Cirrhosis and Liver Disease
Forms Of Liver Disease
The many possible liver diseases can be grouped loosely into three categories: hepatocellular diseases, cholestatic diseases, and mixed forms. In hepatocellular diseases, the liver is typically inflamed and shows signs of injury. Over time, liver cells may begin to die. Causes of hepatocellular liver disease include alcoholic cirrhosis and viral hepatitis, both of which attack liver cells directly. In cholestatic diseases, the flow of fluid through the liver is blocked by such things as gall stones, liver cancer, or biliary cirrhosis. In mixed forms of liver disease, both conditions are present.
The pattern and onset of symptoms can help physicians determine what kind of liver disease is present. Symptoms of liver disease include jaundice, fatigue, itching, pain in the upper abdomen, distention of the abdomen, and intestinal bleeding. However, many forms of liver disease have no symptoms and are diagnosed only during routine blood tests that detect abnormalities in the markers of liver function.
Cirrhosis is an end-stage liver disease. It is characterized by chronic injury to the liver cells, fibrosis (scarring) within the liver, and the formation of regenerative nodules. The causes of cirrhosis include the following:
Alcohol consumption. Excess alcohol consumption is a primary cause of cirrhosis. However, only 10 to 20 percent of alcoholics develop cirrhosis (Beers 2004–2005).
Alcohol lowers the liver’s levels of antioxidants, including vitamin E (Kawase 1989; Leo 1993) and S-adenosyl-L-methionine (SAMe) (Lieber 1997), making the liver vulnerable. In addition, alcohol lowers glutathione, an important internal antioxidant (Speisky 1985; Hirano 1992).
Because heavy drinkers consume a substantial number of calories as alcohol, they consume less vitamin- and mineral-rich food than they otherwise might, exacerbating alcohol-induced nutritional deficiencies. Virtually all individuals with alcoholic hepatitis suffer from malnutrition to a degree more or less proportional to the severity of their disease (Mendenhall 1984).
Survival in alcoholics with moderate or severe hepatitis is directly proportional to how much food they consume. Mortality drops to zero in those consuming 3000 or more calories during treatment (Mendenhall 1995). Similar results were seen with alcoholic cirrhosis patients, except for the most severely malnourished, who may have been too compromised to recover (Hirsch 1993,1999; Gopalan 2000).
In addition to antioxidant depletion, alcoholics tend to have a number of other nutritional deficiencies. These include low levels of vitamin C, riboflavin, zinc, pyridoxine (vitamin B6), and vitamin A (Gruchow 1985; Rosenthal 1973; Ijuin 1998; Fonda 1989; Lumeng 1978; Lieber 2000).
Hepatitis. Hepatitis, another common cause of liver cirrhosis, is caused by infection with the hepatitis B or C virus. Because the symptoms of infection are mild and flu-like, viral hepatitis often goes undiagnosed. Blood donors sometimes find out they are infected when their donated blood undergoes routine screening. Viral hepatitis causes chronic liver inflammation, which results in cirrhosis in the majority of those infected.
Nonalcoholic fatty liver disease. The most common cause of fatty liver disease is alcohol consumption, but it can also be caused by a number of other conditions, including obesity, diabetes, and elevated triglyceride levels. If the condition is associated with obesity, it is sometimes called nonalcoholic fatty liver disease (NAFLD). Up to one-third of patients with NAFLD also have type 2 diabetes, high cholesterol levels, or both. NAFLD is closely associated with metabolic syndrome, a related cluster of conditions including obesity, diabetes, elevated triglycerides, and high blood pressure, which is considered a major risk factor for heart attack. Fatty liver disease is exacerbated by inflammation within the liver, which may hasten its progression to cirrhosis.
Biliary cirrhosis. Biliary cirrhosis results from prolonged obstruction of or injury to the biliary system. One of the liver’s functions is to secrete bile, which is used in the gut in the normal breakdown and absorption of fats from the diet, among other things. Primary biliary cirrhosis, which has no known cause, is characterized by inflammation of the liver and destruction of liver bile ducts by scar tissue. It is associated with various autoimmune diseases, such as Raynaud’s phenomenon.
Cardiac cirrhosis. Cardiac cirrhosis occurs when prolonged, severe right-sided congestive heart failure leads to chronic liver injury, inflammation, and the formation of scar tissue in the liver (fibrosis). The heart cannot handle the venous circulation, causing blood to back up in the body’s major veins. Eventually, the liver becomes engorged and swollen.
Inherited disorders. Various inherited disorders can cause cirrhosis.
Whatever the cause of cirrhosis, it is a difficult disease to manage in its advanced stages, in part because of the complications that it causes. For example, people suffering from cirrhosis also frequently suffer from portal hypertension (i.e., elevated blood pressure in the vein that drains into the liver). This, in turn, can cause complications in the stomach and esophagus, such as ascites (see below). Portal hypertension occurs in about 60 percent of cirrhosis cases in the United States (Kasper 2005). The treatment of portal hypertension often focuses on relieving the underlying liver disease. In serious cases, drugs such a diuretics might be prescribed to reduce blood pressure.
Cirrhosis may entail other complications:
- Esophageal varices. Portal hypertension can cause varicose veins in the esophagus. They can rupture, requiring emergency surgery.
- Ascites. The pressure created by portal hypertension can also cause the liver and intestines to exude fluid into the abdominal cavity, which can become swollen and distended, a condition known as ascites.
- Hepatoma. A compromised liver is more susceptible to cancer. Hepatocellular carcinoma occurs in about 10 to 20 percent of cirrhotic patients (Wolf 2001). Liver cancer is relatively asymptomatic. It is usually not detected until it has progressed significantly. Consequently, the patient’s prognosis is usually poor.
- Hepatic encephalopathy. This is a complex condition characterized by psychological and personality disturbances. Its specific cause is unknown; in serious cases, it can result in coma or death.
While cirrhosis is irreversible, it is usually the result of a chronic condition and thus takes a long time to develop. In fact, many people with developing liver disease (e.g., fibrotic livers) have no symptoms, and their condition is detected only by routine blood tests. If the condition is detected early enough, the patient may have an opportunity to arrest the cirrhotic process before it goes too far.
As is the case with many other diseases, cirrhosis is characterized by inflammation (hepatitis literally means “inflammation of the liver”). This liver inflammation is often caused by a rise in free radicals within the liver. Under normal circumstances, the liver maintains a supply of internal antioxidants to neutralize the free radicals generated by the toxins processed in the liver. However, when the liver antioxidants are low, or when the liver is overwhelmed by continued toxic insults (e.g., alcohol or chronic drug use), damage from free radicals increases, resulting in inflammation and the formation of scar tissue (fibrosis). Thus, it is important to maintain a healthy supply of antioxidants and make positive lifestyle changes, such as abstaining from all alcohol and avoiding environmental toxins whenever possible, to reduce the strain on the liver.
If cirrhosis is allowed to progress and the liver’s function is compromised beyond repair, the only solution is a liver transplant. This is a complicated medical procedure with a significant risk of organ rejection, and even in successful cases, lifelong follow-up therapy with immunosuppressant drugs will be necessary.