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Cirrhosis of the liver: Causes, Modifiable risks and treatment considerations

Digestion, General | March 8, 2016 | Author: The Super Pharmacist

general, liver

Cirrhosis of the liver: Causes, Modifiable risks and treatment considerations

Cirrhosis is scarring of the liver as a result of continuous, long-term liver damage. It is a slow progressing disease in which healthy liver tissue is replaced with scar tissue which blocks the flow of blood through the liver. This slows down the processing of hormones, medication, nutrients and naturally produced toxins that require metabolism and excretion. Cirrhosis can be fatal if left untreated and the liver fails, although treatment can significantly help slow its progression.

Causes and modifiable risk factors

There are many causes associated with cirrhosis of the liver. In the Western world, the most prominent are alcohol misuse and long-term hepatitis C infection, although many cases of the disease are also idiopathic (cause unknown). Globally, more than half of all cirrhosis is attributable to Hepatitis B and C, with alcohol consumption accountable for around 20% of all cases

As cirrhosis is largely asymptomatic in its early stages, many individuals only find out that they have cirrhosis when being tested for other medical conditions.

Alcohol-related cirrhosis

Alcohol-related cirrhosis usually occurs after around 10 years of excessive drinking. Whilst cirrhosis has historically been associated with alcoholism, many heavy social drinkers are also at risk of developing the condition. Women who drink excessively are more susceptible to cirrhosis than men, predominantly as a result of their different body sizes and stature.

Disease Development of Alcoholic Liver Disease

Disease Development of Alcoholic Liver DiseaseIndividuals who continue to drink heavily develop cirrhosis over three definable phases of alcohol related liver disease (ALD).

First stage is ‘fatty liver’, a side effect of the liver breaking excessive alcohol down

Second stage is alcoholic hepatitis, leading to inflammation of the liver

Third stage is full cirrhosis, developed by approximately 10% of heavy drinkers

Hepatitis

Hepatitis is the inflammation of the liver and hepatitis B, C and D can all cause cirrhosis of the liver.

The hepatitis C virus is most often transmitted through blood to blood contact, such as the sharing of needles that are used to inject drugs. Hepatitis B is vaccine preventable.

Non-alcoholic steatohepatitis

The third most prominent cause of cirrhosis is non-alcoholic steatohepatitis (NASH). NASH results in the build up of excess fat in the liver, similarly to ALD. This results in scarring and inflammation which in turn can lead to cirrhosis.

Non-alcoholic steatohepatitisNASH is linked to a wide range of risk factors that are modifiable.

It is associated with a wide range of diseases that have significant lifestyle determinants such as: 

The majority of cases of cirrhosis could be avoided through reducing alcohol intake and maintaining a healthy diet and lifestyle with plenty of exercise.

Other Causes

Some causes of hepatitis do not have modifiable risk factors. These include:

  • Autoimmune liver diseases such as autoimmune hepatitis and primary biliary cirrhosis where the individual’s own immune system attacks healthy organs
  • Budd-Chiari syndrome in which blood clots block the veins that carry blood from the liver
  • Rare genetic conditions such as Wilson’s disease in which there is a build up of excessive copper in the liver.

Symptoms of cirrhosis

Cirrhosis of the liver is largely asymptomatic during in its primary stages, as the liver remains able to function during the early phase of the disease. It is only when the liver becomes more damaged that telltale symptoms of the disease begin to manifest. Symptoms begin to show when the liver is no longer able to create enough proteins to help fluid composition in the bloodstream, process waste chemicals or clot blood effectively.

Common symptoms are:

  • Tiredness and weakness
  • Bleeding and bruising more often and more easily
  • Loss of appetite
  • Jaundice (as a result of the body’s inability to process bilirubin)
  • Changes in mental health as a result of increased hepatotoxicity (this can also lead to a loss of consciousness and hepatic coma)

Treatment strategies 

Cirrhosis cannot be cured, but treatment can manage symptoms and stop the disease from progressing to its later stages, particularly when undertaken in conjunction with lifestyle changes.

The medication required depends on the specific cause of damage to the liver

Disease Development of Alcoholic Liver DiseaseFor people who drink, the reduction of alcohol intake is crucial to improving treatment outcomes.

Hepatitis. For  who have hepatitis related cirrhosis, doctors will prescribe either antiviral therapy or steroids to reduce liver cell injury. Much of the research for antiviral therapy focuses predominantly on Hepatitis B (HBV) and Hepatitis C (HCV) related cirrhosis: a retrospective cohort study undertaken in 2014, observing the effect of the antiviral drugs interferon and ribavirin in a cohort of 170 patients, reported improved clinical long-term outcomes.

Almost all antiviral therapy is combination therapy, with the sustained virological response in most patients being somewhere between 30-50%, as evidenced by a wide range of systematic reviews.

Autoimmune hepatitis. Topical corticosteroids are often administered for individuals with autoimmune hepatitis. They can also be prescribed an alternative immunosuppressant. With appropriate treatment that is administered promptly, it is estimated that 80% of patients who receive immunosuppressant therapy can achieve remission and long-term survival.

Hospital treatment. Treatment with corticosteroids or pentoxifylline to reduce inflammation is common. Pentoxifylline is a non-selective phosphodiesterase inhibitor, although there is ongoing concern regarding its effectiveness when administered alone or as an adjunct therapy to steroids. Topical corticosteroids are also well researched, but similar concerns persist regarding their effectiveness. A number of systematic reviews have been conducted to overcome the low statistical power of many trials that have been conducted with a small sample number, although they often provide inconclusive or contradictory results. There are relatively few studies comparing the merits of corticosteroids and pentoxifylline. Of the small number that do exist, a 2014 study undertaken in South Korea that had 120 participants with severe alcoholic hepatitis, found the efficacy of pentoxifylline to be considerably less when compared to a corticosteroid (prednisolone).

Common symptoms 

  • peripheral oedema (fluid around the legs and ankles)
  • ascites (a build up of fluid around the stomach area)

The amount of free water in the stomach area can make it very difficult for people with cirrhosis to eat and breathe without complication. Salt reduction is the most effective treatment, although diuretics can also be directed at the cause to ease discomfort. Spironolactone is the most common diuretic used.

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