Sir Hosis of the Liver

By Peter Galvin, MD

Pardon the punny title, it comes from an old “Looney Tunes” Bugs Bunny cartoon (how and why I still remember that probably 55 or 60 years after I last watched it, I have no idea). Cirrhosis, however, is not a laughing matter. It occurs when scar tissue replaces normal liver tissue, causing permanent liver damage. Yes, the liver can regenerate itself, but not where scar tissue forms. Cirrhosis affects about 2.2 million people in the U.S. The most common causes are alcohol use disorder, nonalcoholic fatty liver disease, and hepatitis C. However, now that there are medications that can cure hepatitis C infections, hepatitis C is less of a causative factor. Less common causes include hepatitis B, diseases that cause a buildup of iron (hemochromatosis) or copper (Wilson’s disease) in the liver, diseases that cause bile duct obstruction (pancreatic cancer and cholangiocarcinoma [bile duct cancer]), alpha1 antitrypsin deficiency (also causes emphysema), and autoimmune hepatitis.

Those with cirrhosis often have no signs or symptoms for many years. Once signs do develop, they include yellow-colored skin and eyes (jaundice), dilated blood vessels on the face, male breast enlargement, distended blood vessels across the abdomen, atrophy of the testicles, red-colored palms, white-colored nails, and decreased body hair. Symptoms commonly include muscle cramps, itching, poor sleep, and sexual dysfunction. Potential complications can be:

• Ascites: fluid buildup in the abdomen.
• Spontaneous bacterial peritonitis: infected ascites.
• Hepatic encephalopathy: confusion and impaired brain function.
• Variceal bleeding: bleeding due to enlarged veins, often in the esophagus, that burst.
• Hepatorenal syndrome: kidney failure caused by cirrhosis.
• Hepatocellular carcinoma: liver cancer, which affects 1% to 4% of those with cirrhosis.

Cirrhosis can be diagnosed by liver biopsy but is often diagnosed after complications arise, such as encephalopathy, ascites, variceal bleeding, or liver cancer. Cirrhosis is rarely reversible, but ascites can be treated with diuretics (water pills) and spironolactone. Ascitic fluid can be drained from the abdomen (paracentesis) but often rapidly reaccumulates. Encephalopathy can be treated with lactulose and rifaximin. The risk of variceal bleeding can be reduced by medications that decrease pressure (propranolol or carvedilol) and patients with variceal bleeding can have improved one-year survival if a stent is placed in the liver by a transjugular intrahepatic portosystemic shunt (TIPS) procedure. In addition, treatment of the underlying condition is imperative. Total abstention from alcohol, weight loss and nutritional counseling for those with nonalcoholic fatty liver disease up to and including weight-loss surgery, and antiviral medications for those with hepatitis B or C. Those with cirrhosis must be monitored at least every six months for the development of liver cancer. This monitoring includes liver ultrasound and a blood test for alpha-fetoprotein, which is a specific marker for hepatocellular carcinoma. Of course, for those patients with cirrhosis who develop complications, liver transplant should be considered.

For more information go to the National Institute of Diabetes and Digestive and Kidney Diseases at:     www.niddk.nih.gov.

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