Cirrhosis of the liver

Cirrhosis of the liver is a type of liver damage where healthy cells are replaced by scar tissue. The liver is unable to perform its vital functions of metabolism, production of proteins, including blood clotting factors, and filtering of drugs and toxins.

Many people think that only drinking excessive amounts of alcohol causes liver cirrhosis. But there are a number of other ways that the liver can be damaged and lead to cirrhosis.

Depending on the cause, cirrhosis can develop over months or years. There is no cure. Treatment aims to halt liver damage, manage the symptoms and reduce the risk of complications, such as diabetes, osteoporosis (brittle bones), liver cancer and liver failure.

Symptoms of liver cirrhosis

Symptoms depend on the severity of the cirrhosis, but may include:

• appetite loss
• nausea
• weight loss
• general tiredness
• spidery red veins on the skin (spider angiomas)
• easily bruised skin
• yellowing of the skin and eyes (jaundice)
• reddened palms (palmar 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 (shrinking) and impotence in males or amenorrhoea (no periods) in women
• disturbed sleep patterns
• cognitive problems such as memory loss, confusion or concentration difficulties.

Causes of liver cirrhosis

Two of the most well-known causes of liver cirrhosis are long-term excessive alcohol consumption and hepatitis C virus infection. However, there are a number of other conditions that can also lead to liver damage and cirrhosis. In fact, non-alcoholic fatty liver disease (‘fatty liver’) is the most common cause of chronic liver disease in Australia. A small proportion of patients with fatty liver can also develop cirrhosis. Hepatitis B virus infection is an important cause of cirrhosis worldwide.

Alcoholic liver cirrhosis

Excessive and chronic alcohol consumption is the most common cause of liver cirrhosis. Cirrhosis from drinking alcohol can develop over many years.

It is important to remember that the amount of alcohol that will damage the liver can vary from person to person. If a healthy woman drinks the same amount of alcohol as a healthy man, she has a higher risk of cirrhosis. Children are particularly susceptible to damage from alcohol. Some people also have a genetic predisposition to alcohol-related liver injury.

People with a medical condition, especially those affecting the liver, may have a higher risk of damage from alcohol. If you already have hepatitis B or C, or cirrhosis of the liver (from any cause), you are at risk of making your condition worse if you drink alcohol.

Liver cirrhosis and hepatitis

Hepatitis is a general term meaning inflammation of the liver. Viral hepatitis is hepatitis caused by a virus like the hepatitis B or C virus. Chronic hepatitis C is a common cause of liver cirrhosis. Hepatitis B can also cause cirrhosis. With either of these conditions, you increase your risk of developing cirrhosis if you drink alcohol.

Liver cirrhosis and fatty liver

Non-alcoholic fatty liver disease (NAFLD) is a condition where fat accumulates in the liver. It now affects about 20 per cent of Australians. It is becoming more common in children who are overweight or obese.

NAFLD is associated with conditions such as:

• obesity – 20 per cent of people with obesity have fatty liver disease
• high blood cholesterol and triglycerides
• type 2 diabetes.

NAFLD can lead to inflammation of the liver and the formation of scar tissue, a condition called non-alcoholic steatohepatitis (NASH), which can then lead to cirrhosis of the liver. NASH usually occurs in people who are obese, have diabetes or have high blood cholesterol and triglycerides, so controlling these conditions is recommended.

People with NASH have a higher risk of liver damage if they have hepatitis C. The effect of alcohol is debated, but it is probably not recommended if there is significant liver scarring present.

Liver cirrhosis from inherited conditions

Some inherited conditions damage the liver and this leads to the scarring that can contribute to cirrhosis. These conditions include:

• haemochromatosis – the body accumulates iron, which can damage many organs, including the liver
• Wilson disease – the tissues of the body accumulate copper
• galactosaemia – the body is unable to process galactose (a sugar) so it accumulates in the blood and can result in liver damage
• cystic fibrosis – mainly affects the lungs, but can also cause scarring of the liver
• alpha-1 antitrypsin deficiency – can cause lung damage but can also affect liver function and lead to cirrhosis and liver failure.

Other causes of liver cirrhosis

A number of other medical conditions that result in liver damage can cause cirrhosis, including:

• some autoimmune diseases – certain types of cells of the immune system attack and damage the liver. These uncommon conditions that can cause liver cirrhosis include autoimmune hepatitis, primary biliary cholangitis and primary sclerosing cholangitis (inflammation and scarring of the bile ducts).
• exposure to poisons – can damage the liver because one of the liver’s main roles is to remove toxins from the blood. Prolonged exposure to environmental toxins such as arsenic can damage the liver and lead to cirrhosis.
• schistosomiasis – a tropical disease caused by a parasitic worm called Schistosoma. The worm is passed to humans from snails, and the disease is also known as bilharziasis. Chronic schistosomiasis causes damage to internal organs including the liver
• certain medications (such as amiodarone, which is used to manage heart arrhythmias) – in rare cases, may cause cirrhosis in susceptible people
• unknown conditions – can cause cirrhosis in about one third of cases (called ‘cryptogenic cirrhosis’. Some of these are due to non-alcoholic fatty liver disease).

Complications of liver cirrhosis

Without medical treatment, cirrhosis of the liver can lead to a range of potentially life-threatening complications including:

• bleeding from enlarged blood vessels (‘varices’) in the oesophagus or stomach
• build-up of fluid within the abdominal cavity (ascites)
• infection of the fluid found within the abdominal cavity (spontaneous bacterial peritonitis)
• liver failure – loss of liver cells and disruption of blood flow through the liver by scar tissue can impair liver function
• impaired functioning of the brain caused by toxins that the liver has failed to remove (hepatic encephalopathy).
• primary liver cancer – the most common type of cancer caused by cirrhosis is hepatocellular carcinoma
• osteoporosis (brittle bones)

Diagnosis of liver cirrhosis

Tests used to diagnose liver cirrhosis may include:

• medical history
• physical examination
• blood tests, including liver function tests
• urine tests
• imaging studies, including ultrasound, computed tomography (CT scan) or magnetic resonance imaging (MRI)
• transient elastography (Fibroscan^TM), this test uses an ultrasound-based technique to detect liver cirrhosis. This test is less accurate in people with obesity issues unless specially designed XL probes are used.
• liver biopsy, obtaining liver tissue for laboratory examination.

Treatment of liver cirrhosis

Cirrhosis of the liver is incurable but, in some cases, treatment can help to reduce the likelihood that the condition will become worse.

Treatment options include:

• treating the underlying cause of liver damage – for example, treating the underlying hepatitis (B or C) virus infection, or the removal of blood to lower iron levels in haemochromatosis
• making dietary and lifestyle changes – a nutritious low-fat, high-protein diet and exercise can help people to avoid malnutrition
• avoiding alcohol – alcohol damages the liver and harms remaining healthy tissue
• taking certain medications – such as beta-blockers to reduce blood pressure and lower the risk of bleeding or diuretics to remove excess fluid
• avoiding certain medications that can make the symptoms worse – such as non-steroidal anti-inflammatory drugs (NSAIDs), opiates or sedatives
• having regular medical check-ups – including scans to check for liver cancer
• having regular endoscopic procedures to check whether there are varicose veins within the oesophagus or stomach
• having a liver transplant – an option that may be considered in severe cases.

Where to get help

• Your GP (doctor)
• Gastroenterologist
• Dietitian