Liver
CirrhosisIntroduction: In the Western world this
disease is one of the leading causes of death right after cardiovascular disease
and cancer. Among people aged 45 to 65 it is the 3rd leading cause of death. The
tragedy is that most of these cases are preventable and most of the cases are
due to alcohol abuse. In other parts of the world where hepatitis B runs rampant
cirrhosis of the liver is due to the chronic scarring from infectious hepatitis. Hepatitis
C is emerging from the intravenous drug use with contaminated needles and this
will develop into cirrhosis of the liver in virtually all cases in the long-term.
Lately, with obesity being more common, a new cause of getting liver cirrhosis
has emerged. People get the reversible fatty liver disease (also known as "nonalcoholic
fatty liver disease" or NAFLD) where fat is incorporated into
the tissue of the liver. This is associated with diabetes, the metabolic syndrome,
as well as elevated cholesterol and lipids. When any of these are also present
with fatty liver disease an inflammatory condition of the fatty liver leads to
nonalcoholic steatohepatitis (=NASH). In a Danish study patients with NAFLD were
observed for 17 years and less than 1% developed cirrhosis of the liver. However,
1 in 4 patients with NASH (liver cirrhosis that developed out of a fatty liver)
will die within 5 years with liver-related complications. In this context it is
important to know that 2 to 3% of adults in the US have NASH and 20% of these
will develop liver cirrhosis (Ref. 9). Chronic biliary obstruction ( for
instance from gall stones) is another important reason to develop cirrhosis of
the liver. The surface of the liver is knobley instead of shiny and smooth.
This can be seen on this image
of a liver with cirrhosis from the anatomical department of Cornell
University. With end stage cirrhosis of the liver patients develop portal hypertension.
This is a condition where the blood, which normally flows from the veins of the
bowels to the liver will not be able to get into the liver and thus experiences
an increase in pressure in that system (hence the name"portal hypertension").
Venous escape routes get established in these patients, namely via the lower esophageal
veins(esophageal varices), the rectal veins and the periumbilical veins. Symptoms:
Many patients are asymptomatic for several years. The first symptoms may
be weight loss, lack of appetite, nausea and weakness. In patients with biliary
obstruction there often is a chronic skin itch, which leads to an intractable
and very annoying itching leaving scratch marks all over the body. Jaundice from
backed-up bile salts can be seen in the skin in more advanced cases. With
a cirrhosis based on chronic alcohol abuse there may be signs of malnutrition
with wasted muscles and symptoms from chronic pancreatic insufficiency (due to
chronic pancreatitis). Portal
hypertension is common in these patients and often these patients
will die from a sudden massive bleed from ruptured esophageal varices. Other complications
are the development of ascites( free watery fluid in the abdomen), liver failure
with metabolic derangement and systemic bleeding from a lack of clotting factor
production by the cirrhotic liver. Hepatic encephalopathy is another late symptoms
where confusion sets in and thought processes are severely disturbed and behaviors
grossly out of control. This can create severe commotions in the hospital setting,
at home or wherever they are. Treatment:
Before liver transplants had been available for end stage liver cirrhosis,
there was no cure and only symptomatic therapy could be offered. Now the
gastroenterologist will follow these patients and symptomatically treat the various
symptoms until the stage, beyond which the complication rate becomes unacceptable
and a liver transplant is suggested. Pruritus (= itchy skin) can be relieved with
cholestyramine. Toxic substances such as alcohol should be removed whenever possible.
Proper nutrition, if this was a problem needs to be reestablished. In some
autoimmune induced cirrhosis cases there might be a place for azathioprine. For
chronic hepatitis C patients interferon-gamma has been used with some success.
Eventually the gastroenterologist will likely recommend at least to some patients
a liver transplant. This is not an instant cure, as following this procedure the
patient has to be available for regular follow-up visits with occasional laparoscopic
liver biopsies to monitor immune rejection and treat this with immunosuppressant
medication. The transplantation team subjects the potential liver transplant recipient
to screening tests in order to establish the suitability of the person. Transplantation
is not for everyone. However, the alternative is premature death. When
"nonalcoholic fatty liver disease" (=NAFLD) is treated with aggressive
weight loss measures and calorie restriction, nonalcoholic steatohepatitis (=NASH)
and liver cirrhosis can be prevented. |
