There cirrhosis is the consequence of a damage progressive and irreversible al liver. The damage causes the scarring of the liver tissue (fibrosis) and the formation of abnormal structures, such as i nodules regenerative. All this leads to an insufficiency of the liver function and a severe prognosis. The causes of cirrhosis they are mainly viral hepatitis, the abuse of toxic substances such as alcohol and metabolic problems such as diabetes and obesity. THE symptoms of cirrhosis they often appear when the disease is advanced, and include jaundice, fatigue, abdominal distension, weight loss. The cure of cirrhosis consists in eliminating the triggering cause, and in controlling the complications. Prevention of cirrhosis is very important and involves a healthy lifestyle and adequate physical activity.
Cirrhosis of the liver
There cirrhosis is a condition of alteration of the liver tissue with impairment of its function, and is the consequence of a damage progressive and irreversible al liver. The damage causes the scarring of the liver tissue liver fibrosis, with the formation of abnormal structures, such as fibrous septae and nodules regenerative. All this leads to an insufficiency of the liver function and a severe prognosis. The concept of cirrhosis involves both fibrosis and regenerating nodules. The unique presence of fibrosis does not allow the diagnosis of cirrhosis, as it can also be found in other liver diseases.
How does the liver work?
The liver is the largest and most complex organ in the human body. It is responsible for many essential functions for the proper functioning of the body. Among the various functions, the liver processes most of the nutrients which are absorbed during digestion. It produces many substances such as cholesterol, the factors of coagulation and the bile, which is a fluid that facilitates the digestion of fats. In addition, this organ purifies the blood by removing the substances and toxins which can be harmful to our body.
Due to its complexity and exposure to potentially harmful substances, the liver is particularly vulnerable. However, this organ is able to regenerate repairing or replacing damaged fabrics; if an area is damaged, it can be replaced by other fabric.
What is liver cirrhosis?
There cirrhosis it is nothing more than a progression of chronic hepatitis. L'hepatitis is a liver disease characterized by inflammation and damage to liver cells (hepatocytes). When this inflammation persists for more than six months, hepatitis is termed chronic.
In this situation, the patient usually does not symptoms, then the diagnosis can be accidental and detected by blood tests or procedures or imaging tests that detect the presence of liver damage, such as aultrasound of the abdomen. The patient can remain without symptoms or clinical signs for many years, without being able to realize the problem. However, in some cases, chronic inflammation of the liver causes the formation of scar tissue. This is what is known as cirrhosis, which is the final state into which most chronic hepatitis evolves.
L' chronic hepatitis it can follow several routes: progressing very slowly and causing limited damage, or progressing rapidly with extensive liver damage.
To diagnose hepatitis, both the medical history and the medical examination of the patient are very useful tools. to learn more, we usually proceed with blood tests (blood count, transaminases, GGT, albumin and proteins, prothrombin time and coagulation factors) and with an ultrasound of liver is spleen. In some cases, one may be needed liver biopsy to obtain a sample of the organ to study and define the degree of inflammation and fibrosis of the liver.
Causes of cirrhosis
Cirrhosis can be due to a number of causes, although in most cases it is linked to excessive and continuous consumption of alcohol (alcoholism or active potus), a chronic virus infection such as that of hepatitis B (HBV) and hepatitis C (HCV), or from a state of excessive insulin resistance, found in people suffering from obesity, diabetes and / or from metabolic syndrome. Cirrhosis can also be due to other viral, hereditary, genetic, inflammatory, autoimmune diseases, as well as from the chronic intake of certain drugs or exposure to chemicals.
Cirrhosis and alcohol abuse
There alcoholic cirrhosis, also called exotoxic cirrhosis, it is the most common type of chronic liver disease. The minimum period of abuse of alcohol for the onset of cirrhosis it is about 10 years. However, not all chronic alcoholics develop cirrhosis, which occurs in about 15-20% of long-term alcohol abusers. It is therefore believed that other factors must also be involved, such as a genetic predisposition or the presence of other causes of liver damage. Patients with alcoholic cirrhosis have an alcohol consumption of more than half a liter of wine or a liter of beer per day.
Why alcohol causes fibrosis in the liver is not yet fully known. Women are known to be more susceptible to liver damage than men, so even small amounts of alcohol can cause long-term damage.
Cirrhosis secondary to chronic viral hepatitis
The viral hepatitis they are caused by viruses that have a predisposition for the liver (hepatic tropism). Not all hepatitis viruses cause chronic viral hepatitis which can then evolve towards cirrhosis; this phenomenon is more frequent in hepatitis secondary to hepatitis B or C virus infections, while it is absent in the case of hepatitis A or E virus infection.
Up to 10% of cirrhosis is caused by the virus of hepatitis B. and over 30% of cirrhosis in Italy are secondary to a chronic infection by the virus ofhepatitis C. If we consider that alcoholism and viral cirrhosis together represent the 80% of all cases of cirrhosis, we understand the extent of the problem. Fortunately, there are nowadays effective remedies for viral cirrhosis B and C, and hopefully they can lead to the eradication of the HCV virus within the next 20 years.
Cirrhosis secondary to metabolic syndrome and insulin resistance
An increasingly frequent type of cirrhosis is secondary to insulin resistance is metabolic syndrome. It affects subjects often obese, with high levels of triglycerides (hypertriglyceridemia) and / or low HDL values, frequently suffering from carbohydrate intolerance fasting or from diabetes. It all started with the development of fatty liver disease, defined NAFLD (Non-alcoholic fatty liver disease or non-alcoholic fatty liver disease), which evolves into NASH (Nonalcoholic steatohepatitis or nonalcoholic steatohepatitis), up to the development of liver damage that is no longer reversible and therefore of metabolic cirrhosis overt.
Cirrhosis secondary to autoimmunity
There are particular types of cirrhosis secondary to autoimmune diseases such as autoimmune hepatitis, there primary biliary cholangitis (CBP, until recently known as primary biliary cirrhosis) and the sclerosing cholangitis. These diseases have in common the secondary genesis to mechanisms of autoimmunity: there are antibodies directed towards the organism's own antigens (autoantibodies), which gradually but continuously damage the liver tissue. The most frequent autoantibodies in these conditions are anti-nuclei (ANA), anti-smooth muscle (ASMA) and liver-kidney microsome (anti-LKM) in chronic autoimmune hepatitis, anti-mitochondria (AMA) in primary biliary cholangitis. .
Cirrhosis secondary to hereditary diseases
Some inherited diseases can cause chronic damage to liver tissue, up to full-blown cirrhosis. Diseases such as hemochromatosis (accumulation of iron in the liver and other organs), Wilson's disease (also called disease of Wilson, excessive copper deposition occurs in the liver), or the deficit genetic of alpha-1-antitrypsin they can cause cirrhosis in a not inconsiderable number of people.
Cirrhosis linked to an inflammation or obstruction of the bile ducts
Chronic obstruction of the liver bile ducts (the small ducts where bile circulates) causes inflammation in the liver, leading to biliary cirrhosis. Two main forms are recognized, primary biliary cholangitis (formerly known as primary biliary cirrhosis) and sclerosing cholangitis, which we have already mentioned in the paragraph above relating to autoimmune diseases.
Other causes of cirrhosis
Some drugs, such as metrotexate or amiodarone, they can be harmful to the liver and can cause changes in liver tissue leading to cirrhosis. Some heart diseases, such as chronic heart failure, some intestinal surgeries can also cause the development of liver cirrhosis.
There cirrhosis of the liver is contagious? In itself it is not a contagious disease, while some of the causes of cirrhosis are contagious, for example viral hepatitis, which can be transmitted through sexual intercourse or through infected blood.
Symptoms of liver cirrhosis
What are the main ones symptoms of cirrhosis? Numerous patients suffering from this chronic liver disease have no symptoms: show no clinical signs of liver damage or changes in blood tests. In these cases we speak of compensated cirrhosis: the body has found some mechanisms to prevent onset gods symptoms due to liver failure. These compensatory mechanisms, while keeping them symptom-free, are not entirely beneficial to the patient, as they are ultimately responsible for many of the complications of cirrhosis that will arise later.
Some patients have one instead decompensated cirrhosis. In these people, the compensatory mechanisms have been overcome by the disease and therefore signs and symptoms typical of cirrhotic disease appear, secondary to the development of portal hypertension. In fact, in these patients the hardened liver does not allow the correct passage of blood inside them: this, together with the reduced purifying function of the liver, with the accumulation of free radicals of oxygen, nitric oxide and other toxins, creates a condition of greater pressure venous blood in the portal vein.
THE symptoms of cirrhosis that can appear in a cirrhotic patient include:
- loss of appetite
- tiredness and weakness
- weight loss
- yellow skin and eyes (jaundice)
- veins in relief on the abdomen
- presence of small angiomas on the skin of the back and abdomen (spider nevi)
- presence of palmar erythema
- hepatomegaly, i.e. an enlarged and palpable liver
- splenomegaly, that is, an enlarged and palpable spleen
However, the most important clinical practice of cirrhosis is that which derives from its fearsome complications, linked precisely toportal hypertension, such as:
- digestive bleeding secondary to ruptured varices of the esophagus or stomach
- ascites (excessive accumulation of fluid in the abdomen),
- hepatic encephalopathy with confusion and disorientation
- greater susceptibility to infections such as urinary infections or spontaneous bacterial peritonitis
- increased risk of sepsis (widespread infection)
- hepatocarcinoma, liver cancer.
Complications of cirrhosis
Here are some of the problems and complications that can arise following the development of cirrhosis:
The portal vein is a very large vein whose function is to carry nutrients to the liver to be used for metabolism. The increased pressure in the portal venous system is known as portal hypertension. In liver cirrhosis, this pressure increase is due to an obstruction of the blood flow in the liver due to liver changes typical of the cirrhotic patient (fibrosis and alteration of the normal structure of the organ). Portal hypertension is responsible for the other main ones complications of the cirrhosis.
Gastrointestinal bleeding from gastroesophageal varices
By increasing the pressure in the portal vein, blood flow is partly diverted through other blood vessels, causing the veins in the esophagus and stomach to dilate. These venous dilations are known as varices, and from the clinical point of view those found in the esophagus are much more important (varices esophageal), compared to gastric varices.
If any of these varices rupture, which happens in over a third of patients with advanced cirrhosis during their existence, a digestive bleeding, manifested in the form of vomiting with blood content, thehematemesis. Bleeding from esophageal varices is a life-threatening emergency (25-50% of mortality) and requires immediate medical intervention.
Excessive accumulation of fluid in the abdominal cavity is called ascites you hate ascitic effusion, and is due to portal hypertension and decreased blood albumin secondary to liver failure. L'albumin it is a very important protein to maintain proper oncotic pressure of blood vessels, as well as having purifying and transport functions. Ascites occurs with a progressively more and more distended abdomen due to the accumulation of peritoneal effusion between the intestinal loops, spleen and liver. When the fluid accumulates in significant quantities, it produces tense ascites that is accompanied by noticeable swelling of the abdomen and, often, abdominal pain.
In all patients with ascites, one should be done abdominal puncture, defined exploratory paracentesis, to take a sample of the ascitic fluid and to study the causes.
How to care L'ascites? Treatment of ascites usually starts with reducing salt in the diet ( sodium restriction ) and later with drugs diuretics such as furosemide, spironolactone or potassium canrenoate. If the accumulation of fluid does not resolve with medical therapy and diet (refractory ascites), the removal of the ascites is done by puncturing the abdominal wall and draining the fluid ( evacuative paracentesis ), together with intravenous albumin infusion.
Spontaneous bacterial peritonitis
Spontaneous bacterial peritonitis (PBS) can be defined as a ' infection of the ascitic fluid without an apparent cause of abdominal contamination. In cirrhosis, antibacterial defense systems are altered by various compensatory mechanisms, as explained in the first part of the article. Furthermore, the phenomenon of bacterial translocation of germs from the intestine to the abdominal cavity in these patients is accentuated.
This explains the high incidence of infections in these patients. Of the infections, the most prominent is spontaneous bacterial peritonitis, which usually presents with abdominal pain and fever. Many times patients present with mild or absent abdominal symptoms, and the onset of infection is expressed as worsening liver disease or the onset of encephalopathy, a confusional state typical of people with advanced cirrhosis.
The treatment is carried out with antibiotics and infusion of intravenous albumin.
When the liver it is damaged, it stops filtering toxic substances from the blood. This results in increased levels of compounds such as ammonia (in the form of ammonium) and other elements that can reach the central nervous system and cause significant damage. Brain changes caused by liver disorders are summarized under the name of hepatic encephalopathy or portosystemic encephalopathy. This disease impairs cognitive function and leads to the onset of mental confusion, drowsiness, tremors, up to coma. Although it seems a serious problem, it is completely reversible with medical treatment, which consists of the administration of laxatives such as lactulose or mannitol, antibiotics which reduce ammonia-producing bacterial flora, such as neomycin or the rifaximin, ed branched chain amino acids to reduce the amount of "bad" amino acids that act as false neurotransmitters in the brain.
It is a very serious complication in patients with cirrhosis and ascites, and consists in the development of a kidney failure acute. The cause of this condition appears to be the reduction of renal perfusion, and it is known that spontaneous bacterial peritonitis, gastrointestinal bleeding and the use of large quantities of alcohol are situations that favor its onset. Treatment is medical, through the infusion of terlipressin,norepinephrine, or, less effectively, of midodrine ed octreotide, together albumin. The ultimate cure for these patients is liver transplantation.
The development of liver cancer (hepatocarcinoma) is a real danger in people with cirrhosis. Liver cancer can be single or multiple (multifocal), it is diagnosed through methods such as ultrasound of the upper abdomen, abdominal CT scan or abdominal magnetic resonance. It can be treated surgically, through the liver resection of the affected segment: this is done in the case of a single nodule and good residual liver function.
Alternatively they are carried out thermal ablation radio frequency or procedures alcoholizations (, small injections of alcohol into the lump, in both cases the end result is the "burn" of the area of the liver that contains the lump). If the disease is extensive, there are systemic treatments such as chemoembolization transhepatic (TACE) or chemotherapy, although the latter has not yet produced great results.
Again for many patients the only definitive therapy is the transplant of liver.
There diagnosis of the cirrhosis can be carried out according to the following steps:
Signs and symptoms of chronic liver damage such as yellowing of the skin and sclerae may be observed during patient inspection (jaundice), abdominal swelling and weight loss (lost of weight). However, such signs are not always present. Other frequent signs are the presence of small starry angiomas, the spider naevi on the skin of the back and trunk, and the redness of the palms, thepalmar erythema Careful examination of the patient, however, may reveal other signs that may lead to suspicion of liver disease.
By examining the abdomen, one can determine whether the liver is enlarged or not (hepatomegaly), however, as cirrhosis progresses, it may not be as noticeable. By this time, blood flow is already so impaired that it can cause venous congestion in other organs such as the spleen, causing the development of splenomegaly (enlarged spleen).
The analysis of the blood they can indicate the presence of inflammation of the liver, such as if they are found elevated transaminases (AST and ALT), increase of the GGT, hyperbilirubinemia (increase in direct and indirect bilirubin). However, in compensated cirrhosis, the analytical results may also be close to normal. In advanced cirrhosis, the analytical signs of liver failure, with reduction of total proteins (hypoprotidemia) and albumin (hypoalbuminemia), increase in coagulation times (high PT and high INR) and reduction of platelets and white blood cells (thrombocytopenia and leukopenia).
Diagnostic for images
Some imaging tests may be needed to determine the extent of the disease, such as ultrasound abdominal, computerized axial tomography (CT scan of the abdomen) or MRI of the abdomen, the MRI abdomen.
The definitive diagnosis of cirrhosis is based on a sample of liver tissue (liver biopsy).
Treatment of cirrhosis
Cirrhosis is not curable, as liver damage is difficult to reverse, although its progression is very slow in most cases. In fact, although it is commonly believed that there is no treatment that modifies the natural history of the disease, recent evidence seems to show that removing the cause of liver damage (e.g. stopping drinking or treating hepatitis B or C), they can at least partially reverse liver damage. If the removal of the cause triggering is not possible, the treatment of cirrhosis must be aimed at the prevention or control of complications.
General measures in the treatment of cirrhosis
Although this disease is a non-reversible phenomenon, several measures can be taken to reduce liver damage.
- Stop of drink alcohol: abstinence is the best therapy to restore a fatigued liver.
- To limit the consumption of hepatotoxic drugs: due to impaired liver function, most drugs cannot be metabolized and eliminated properly.
- Avoid other pathologies. Reduced liver function causes greater difficulty in fighting infections, making them more dangerous for cirrhotic patients. It is very important to avoid contact with potential sources of infection and to be vaccinated against viral hepatitis A and B, influenza and pneumococcus.
- Hire one rich diet of fruit vegetables is cereals. Sometimes it is necessary to administer vitamin supplements (vitamins A, D and K). Dietary recommendations also include reducing the salt content in dishes to prevent fluid accumulation. In cirrhosis, it is essential that the diet does not contain an excessive amount of protein as it can favor the development of hepatic encephalopathy.
In general, the patient with simple cirrhosis does not need any treatment, unless his cirrhosis is due to a disease that requires specific treatment.
For example, patients with chronic hepatitis B should be treated with a anti-HBV antiviral therapy (the most commonly used drugs are tenofovir, adefovir and telbivudine).
Patients with cirrhosis secondary to chronic hepatitis C should be treated with antiviral therapy anti HCV specific (the most widely used and known drug is currently sofosbuvir).
To prevent esophageal varices from rupturing and causing digestive bleeding, medications to reduce venous pressure, such as beta blockers propanolol and carvedilol, and surgical techniques to eliminate varicose veins (binding or sclerosis of esophageal or gastric varicose veins).
Excessive accumulation of fluid in the lower limbs or abdomen can be treated by limiting the intake of salt and fluids, and secondly with drugs diuretics that can remove it. The most used drugs are i loop diuretics (furosemide) and i savers of potassium (spironolactone or potassium canrenoate).
If diuretics are not enough, they can be done paracentesis evacuative periodically.
Itching, which can be caused by high concentrations of metabolites in the blood can be treated with cholestyramine or other chelating drugs.
Treatment of hepatic encephalopathy is usually done with laxatives and antibiotics intestinal disinfectants (rifaximin or neomycin) to reduce ammonia levels in the blood.
Treatment of renal failure in patients with cirrhosis is via elimination of nephrotoxic drugs (such as anti-inflammatories or certain antibiotics), with adequate hydration and, if necessary, with the use of vasoconstrictors kidney (terlipressin, midodrine, noradrenaline) together with intravenous albumin infusion.
It can heal from cirrhosis? the answer is yes! The definitive therapy in the most serious patients is liver transplantation. Unfortunately, this is not a solution within the reach of all patients, due to the scarcity of available organs. Criteria have therefore been established to allocate livers available only to patients who need them most but who at the same time are most likely to survive the transplant operation.
Survival of cirrhosis
How long do you live with cirrhosis? There survival of cirrhosis it is very variable. In people with early cirrhosis, or in those who have removed the cause of liver damage (for example, who have stopped drinking or who have drawn the hepatitis virus), thelife expectation it is almost comparable to that of healthy peopleTags: Liver Gastroenterology