Healthy liver tissue carries out many crucial processes within the body, including detoxification (filtering harmful substances out of the body), bile production (to help digestion), and protein synthesis1. The impaired function of liver tissue can, therefore, have harmful effects. Liver cirrhosis is a condition where scar tissue replaces healthy tissue in the liver, preventing it from functioning correctly2. There are over 54,000 deaths per year in the US related to chronic liver disease and cirrhosis, making it the 10th most likely cause of death3.
This article will discuss the symptoms and causes of liver cirrhosis, potential complications, and the importance of early detection in a positive outcome.
What is Liver Cirrhosis?
Liver cirrhosis is permanent scarring of the liver where healthy tissue is replaced by scar tissue. Cirrhosis occurs over many years and is caused by the accumulative effects of chronic liver damage. The liver attempts to repair itself in response to damage by developing fibrosis (scar tissue), however, this does not function as healthy liver tissue4. The early stages of cirrhosis are known as compensated cirrhosis, as the liver can still function despite the scarring. The later stages are known as decompensated cirrhosis, as the liver can no longer function effectively due to increased scarring5. At the decompensated cirrhosis stages of the disease, symptoms will be evident and the liver will begin to fail.
Early Signs and Symptoms of Cirrhosis
Earliest Symptoms of Cirrhosis
The first stages of cirrhosis may not show obvious symptoms or symptoms specific to liver disease, making it difficult to identify. Symptoms may include6:
- Feeling tired and/or weak
- Itchy skin
- Poor appetite
- Weight loss
- Nausea and vomiting
- Mild pain or discomfort in the abdomen
- Muscle loss
Physical Manifestations
As cirrhosis progresses, symptoms become more extreme, including:
- Distended (swollen) abdomen, known as ascites
- Lower leg, ankles, or feet swelling, known as edema
- Severely itchy skin
- Bleeding or bruising easily
- Skin spots, such as spider angiomas (spider-like blood vessels above waist level)
- Dark coloured urine
Neurological and Systemic Symptoms
The liver’s impaired ability to carry out its normal functions can lead to a build-up of nutrients and toxins, leading to further symptoms, including:
- Hepatic encephalopathy – a build-up of toxins, such as ammonia, in the blood resulting in brain dysfunction. Symptoms can include memory loss, mood and personality swings, problems with impulse control, and loss of coordination7.
- Jaundice – yellowing of the skin and whites of the eyes caused by a build-up of bilirubin (a waste product)8.
- Terry’s nails – nail discoloration where most of the nail looks white except for a thin pink or brown line at the tip9.
Common Causes and Risk Factors
Alcohol and Hepatitis-Related Cirrhosis
Alcohol and hepatitis are two of the main causes of cirrhosis2. Excessive and prolonged alcohol consumption can result in liver damage and cirrhosis through multiple mechanisms, such as fat accumulation, the release of toxic byproducts, and chronic inflammation10,11,12. Hepatitis C is a virus that infects liver cells. It is spread through blood-to-blood contact, such as sharing needles13. If the virus remains untreated, it interferes with the immune system leading to chronic immune activation. Over time, this will result in damage to the liver and scarring14.
Non-Alcoholic Fatty Liver Disease (NAFLD) and Other Metabolic Causes
Although commonly associated with alcohol consumption, cirrhosis can occur in individuals who consume no alcohol. In these situations, it is often associated with metabolic causes, such as obesity, diabetes, and hypertension. Similar to alcohol use, fat accumulation builds up around the liver and can result in inflammation and damage to liver cells15. Insulin resistance increases the breakdown of fat stores in the body, resulting in an increase in circulating free fatty acids which can be deposited in the liver15.
Genetic and Autoimmune Factors
Cirrhosis can be caused by inherited health conditions, such as hemochromatosis – a condition iron is deposited in the liver, causing damage and subsequent cirrhosis – and Wilson disease – a condition where copper accumulates in the liver and causes liver failure or cirrhosis16. Autoimmune diseases, where the immune system attacks the body itself, can also lead to liver cirrhosis. High levels of harmful factors, such as reactive oxygen species, are released by the immune cells, resulting in the damage and death of liver cells and potential cirrhosis if left untreated17.
Progression and Complications
Portal Hypertension and Bleeding
The portal venous system carries blood from the stomach and intestines into the liver. Cirrhosis of the liver can block the portal vein, leading to increased pressure in the venous system. This increases the chances of internal bleeding from a burst vein18.
Liver Failure and Multiorgan Effects
If left untreated, cirrhosis can lead to acute liver failure, which can further lead to multi-organ failure and death. The early stages of liver failure may cause symptoms such as fatigue, nausea, and abdominal pain, whereas chronic liver failure symptoms include jaundice, hepatic encephalopathy, and multiple infections due to decreased immunity19.
Increased Liver Cancer Risk
Cirrhosis is the leading cause of liver cancer. Those diagnosed with cirrhosis are recommended to undergo cancer screening regularly to identify the development of cancer as early as possible, which increases the possibility of a positive outcome20.
Diagnosis Methods
Blood Tests and Liver Enzyme Levels
Blood tests are commonly used in the diagnosis of cirrhosis. These measure specific factors in the blood which may be elevated if cirrhosis or liver damage is present. These include ALT, AST, bilirubin, and albumin21. Tests can also be carried out to assess clotting factors. These are synthesized in the liver and so liver dysfunction can result in an increased time taken for blood to clot22.
Imaging and Biopsy
Doctors commonly use imaging methods, such as MRI, CT scans, and ultrasounds to detect the presence of liver scarring and potential tumors within the liver. These imaging methods can also be used to assess cirrhosis progression after diagnosis. Although no longer necessary for a diagnosis of cirrhosis, a liver biopsy may be required to assess the underlying cause of the liver disease21.
Prevention and Risk Reduction
Lifestyle Modifications
Although there is no cure for cirrhosis, the liver has a high level of regenerative capacity. If the trigger for cirrhosis is identified and treated, the damage to the liver may be reduced. The goal of treatment is to address the underlying causes of the cirrhosis in order to prevent or slow the progression of the disease. Steps can be taken, such as reducing alcohol intake, eating a liver-healthy diet, managing weight, and aiming to prevent the development of metabolic conditions, such as type 2 diabetes2.
Monitoring and Early Detection
The early stages of cirrhosis are asymptomatic, meaning that the disease often progresses significantly before it is diagnosed and treatments can be put in place to slow progression. The earlier that the disease is diagnosed, the better the prognosis as less of the liver will be scarred. Routine liver function tests are, therefore, advisable for those at increased risk of developing the disease, such as those who are obese, have an alcohol use disorder, have a family history of liver disease, or who have been diagnosed with hepatitis C23.
Screening for Liver Complications
Those with diagnosed cirrhosis should undergo regular screening to monitor the progression of the scarring, in addition to potential complications, such as liver cancer. The earlier that complications are detected, the less they will have progressed and, therefore, the better the treatment outcome24.
Conclusion
Liver cirrhosis is the permanent scarring of the liver. It is a serious health condition that can result in acute liver failure and potentially death. The early stages of cirrhosis are asymptomatic or produce non-specific symptoms. However, by the time symptoms appear, cirrhosis has significantly progressed and irreversible liver damage may have occurred. In addition, complications may have developed, such as liver cancer, portal hypertension, and even full liver failure. Although alcohol abuse and hepatitis C infection are the most common causes of cirrhosis, metabolic factors (such as obesity and type 2 diabetes) can also increase your risk of developing cirrhosis. Lifestyle alterations, such as decreasing alcohol intake, can substantially lower your risk of developing cirrhosis and will slow down the progression of cirrhosis.
Early diagnosis is key to preventing the progression of cirrhosis to the point of liver failure. You should seek medical advice if you experience any of the early warning signs of cirrhosis, and should consider regular screening tests, especially if you have an increased risk of developing cirrhosis.
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