Health

Hepatic Cirrhosis: Pathophysiology, Clinical Features, Diagnosis & Treatment

By March 15, 2017 No Comments

Hepatic Cirrhosis is a chronic disease characterized by replacement of normal liver tissue with diffuse fibrosis that disrupts the structure and function of the liver. It is an abnormal liver condition in which there is irreversible scarring of the liver. Most of the patients are between 40 and 60 years of age. Cirrhosis or scarring of the liver is divided into three types:

Alcoholic cirrhosis: This is most frequently caused by chronic Alcoholism and is the most common type of cirrhosis in which the scar tissue characteristically surrounds the portal areas.

Postnecrotic cirrhosis: This is a late result of a previous bout of acute viral hepatitis in which there are broad bands of scar tissue.

Biliary cirrhosis: This type of cirrhosis usually results from chronic biliary obstruction and infection (cholangitis). It is much less common than the other types in which scarring occurs in the liver around the bile ducts.

Pathophysiology of Hepatic Cirrhosis

Although several factors have been implicated in the etiology of cirrhosis, Alcohol consumption for a long term is considered as the major causative factors. However, a nutritional deficiency with reduced protein intake contributes to liver destruction in cirrhosis. Still, the excessive alcohol is the major causative factor in fatty liver and its consequences. But cirrhosis has also occurred in people who have no history of alcohol intake and those who consume the normal diet. Alcoholic cirrhosis is characterized by episodes of necrosis involving the liver cells, which sometimes occur repeatedly throughout the course of a disease. The destroyed liver cells ate gradually replaced by scar tissue. Eventually, the amount of scar tissue exceeds that of the functioning liver tissue.

The portion of the liver chiefly involved in cirrhosis consists of the portal and the periportal spaces, where the bile canaliculi of each lobule communicate to form the liver bile ducts. These areas become the sites of inflammation and the bile ducts become obstructed with thickened bile and pus. The liver attempts to form new bile channels; hence there is an overgrowth of tissue made up largely of disconnected, newly formed bile ducts and surrounded by scar tissue.

Clinical features of Hepatic Cirrhosis

Signs and symptoms of cirrhosis increase in severity as the disease progresses. Their severity is used to categorize the disorder as compensated or decompensated cirrhosis.

Be alert for the following signs and symptoms:

Compensated cirrhosis

  • Intermittent mild fever
  • Vascular spiders
  • Reddened palms
  • Unexplained epistaxis
  • Ankle edema
  • Vague morning indigestion
  • Flatulent Dyspepsia
  • Abdominal pain
  • Enlarged liver and splenomegaly

Decompensated cirrhosis

  • Ascites
  • Jaundice
  • Weakness and muscle wasting
  • Weight loss
  • Continues mild fever
  • Purpura due to decreased platelet count
  • Epistaxis
  • Hypotension
  • White nails
  • Gonadal atrophy

Other symptoms include

  • Liver enlargement early in the course (fatty liver); later in course, liver size decreases from scar tissue.
  • Portal obstruction and ascites: organs become the seat of chronic passive congestion resulting in ingestion and altered bowel function.
  • Infection and peritonitis
  • Edema
  • Vitamin deficiency  (A, C, and K) and anemia.
  • Mental deterioration with impending hepatic encephalopathy and hepatic coma.

Diagnostic findings and Assessment

  • Liver function tests (for instance serum alkaline phosphatase, aspartate aminotransferase [AST], serum glutamic oxaloacetic transaminase [SGOT], alanine aminotransferase [ALT], serum glutamic pyruvic transaminase [SGPT], prothrombin time, ABGs and biopsy.
  • Medical history, history of alcoholism and physical examination
  • Ultrasound scanning
  • CT scan
  • MRI
  • Radioscopic liver scans
  • Peritoneal tapping for ascites

Complications

  • Spontaneous Bacterial Peritonitis
  • Gastrointestinal bleeding
  • Hepatic encephalopathy
  • Splenomegaly
  • Hepatorenal syndrome
  • Electrolytes, acid-Base misbalance
  • Liver cancer
  • Death may occur in very late stage and if left untreated.

Preventive measures of Hepatic Cirrhosis

  • Don’t abuse alcohol (most importantly)
  • Eat low fat and low-sodium diet (healthy diet)
  • Maintain a bodyweight and have regular exercise
  • Avoid any type of infection and hepatitis
  • Use the drugs only after consultation with your physician. Overuse of drugs can be problematic for the liver to process drugs.
  • Vaccination against hepatitis B

Treatment of Hepatic Cirrhosis

Symptomatic management is based on presenting signs and symptoms of the patient. Treatment includes antacids, vitamins and nutritional supplements, balanced diet; potassium-sparing diuretics for ascites and avoidance of alcohol. Colchicine, anti-inflammatory agents may increase the period of survival in patients with mild to moderate cirrhosis. Antacids or histamine-2 (H2) antagonists are prescribed to decrease gastric distress and minimize the possibility of Gastrointestinal bleeding. Although the fibrosis of the cirrhotic liver cannot be reversed, its progression may be halted or slowed by such measures.

Many patients who have the end-stage liver disease (ESLD) with cirrhosis use the herb milk (Silybum marianum) to treat jaundice and other symptoms. This herb has been used for over centuries because of its healing and regenerative properties for liver disease. Primary biliary cirrhosis with Ursodeoxycholic acid (Actigall, URSO) improves liver function.

Liver transplantation is done to treat life-threating end stage of liver disease for which no any other form of treatment is available. The surgical transplantation procedure involves total removal of the scarred liver and replacement with a healthy liver in the same anatomic location. The success rate of liver transplantation depends on successful immunosuppression. Despite the success of immunosuppression in reducing the incidence of rejection of transplanted organs, liver transplantation is not routine and may be accompanied by complications related to the lengthy surgical procedure, immunosuppressive therapy, infection and difficulties encountered in reconstructing the blood vessels and biliary tract.

The patient and family should have complete knowledge about the transplantation including ethical issues, consent from the donor, its complications (bleeding, infection and rejection), long-term follow-up, various encounters with infection, systemic problems and rate of failure or success. Because liver transplantation is now an established therapeutic modality, rather than an experimental procedure, the number of liver transplantation centers is increasing.

Home-based care of Hepatic Cirrhosis

  • Referral to Alcoholics anonymous, psychiatric consultation, counseling, rehabilitation or spiritual advisor if indicated.
  • Have a low sodium diet
  • Have a written instruction, teaching, support and reinforcement
  • Rest and change in lifestyle  (healthy diet and exercise)
  • Should have a knowledge regarding the emergency complication and its immediate management
  • Refer to  the home care nurse if needed
  • Hence, Long-term follow-up

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