Liver cirrhosis

Cirrhosis is usually asymptomatic, especially in the initial stages. The symptoms in the early stage of cirrhosis are not visible as the liver can still function despite being damaged. The symptoms start appearing after the liver becomes more severely damaged. The initial symptoms, if the liver becomes more severely damaged, are:

• Tiredness and weakness
• Malaise or feeling sick
• Insomnia
• Nausea and vomiting
• Loss of appetite resulting in weight loss
• Redness in the palms of the hands
• Mild pain or discomfort in the upper right side of the abdomen

If cirrhosis progresses further, some of the symptoms and complications include:

• Small spider-like veins underneath the skin
• Severe itching
• Easily bleeding or bruising, nosebleeds, and bleeding gums
• Yellowing of the skin (jaundice)
• Vomit containing blood
• Dark urine or tarry-looking stool
• Swelling of legs, ankles, and feet (edema)
• Painful swollen stomach from a build-up of fluid (ascites)
• Confusion, drowsiness, memory loss, hallucinations, or slurred speech (hepatic encephalopathy)
• In women, heavy menstrual bleeding, irregular periods, or absence of periods not related to menopause
• In men, loss of sex drive, breast enlargement (gynecomastia), testicular atrophy, or impotence

Liver cirrhosis may be caused by a wide range of diseases and disorders. Signs of liver cirrhosis progress gradually over time, ultimately resulting in liver failure if not adequately treated.

• Long-term hepatitis infections (chronic): A chronic liver infection can lead to damaged liver cells over several years, resulting in cirrhosis. Hepatitis B and C infections are the most common causes.
• Chronic alcoholism: Consumption of alcohol causes inflammation to liver cells, effectively poisoning them and resulting in the build-up of scar tissue. Excessive alcohol consumption over a decade or more leads to cirrhosis. The amount of damage varies among individuals and can be influenced by familial susceptibility.
• Non-alcoholic fatty liver (or steatohepatitis): Fatty build-up in the liver over time can lead to cirrhosis. Scar tissue that develops is often linked with conditions such as coronary artery disease, diabetes, obesity, high cholesterol, protein malnutrition, and corticosteroid treatment.
• Toxic substances or medications: Certain medications such as alphamethyldopa, amiodarone, methotrexate, isoniazid, as well as certain poisons and environmental toxins, can contribute to liver scarring and damage.
• Inherited (genetic) disorders: Genetic conditions can interfere with the liver's metabolism and its ability to manage the accumulation of iron (hemochromatosis) and copper (Wilson’s disease). Other disorders include cystic fibrosis, alpha-1 antitrypsin deficiency, tyrosinemia, fructose intolerance, glycogen storage disease, galactosemia, abetalipoproteinemia, and urea cycle defects such as ornithine carbamoyltransferase deficiency and Alagille syndrome.
• Autoimmune liver disease: Autoimmune infections occur when the body’s immune system attacks healthy tissues, including the liver. Autoimmune hepatitis is an example where the immune response malfunctions and damages liver cells instead of fighting infections.
• Cardiac cirrhosis: The heart's inability to pump effectively can cause blood to collect in the liver, leading to chronic passive congestion, damage to liver cells, swelling, and pain. Factors contributing to cardiac cirrhosis include infections of the heart muscle or sac, heart valve dysfunction, and smoking.
• Biliary cirrhosis: Bile, produced by the liver to aid in fat digestion, can back up due to conditions affecting the bile ducts, leading to liver function breakdown. Causes include poorly formed bile ducts (biliary atresia), destruction of bile ducts (primary biliary cirrhosis), and hardening and scarring of bile ducts (primary sclerosing cholangitis).
• Infections: Infections such as congenital or tertiary syphilis, brucellosis, echinococcosis, and schistosomiasis can lead to cirrhosis.
• Idiopathic/miscellaneous: Common idiopathic causes include idiopathic portal fibrosis, Indian childhood cirrhosis, and polycystic liver disease.

Stages Of Liver Cirrhosis

Liver cirrhosis is a progressive condition that can last long-term. Based on the severity of liver damage, it can be classified into four stages:

• Stage 1: Inflammation: This is the initial stage of liver cirrhosis. The person may feel fatigued or lack energy. There are no notable symptoms yet, but if the root cause can be treated, recovery is possible.
• Stage 2: Fibrosis: In this stage, scar tissue increases, replacing healthy liver cells, leading to portal hypertension. Partial reversal of liver cirrhosis is still possible at this stage.
• Stage 3: Liver cirrhosis: This stage is characterized by fluid accumulation in the abdominal cavity (ascites). Symptoms indicating poor liver function include eczema, widespread itchiness, weight loss, loss of appetite, confusion, lower leg swelling, shortness of breath, yellow or pale skin, and changes in blood sugar levels. At this stage, cirrhosis becomes irreversible, and a liver transplant may be recommended.
• Stage 4: Liver failure: The final stage results from extensive scar tissue. Symptoms are similar to stage 3 but include intensified confusion, hand tremors, high fever, personality changes, abdominal infections, and kidney failure leading to infrequent urination. Urgent liver transplant becomes necessary at this stage.

• High cholesterol (due to high cholesterol, the liver is unable to break down fatty deposits, which can lead to liver damage)
• Being overweight or obese
• Excessive alcohol consumption
• Pre-existing viral hepatitis
• Hypertension
• Sleep apnea
• Gout
• Long-term treatment with corticosteroids
• Chronic exposure to environmental toxins like arsenic

People with early-stage cirrhosis of the liver usually do not have any symptoms. Cirrhosis is first detected by a routine blood test or checkup. A combination of laboratory and imaging tests is conducted to confirm a diagnosis.

The general diagnostic procedure follows these steps:

1. Medical history
   A doctor will discuss all obvious symptoms, the severity, the duration of symptoms, and will take a complete medical history. Family history details and any signs of genetic predisposition will also be assessed.
2. Physical examination
   During a physical examination, a doctor will look for signs of impaired liver function such as pale skin, jaundice, red palms, gynecomastia (in men), small or enlarged testicles, and an enlarged liver or spleen. An enlarged liver can be felt along the lower edge of the right rib cage, while an enlarged spleen can be felt just below the left rib cage.
3. Blood tests
   Your doctor may recommend the following blood tests:
   • Liver function test (LFT): This test can show abnormal liver enzyme levels, indicating possible liver damage. Increased levels of bilirubin, liver enzymes (alanine transaminase [ALT], aspartate transaminase [AST], and alkaline phosphatase [ALP]), or decreased levels of blood proteins can signal cirrhosis.
   • Kidney function test (KFT): This test assesses creatinine levels, a waste product that helps determine kidney function. In later stages of cirrhosis, kidney function may decline.
   • Complete blood count (CBC): This test may indicate signs of infection and anemia, potentially caused by internal bleeding.
   • Other blood tests: Antibodies are screened for hepatitis infections (mainly B and C), along with tests for autoimmune liver conditions, including antinuclear antibody (ANA), anti-smooth muscle antibody (SMA), and anti-mitochondrial antibody (AMA).
4. Imaging tests
   The following imaging tests can reveal the size, shape, texture, and stiffness of the liver, identifying abnormalities (scarring) within the organ:
   • Abdominal ultrasound: A non-invasive procedure using sound waves to create images of the abdomen and pelvis, including the liver. Doppler ultrasound evaluates blood flow to and from the liver. It is usually the first radiographic test performed in cirrhosis evaluation due to its cost-effectiveness and lack of radiation exposure.
   • Abdominal computed tomography (CT): This procedure combines special x-ray equipment with computers to produce detailed digital images of the liver, helping to determine the severity of cirrhosis and other liver diseases.
   • Body magnetic resonance imaging (MRI): This technique uses a powerful magnetic field, radio frequency pulses, and a computer to produce detailed liver images. A dye may be injected to enhance visibility of the liver on the scan, allowing assessment of damage from various liver diseases.
   • Magnetic resonance cholangiopancreatography (MRCP): A special type of MRI used to evaluate parts of the liver and gallbladder.
   • Magnetic resonance elastography (MRE): This test assesses liver stiffness and scarring severity, detecting fibrosis earlier than other imaging tests. It can be performed using ultrasound or MRI.
   • Transient elastography (fibroScan): This test quantifies liver fibrosis (scarring).
   • Upper endoscopy: A lighted flexible camera is inserted through the mouth into the upper digestive tract to view enlarged blood vessels at risk of bleeding due to cirrhosis.
5. Liver biopsy
   In a liver biopsy, small tissue samples are taken from the liver using a needle or during surgery. This procedure is usually considered when other tests have failed to confirm a diagnosis of cirrhosis and when the benefits of biopsy outweigh the risks. The accuracy of cirrhosis diagnosis ranges from 80 to 100 percent, depending on the number and size of samples and the sampling method.

Even though the liver is the only organ in the body with regenerative capacity, it is essential to treat it with respect and care. The following steps can be taken to prevent liver cirrhosis:

1. Limit alcohol intake
   Alcohol should always be consumed in moderation. Men should not have more than two drinks per day, while women and the elderly should not consume more than one drink per day. However, it is always better to completely abstain from alcohol, especially in cases of liver disease. This includes avoiding all beer, wine, coolers, whiskey, gin, rum, brandy, and liquors.
2. Diet considerations
   A healthy diet plays an important role in the prevention of liver diseases. The diet should include:
   • Fruits
   • Vegetables
   • Whole grains
   • Lean protein sources
   • Unsalted nuts
   • Seeds
   • Low-fat dairy products
   Salt intake should be limited. If a lack of salt affects taste, flavor can be enhanced with lemon juice, vinegar, herbs, or spices. Foods high in sodium, such as ketchup, pickles, soy sauce, and hot sauces, should be avoided. Restaurants and fast food often add a lot of salt, so it is advisable to avoid them or request meals prepared without salt. Canned vegetables that are loaded with salt should also be avoided. Eating foods with healthy fats is important. Unsaturated fats should be consumed instead of saturated fats and trans fats. In cases of hemochromatosis, iron supplements and multivitamins with iron and Vitamin C should be avoided. In cases of Wilson's disease, foods high in copper should be eliminated from the diet. These foods include shellfish, organ meats, nuts, chocolate, mushrooms, kale, asparagus, parsley, potatoes with skin (both white and sweet), lima beans, soybean, sprouts, and spinach.
3. Maintain a healthy weight
   An excess amount of body fat can damage the liver. Always consult a doctor regarding weight maintenance and weight loss plans if you are obese or overweight.
4. Reduce the risk of hepatitis
   By avoiding hepatitis infection (particularly hepatitis B and C), a person can significantly reduce the risk of developing liver cirrhosis. To further lower the risk:
   • Avoid unprotected sex
   • Avoid sharing needles
   • Do not get tattoos or body piercings in an unsterilized environment. Ensure that instruments are properly sterilized and needles are not shared.
   • Get vaccinated. It is recommended that all infants and high-risk individuals, such as healthcare providers and rescue personnel, be vaccinated against hepatitis B. There is no vaccine for hepatitis C.

Here are a few more tips that can help in the detoxification of the liver.

Treatment for cirrhosis depends on the cause and extent of liver damage. The goals of treatment are to slow the progression of scar tissue in the liver. Cirrhosis cannot be cured, but treatment focuses on preventing further liver damage, easing symptoms, and reducing the impact of complications.

Treatment of Alcohol Dependence

People with cirrhosis caused by excessive alcohol should stop consuming alcohol. If quitting alcohol is difficult, a doctor may recommend a treatment program for alcohol addiction. Some programs include:

• Counseling: This helps individuals focus on strategies to stop drinking.
• Rehab Programs: Programs designed to provide help for alcohol addiction.
• Prescribed Medications: Disulfiram and acamprosate are used to control alcohol cravings and discomfort.

Medications

The required medication depends on the underlying cause of liver damage:

• If cirrhosis is due to long-term viral hepatitis, antiviral medicines like lamivudine, entecavir, and tenofovir disoproxil fumarate may be prescribed.
• If cirrhosis is caused by copper build-up from Wilson’s disease, medications such as D-penicillamine and trientine are utilized.

In addition to medications for the underlying cause of cirrhosis, certain medications may be used to treat complications:

• Portal Hypertension: Blood pressure medications can help lower pressure in the portal vein, reducing the risk of internal bleeding and spleen damage. Propranolol is commonly used.
• Hepatic Encephalopathy: Lactulose can help reduce the absorption of harmful substances in the brain. Antibiotics like rifaximin are also used.
• Ascites and Edema: Diuretics such as spironolactone or furosemide may be prescribed to reduce fluid accumulation in the abdomen or legs.
• Infections: Antibiotics may be prescribed to prevent or treat infections. Intravenous antibiotics can be administered for peritonitis associated with ascites.
• Itching: Drugs such as cholestyramine and colesevelam may relieve itching related to liver cirrhosis and lower high blood cholesterol levels.
• Malnutrition and Osteoporosis: Nutritional supplements may be prescribed to address malnutrition associated with cirrhosis and to prevent weak bones or osteoporosis.

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

This procedure treats portal hypertension caused by cirrhosis. A small tube or stent is placed into the liver to redirect blood flow back towards the heart.

Liver Transplantation

In advanced cases of cirrhosis, when the liver ceases to function, a liver transplant is the last treatment option. This procedure involves replacing a diseased liver with a healthy liver from a deceased donor or part of a liver from a living donor. Candidates for liver transplants undergo extensive testing to determine their health status and suitability for surgery.

Cirrhosis of the liver is a chronic disease that occurs as a result of damage to the liver over several years. It is a progressive disease in which healthy liver tissue is destroyed and replaced by scar tissue, resulting in poor liver function. While undergoing treatment, some home care tips that can be really helpful include:

1. Lifestyle Changes

• Quit smoking
• Avoid alcohol
• Practice good hygiene

2. Dietary Changes

Malnutrition is common in cirrhosis as it makes it more difficult for the body to process nutrients, leading to weakness and weight loss. It is important to eat a healthy, balanced diet that includes:

• Fruits and vegetables
• Whole grains
• Lean protein sources
• Unsalted nuts and seeds
• Low-fat dairy products

Cutting down on salt can help reduce swelling in the legs, feet, and abdomen caused by fluid build-up. Eating healthy snacks between meals or having 3 to 4 small meals each day, rather than 1 or 2 large meals, may also be beneficial. Read about food items that you can include in your diet for a healthy liver.

3. Exercise

Yoga and tai chi may help patients overcome fatigue commonly associated with liver disease. Some light exercises can include:

• A home-based aerobic routine
• Dancing as a form of exercise
• Lifting light weights
• Yoga, such as pranayama

If cirrhosis progresses and the liver is no longer able to function (decompensated cirrhosis), complications may arise that require treatment.

• Portal hypertension: Cirrhosis slows down normal blood flow through the liver, leading to portal hypertension, which is an increase in pressure within the portal vein that carries blood from the digestive organs to the liver.
• Swollen or bleeding veins: Portal hypertension can redirect blood to smaller veins, causing the veins in the esophagus or stomach to become swollen (esophageal varices and gastric varices). Excessive pressure can cause these veins to burst, leading to serious bleeding. If the liver cannot produce enough clotting factors, it can contribute to continuous bleeding.
• Fluid retention in the tummy or legs: A build-up of fluid in the abdominal area (ascites) or legs and ankles (peripheral edema) is a common complication of elevated portal pressure. Edema and ascites can also occur due to the liver's inability to produce blood proteins like albumin.
• Hepatic encephalopathy: Cirrhosis hampers the liver's ability to clear toxins from the blood, leading to a build-up in the brain that can cause symptoms like mental confusion, drowsiness, and difficulty concentrating. Long-term hepatic encephalopathy can result in unresponsiveness or coma.
• Bleeding: Cirrhosis can impair the liver's ability to produce sufficient clotting factors, increasing the risk of severe bleeding from cuts, wounds, surgeries, or dental work.
• Splenomegaly or enlargement of the spleen: Portal hypertension can cause swelling of the spleen, leading to the entrapment of white blood cells and platelets. A reduction in white blood cells and platelets in blood tests may be an early sign of cirrhosis.
• Jaundice: Cirrhosis affects the liver's ability to eliminate bilirubin, a waste product from the blood, leading to jaundice, characterized by yellowing of the skin, whites of the eyes, and mucous membranes.
• Infections: Cirrhosis reduces the body’s immunity to fight infections. Ascites or fluid retention in the abdomen can lead to a serious infection known as bacterial peritonitis.
• Osteoporosis: Some patients with cirrhosis may experience a loss of bone strength, increasing the risk of fractures.
• Diabetes: Cirrhosis can worsen existing type 2 diabetes by increasing insulin resistance, a hormone that controls blood sugar levels.
• Liver cancer: Cirrhosis increases the risk of liver cancer, particularly hepatocellular carcinoma (HCC). Many symptoms of liver cancer overlap with those of cirrhosis, making regular checks for liver cancer important.

Home Remedies

• Papaya seeds: According to Ayurveda, papaya seeds can aid in the treatment of cirrhosis by supporting liver detoxification.
  Tip: Grind fresh papaya seeds to extract 1 tablespoon of juice, add two tablespoons of lemon juice, and drink this mixture twice a day for a month to enhance liver function.
• Vitamin C: This vitamin has protective effects against oxidative damage in the liver and helps prevent fatty buildup and cirrhosis.
  Tip: Include vitamin C-rich foods like blackberries, lemons, and oranges in your diet.
• Turmeric: A rich source of antiseptics with antibacterial, antifungal, and antioxidant properties, turmeric can significantly benefit liver health.
  Tip: Add a tablespoon of turmeric to hot milk with honey and drink this once a day for about a month.
• Apple cider vinegar (ACV): ACV improves fat metabolism and acts as a detoxifying agent for the liver.
  Tip: Mix a tablespoon of ACV and a teaspoon of honey in a glass of water. Drink this mixture three times a day for a healthier liver.
• Green tea: Rich in antioxidants, green tea reduces oxidative stress that can lead to cirrhosis. It also offers protective effects against liver disease and has antiviral properties that help combat viral hepatitis.
• Milk thistle: This Mediterranean herb has been used for centuries to treat liver issues. It serves as a powerful liver cleanser by rebuilding liver cells, reducing liver damage, and eliminating toxins processed by the liver.

Often, receiving a diagnosis of liver cirrhosis can be a life-altering and challenging situation for patients and their caregivers. Coming to terms with the diagnosis can invoke feelings of loneliness, depression, anger, rage, guilt, and the need to limit alcohol intake. However, it is important to remember that a diagnosis of liver cirrhosis does not necessarily mean the end of life. It is possible to live a happy life even after being diagnosed with liver disease.

Make sure that the person understands the diagnosis and its health implications.

Motivate the patient to stay socially active by:

• Going to a movie
• Taking a walk in a park
• Engaging in community activities, such as attending functions
• Helping them join a support group

Encourage them to spend time with friends and family so that if a person indulges in alcohol, they can help control mood swings and calm their senses.

Love, understanding, patience, and reassurance are cornerstones of living with loved ones.