Liver Cirrhosis and Portal Hypertension
What is liver cirrhosis?
Liver cirrhosis refers to a shrunken, scarred and hardened liver with failure of liver function. It results from chronic (long-term) damage to the liver from various causes, leading to progressive scarring of the liver over years. Common causes of liver cirrhosis include chronic viral hepatitis infection (chronic hepatitis B or C), excessive alcohol intake, autoimmune liver disease and fatty liver disease.
Liver cirrhosis is a serious condition because once the liver becomes cirrhotic, the damage to the liver is irreversible. This leads to progressive liver failure, complications of cirrhosis, liver cancer and eventual death.
What is portal hypertension?
Portal hypertension refers to increased blood pressure in the blood vessels supplying the liver (the portal vein). This is a common complication of liver cirrhosis. The hardened liver obstructs blood flow from the portal vein, leading to elevated pressures in the portal vein. This results in enlargement of the spleen (splenomegaly), development of swollen veins in the stomach and esophagus (varices) and accumulation of fluid in the abdomen (ascites). Most of the symptoms and signs of liver cirrhosis are a result of the development of portal hypertension.
You may be at risk of liver cirrhosis if you have one of the following conditions:
a. Chronic hepatitis B
b. Chronic hepatitis C
c. Chronic excessive alcohol intake
d. Fatty liver disease (non-alcoholic steatohepatitis)
e. Autoimmune liver disease (autoimmune hepatitis, primary biliary cirrhosis or primary sclerosing cholangitis)
f. Wilson disease, hemochromatosis and other rare inherited liver diseases.
Patients with early liver cirrhosis often have no detectable symptoms or signs of disease. Such patients may feel completely well and healthy and are often diagnosed based on abnormal blood tests or liver scans. This condition is known as compensated cirrhosis, which is associated with a favorable median survival of more than 10 years. Patients with early, compensated cirrhosis are often diagnosed on regular ultrasound screening during follow-up for chronic liver disease (e.g. chronic viral hepatitis or fatty liver disease).
Patients with more advanced liver cirrhosis may develop the following signs and symptoms:
a. Ascites (swelling of the abdomen due to accumulation of fluid)
b. Pedal edema (swelling of the ankles and feet)
c. Spider naevi (dilated blood vessels on the upper chest and arms)
d. Splenomegaly (enlarged spleen)
e. Hepatic encephalopathy (drowsiness or confusion due to inability of the liver to break down toxins in the blood)
f. Varices (swollen veins in the esophagus and stomach that develop due to obstruction of blood flow in the liver)
g. Variceal bleeding (vomiting of blood or passage of black stools due to bleeding from ruptured varices)
h. Jaundice (yellowing of the eyes and skin) associated with dark, teacolored urine
i. Development of liver cancer
The development of such complications signals that the patient’s cirrhosis has progressed to a late stage (known as decompensated cirrhosis). Decompensated cirrhosis is a serious condition that needs to be managed by a liver specialist as it can lead to various serious complications such as internal bleeding, life-threatening infections, liver failure and liver coma known as encephalopathy.
Liver cirrhosis is diagnosed via the following modalities:
- Liver imaging (ultrasound, CT or MRI of the liver)
- Liver stiffness measurement using Fibroscan®
- Liver biopsy (removal of a small sample of liver tissue for histological analysis)
The doctor may suspect liver cirrhosis in people with risk factors for cirrhosis who have abnormal blood tests, abnormal liver imaging or one of the signs and symptoms listed above.
Liver imaging is highly specific for the diagnosis of liver cirrhosis in which the liver has a shrunken and nodular appearance. Early cirrhosis is more difficult to diagnose as these patients may show a normal liver image during the scan. Early cirrhosis is often diagnosed by liver stiffness measurement (Fibroscan®). Sometimes a liver biopsy is required to confirm the diagnosis of early cirrhosis.
Patients with liver cirrhosis will benefit from the following treatment which include:
1. Treatment of the underlying cause of liver cirrhosis
- Patients with alcoholic liver cirrhosis must stop all intake of alcohol
- Patients with chronic hepatitis B and C should be started on antiviral treatment if there are no contraindications
- Patients with autoimmune hepatitis may require treatment with steroids
2. Treatment of portal hypertension to reduce risk of variceal bleeding by:
- Non-selective beta blocker medication (e.g. propranolol) for lowering of portal pressure to reduce risk of variceal bleeding
- Endoscopic ligation (banding) of esophageal varices to treat acute bleeding or prevent future variceal bleeding
- Endoscopic sclerotherapy (histoacryl injection) of gastric varices to treat acute bleeding
3. Treatment and prevention of ascites include:
- Maintenance of a strict low salt diet
- Maintenance diuretic medication (e.g. spironolactone or furosemide) to remove excess fluid from the body
- Patients who have persistent ascites that do not respond to medications may require paracentesis, Transjugular Intrahepatic Portosystemic Shunt (TIPS) or liver transplant.
4. Treatment and prevention of hepatic encephalopathy include:
- Regular bowel clearance in order to reduce build-up of toxins in the bloodstream that may precipitate encephalopathy
- Avoidance of sedatives that may worsen encephalopathy
5. Surveillance for liver cancer
- Patients with cirrhosis should undergo regular abdominal ultrasound and alfa-fetoprotein (AFP) blood tests at least once every six months Diseases Gastroenterology
6. Treatment of cirrhosis-related infections
- Cirrhotics need to be closely monitored for infections (e.g. spontaneous bacterial peritonitis) and should be referred for early treatment with antibiotics
7. Early assessment for liver transplant
- Cirrhotic patients who develop decompensation events should be referred for liver transplant