Prevention and Treatment of Liver Cirrhosis

By Dr V Anantha Narayanan,
Retired Professor of Gastroenterology,
Amritha Medical Institute,
Kochi

The liver is the largest organ in the body and it is located in the right upper abdomen. It is a vital organ and has a wide range of functions. It helps digest food, stores energy and removes poisons. It has a major role in metabolism, including regulation of glycogen storage, decomposition of red blood cells, plasma protein synthesis especially albumin and proteins necessary for coagulation functions, production of certain hormones, and detoxification of toxic substances and their removal. Bile necessary for fat digestion is synthesised by the liver.

There are many kinds of liver diseases that affect these functions. Viruses can cause acute hepatitis; drugs and poisons can damage liver. Non-alcoholic fatty liver diseases due to overweight, lack of exercise, diabetes, etc., are causes affecting the liver.

Alcohol and liver
This is a chronic progressive disease of liver in which normal liver cells are replaced by scar tissue. The disease comes on slowly over years and all parts of the liver can be affected. The commonest cause of cirrhosis is alcohol, viral hepatitis B or C, and non- alcoholic fatty liver disease.

Over 40 grams of alcohol for over 3 years can damage the liver in 25% to 30% of drinkers. 10 grams of alcohol is equivalent to 30 ml of hard liquor (whisky, rum, brandy, etc). 10 grams of alcohol is equivalent to 100 ml of wine and 225 ml of beer. World Health

Organisation (WHO) reports about 2 billion alcohol consumers worldwide, and 76.3 million people with alcohol-related liver disease.

In India, Kerala is the number one state in terms of alcohol-related cirrhosis. Alcohol causes 2.5 million deaths (3.8 % of total deaths) and 69.4 million disability adjusted life years (DALY), according to WHO. One DALY is equal to one year of totally life lost and is a measure of the burden of the disease.

Heavy drinkers will eventually develop fatty liver. The liver breaks down alcohol into carbon dioxide and water, causing fatty liver. As soon as excessive drinking stops, the symptoms of fatty liver go away. However, 20% to 30% of those who continue drinking heavily will develop alcoholic hepatitis, the next stage. About 10% of heavy drinkers will subsequently develop cirrhosis – the third stage of alcoholic liver disease.

According to National Health Service (NHS), of the United Kingdom, excessive alcohol consumption is when a man drinks over 21 units, and when a woman drinks over 14 units a week. Toxins, including alcohol, are broken down by the liver. However, if the amount of alcohol is too high, the liver will be overworked, and the liver cells can eventually become damaged.

Heavy, regular and long-term drinkers are much more likely to develop cirrhosis, compared to other healthy people. It is a myth that only alcoholics are at risk – regular and heavy social drinking is also linked to a higher probability of developing cirrhosis.

Typically, heavy drinking needs to be sustained for at least 10 years for cirrhosis to develop. The period varies according to each individual. Regular heavy female drinkers are more likely to develop symptoms compared to men who consume the same amount.

End-stage liver disease
Alcohol can damage the liver in three ways: fatty liver where complete abstinence reverses the condition; alcoholic hepatitis; and cirrhosis of the liver.

In cirrhosis, the liver tissue is replaced by scar tissue and liver functions are deranged. The symptoms and signs of the disease are due to either failure of the liver-cell functions or the result of portal hypertension. The portal vein feeds the liver with absorbed nutrients, and, because of scar formation (fibrosis), the portal vein meets with resistance and the pressure in the portal vein is raised – and this is called portal hypertension. Raised portal pressure causes collateral blood flow and the blood vessels become enlarged, which is called varices, and are more likely to bleed, causing vomiting of blood.

No symptoms
Cirrhosis often has no symptoms or signs until the liver damage is extensive. The earliest symptoms are fatigue and loss of appetite. Vomiting of blood can occur. Yellowish discolouration of eyes (jaundice), fluid accumulation in abdomen (ascites) and swelling of feet are other symptoms.

If toxic substances are not removed by the liver, substances like ammonia and product of protein metabolism (normally removed by healthy liver) can accumulate and derange cerebral functions and cause personality changes, altered bravery and behavioural changes.

Diagnosis is usually by blood tests. In the case of cirrhosis, liver function tests are deranged. Albumin level goes down (normal above 3.5 g/ dl). Platelets go down, and bleeding time and prothrombin time increases. Ultrasound scan shows a coarse liver with altered echotexture with enlarged spleen, and endoscopy shows varices. Liver biopsy confirms diagnosis, but may not be necessary if there are varices with deranged liver
function tests.

Causes
It is important to determine the cause of cirrhosis because treating that underlying cause can help prevent further liver damage. A wide range of diseases and conditions can damage the liver and lead to cirrhosis. Some of the causes of cirrhosis are inherited or thought to be inherited. They are:

• Iron buildup in the body (hemochromatosis)
• Cystic fibrosis
• Copper accumulated in the liver (Wilson’s disease)
• Poorly formed bile ducts (biliary atresia)
• Inherited disorders of sugar metabolism (galactosemia or glycogen storage disease)
• Genetic digestive disorder (Alagille syndrome)
• Liver disease caused by the body’s immune system (autoimmune hepatitis)

Others occur later in life. They are:
• Chronic alcohol abuse
• Hepatitis C
• Hepatitis B
• Fat accumulating in the liver (nonalcoholic fatty liver disease)
• Destruction of the bile ducts (primary biliary cirrhosis)
• Hardening and scarring of the bile ducts (primary sclerosing cholangitis)
• Infection by a parasite common in developing countries (schistosomiasis)

Some people may have more than one cause for cirrhosis, such as alcohol abuse and viral hepatitis. If doctors cannot find a cause for the condition, it is called cryptogenic cirrhosis. Up to 20% of people with cirrhosis have cryptogenic cirrhosis.

Treatment
The treatment of cirrhosis is removal of the cause. If due to alcohol, complete abstinence is a must. If due to viral B or C antiviral treatment, cautiously as in damaged liver, the patient may not tolerate antiviral drugs. Along with that, give liver support with low-fat and easily digestible diet, drugs like URSODEOXYCHOLIC ACID and laxatives for good bowel movements. Amino acids and vitamin supplements as needed.

Once the liver tissues are replaced by scar tissues, the aim of treatment is to arrest progression of fibrosis and preserve the normal liver tissues.

The severity of liver damage is assessed by levels of albumin and coagulation function derangement. There is a scoring system based on the tests called MELD score, and if it is higher than 15, it shows severe damage to liver. And, in end-stage liver disease, the only option is liver transplantation.

Prevention
Primary prevention aims at increasing awareness, prevention programmes, striving to educate communities about the risks associated with alcohol, and giving clear message about the consequences of drinking. For viral B, immunisation is available, and vaccination against Hepatitis B is a must in high-prevalence areas. For Hepatitis C, safe sex practice is necessary. Disposable syringe should be used for injection.

For non-alcoholic fatty liver disease, lifestyle modification, safe diet, avoiding too much of fat, eating plenty of vegetables and fruits, daily exercise, optional control of sugar (if diabetic), and anti-cholesterol drugs (if cholesterol is high) may help in preventing fatty liver.

Liver cancer occurs as a squeal in about 20% of cirrhosis, and, therefore, periodic checkup and taking treatment to arrest progression of disease is vital. With increased awareness among the public, liver health can be improved and cirrhosis prevented to a large extent. Remember that your liver is very tough. It will keep working even if badly damaged, and can continue to repair itself until it is severely damaged.

Points to note
• Cirrhosis is scarring of the liver. Scar tissue replaces healthy liver tissue.
• Some common causes of cirrhosis include heavy alcohol use, hepatitis infections, and non-alcoholic fatty liver disease.
• In the early stages of cirrhosis, one may have no symptoms. As the disease gets worse, cirrhosis can cause serious problems.
• Once one has cirrhosis, nothing can make all the scar tissue go away. However, treatment can prevent cirrhosis from getting worse.
• If too much of scar tissues are formed and the liver fails, one will need a liver transplant.
• One can take steps to prevent cirrhosis or keep it from getting worse.