the extracellular matrix and it degradation with subsequent distortion of the normal architecture. The extracellular matrix is produced by stellate cells of the liver. These cells get activated and produce collagen. The activation is via cytokines released by Kupffer cells, and sinusoidal endothelium as a response to injury. The injury is usually chronic as in alcoholism.

The collagen is deposited in the space of Disse with subsequent reduction in the size of the sinusoids leading to their capillarization. The fibrosis continues with area of regeneration which eventually leads to the end stage of cirrhosis [3].

Prevention

Vaccination against the infective causes is necessary. With those treatable diseases such as hepatitis B, early identification and appropriate treatment is paramount in halting the fibrosis before it becomes irreversible [10].

Summary

Liver cirrhosis is the end stage of progressive liver fibrosis with the characteristic regeneration nodules and fibrosis. This process may take weeks to years and is caused by a number of diseases and environmental factors. Cirrhosis is defined histologically as a diffuse hepatic process with fibrosis and areas of regeneration. The fibrosis is caused by the laying down of excess extracellular matrix. Initially it is reversible, but by the time it progresses to cirrhosis which is considered irreversible [1]. 

Patient Information

  • Definition: Liver cirrhosis is a disease where the liver is irreversibly scared. The reasons for the scarring are multiple. The inciting cause usually causes the scarring over a prolonged time, of up to 40 years. Damage to the liver can cause bleeding, body swelling and a big belly full of fluid. 
  • Cause: Causes are multiple and include infections such as hepatitis B and C. Another common cause is excessive alcohol intake. Other causes may be familial.
  • Symptoms: Some people may have no symptoms while others may be very sick with yellowing of the eyes, swelling of the legs and body, fatigue and decreased appetite. There may be also easy bruising. There also may be heavy internal bleeding from the food pipe which may be fatal. The worse the patient gets the more confused they get, till they eventually fall into a coma 
  • Diagnosis: The test that give the best results is a biopsy. The doctor gets a piece of the liver and sends it for diagnosis. Blood test may be done to find out the causes of the cirrhosis. 
  • Treatment: There is no treatment as the cirrhosis is permanent. The only option is to have a liver transplant. Usually people get a liver when they become symptomatic and the cause cannot be reversed. The outcomes after surgery are improving with time.

References

Article

  1. Harrison’s principals of Internal medicine 18th edition McGraw hill chapter 308.
  2. Heidelbaugh JJ, Bruderly M. Cirrhosis and chronic liver failure: part I. Diagnosis and evaluation. Am Fam Physician 2006; 74:756.
  3. Friedman SL. Hepatic fibrosis. In: Schiff ER, Sorrell MF, Maddrey WC, eds. Schiff's Diseases of the Liver. 8th ed. Philadelphia, Pa: Lippincott-Raven; 1999:371-85
  4. Freeman RB. Overview of the MELD/PELD system of liver allocation indications for liver transplantation in the MELD era: evidence-based patient selection. Liver Transpl. Oct 2004;10(10 Suppl 2):S2-3
  5. Burra P, Germani G, Masier A, et al. Sexual dysfunction in chronic liver disease: is liver transplantation an effective cure? Transplantation 2010; 89:1425.
  6. Simonovský V. The diagnosis of cirrhosis by high resolution ultrasound of the liver surface. Br J Radiol 1999; 72:29.
  7. Di Lelio A, Cestari C, Lomazzi A, Beretta L. Cirrhosis: diagnosis with sonographic study of the liver surface. Radiology 1989; 172:389.
  8. Sanford NL, Walsh P, Matis C, et al. Is ultrasonography useful in the assessment of diffuse parenchymal liver disease? Gastroenterology 1985; 89:186.
  9. Abt PL, Desai NM, Crawford MD, et al. Survival following liver transplantation from non-heart-beating donors. Ann Surg. Jan 2004;239(1):87-92
  10. Bonis PA, Friedman SL, Kaplan MM. Is liver fibrosis reversible? N Engl J Med 2001; 344:452.

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Last updated: 2018-06-22 09:34