Cirrhosis of the liver
definition
Liver cirrhosis is a disease in which there is a connective tissue and nodular remodeling of the liver. Liver cirrhosis usually results from the progressive destruction of the liver tissue.
The destruction of healthy liver tissue can be triggered by a variety of factors. The most important triggers of liver cirrhosis include viral hepatitis, toxic liver damage from alcohol and drugs, and congenital liver diseases, with autoimmune hepatitis leading the way.
The rare triggers of liver cirrhosis include diseases such as hemochromatosis (iron storage disease), Wilson's disease (copper storage disease) and primary sclerosing cholangitis. Accordingly, congenital and acquired causes of liver cirrhosis can be distinguished. Cirrhosis of the liver forms the final line of chronic and, in rare cases, acute liver diseases. This means that the liver can no longer carry out its varied tasks and thus important detoxification processes and synthesis processes can no longer be carried out.
The liver is the central metabolic organ in our body and takes on a large number of different tasks.
Among the most important Functions of the liver belong:
- the storage and supply of glucose,
- the production of coagulant proteins (Clotting factors),
- the metabolism of urea,
- the detoxification of drugs and other exogenous substances,
- the production of bile acid and the production of albumin, the body's most important blood protein.
With a pronounced Cirrhosis of the liver all these tasks are disrupted. The connective tissue remodeling of the liver can also have an effect on the cardiovascular system, as the blood flows out of the intestine (Enterohepatic cycle) accumulates in front of the liver and thus leads to the formation of Varicose veins that could potentially cause life-threatening bleeding.
Causes of cirrhosis of the liver
The causes of liver cirrhosis are manifold and can be divided into congenital causes on the one hand and acquired causes on the other.
Acquired causes are by far the most common causes. Acquired cirrhosis of the liver is usually the result of infectious events such as hepatitis. The virus hepatitis (A, B, C), in particular the mostly chronic course hepatitis C, damages the healthy liver tissue bit by bit, which leads to a loss of liver function.
The liver reacts to chronic inflammatory processes, i.e. those that last for a long time, with the formation of so-called pseudolobuli and regenerated nodes. Regenerative knots arise when the liver tries to rebuild the lost liver tissue in order to counteract the loss of function.
Read more on the topic: Medicines for hepatitis C.
These regenerated nodes consist of tough connective tissue that harden the liver tissue and thus create the typical nodular surface.In addition, cirrhosis of the liver can be caused by toxic substances such as drugs and alcohol. Alcoholic liver cirrhosis is the most common form of cirrhosis in the western world.
This means that over 50% of cirrhosis can be traced back to alcoholism.
Cirrhosis usually occurs when the detoxification capacity of the liver is overwhelmed and reactive toxins are created that damage the liver tissue. An iron-containing enzyme called cytochrome P450 is responsible for the detoxification or metabolism of drugs. Some drugs manage to switch off this enzyme, which would lead to a reduced detoxification function.
The so-called congestive cirrhosis belongs to the other forms of cirrhosis. This is caused by a right heart failure. Right heart failure has the consequence that the blood in front of the right heart builds up in the liver and thus the liver tissue is compressed and destroyed. However, this form only occurs very late, as the heart must have already been very damaged and this is usually associated with a long-term illness. Fatty liver is another liver disease that can lead to cirrhosis of the liver. This can occur without any previous illness, e.g. For example, through poor nutrition, but can also be the result of years of alcohol abuse. Other complex genetic diseases, such as iron storage disease, can also lead to liver cirrhosis.
Read more on the topic: Liver insufficiency and nutrition in cirrhosis of the liver.
These can be the accompanying symptoms
Liver cirrhosis is based on a chronic disease of the liver and is therefore associated with many liver-specific symptoms.
Typically, liver malfunctions occur, which are noticeable in the metabolism and in the molecules produced by the liver.
As a result of liver cirrhosis and the accompanying liver dysfunction, the production of coagulation factors can be reduced, so that a bleeding tendency arises.
At the same time, the products that are normally excreted by the liver increase in the body, causing symptoms of poisoning such as yellowing of the eyes (sclera) and skin. In the late stages, the substances accumulate in the brain and lead to what is known as hepatic encephalopathy.
A congestion of the liver vessels is also not uncommon, so that initially high blood pressure occurs in the vessels of the liver.
This creates bypass circuits, which is noticeable in the late stages of liver cirrhosis through so-called varices (thick, newly formed blood vessels) on the esophagus and, for example, around the navel.
A backlog of blood into the spleen with an enlargement of the organ also occurs frequently. The high blood pressure in the liver vessels often causes water retention in the abdomen (ascites), which is additionally increased by the lack of protein production by the liver. The build-up of bile in the liver can also cause digestive problems. In addition, cirrhosis of the liver leads to a connective tissue remodeling of the tissue, so that the liver feels hard and knotty.
Water in the stomach
The water in the abdomen, also called ascites, is a typical complication of liver cirrhosis.
It mainly occurs when the liver is no longer producing enough protein.
The protein (especially the albumin) is usually in the blood and binds fluid to itself there.
If the albumin concentration is reduced, less fluid is bound in the vessels so that it escapes into the tissue.
The process is reinforced by the build-up of blood in the liver vessels, so that fluid can easily escape from there into the tissue.
itching
In cirrhosis of the liver, itching is a typical sign that toxins are accumulating in the body.
When their concentration is greatly increased, they also accumulate in the skin.
This can be seen in the form of jaundice (so-called jaundice), in which the skin turns yellow due to the blood pigment that has not broken down.
In addition, there is pronounced itching caused by these toxic substances.
Joint pain in cirrhosis of the liver
Joint pain is also a result of cirrhosis of the liver.
Typically, joint pain is associated with autoimmune diseases of the liver.
The body turns its immune cells against itself.
It thereby destroys the liver, which can cause cirrhosis of the liver and also attacks the joints.
But joint pain can also occur with non-autoimmune liver cirrhosis.
They are usually the result of a build-up of toxins that are deposited in the joints.
Back pain in cirrhosis of the liver
With cirrhosis of the liver, back pain can arise as a result of the expansion of the liver capsule.
At the onset of cirrhosis, the organ enlarges, which can lead to capsule stretching and subsequently to capsule stretching pain that can radiate into the back.
In the later stages, massive ascites (the pronounced accumulation of water in the abdomen) can also cause back pain.
Bad breath in cirrhosis of the liver
Bad breath in cirrhosis of the liver typically smells sweet and is also due to the liver's reduced metabolic performance.
As a result, various toxins accumulate, some of which are now excreted through the breath and thus cause bad breath.
Cirrhosis pain
Pain does not necessarily occur in the context of liver cirrhosis.
The liver cells themselves, which perish in cirrhosis, do not have any pain-conducting nerve cells and therefore cannot trigger pain stimuli in the brain.
Pain mainly occurs when the liver enlarges as an entire organ.
Diffuse upper abdominal pain occurs.
Other complications, such as bypass bleeding and ascites, can also cause pain.
Please read the following article: Pain relievers for liver diseases
What is the course of the disease?
Liver cirrhosis usually lasts for several years.
Due to various substances that damage the liver (medication, alcohol, drugs, fat), the liver initially becomes fatty.
In most cases, this can still be reversed if the trigger substances are adequately dispensed with.
If this does not succeed, the connective tissue remodeling of the liver begins, which slowly becomes noticeable in the form of liver cirrhosis.
First of all, the liver enlarges (usually with the fatty tissue of the organ).
There is a deterioration in the synthesis performance, the coagulation function gradually decreases and blood breakdown products accumulate.
The production of proteins is also being scaled back, so that over time more and more water is retained in the stomach.
The increased accumulation of toxic metabolic products also leads to involvement of the brain in advanced stages, the so-called encephalopathy.
In the final stage, the liver is small and nodular again, there is little coagulation, there are many bypass circuits in the liver and cognitive performance declines due to the involvement of the brain.
Read on under:
- These are the symptoms of cirrhosis of the liver
- Stages of cirrhosis of the liver
Frequency / epidemiology
The incidence (occurrence) in the western world is approximately 250 per 100,000 inhabitants per year, and is about twice as common in men as in women.
The diagnosis of cirrhosis of the liver
What do you see in the blood count?
Cirrhosis of the liver is shown in the blood count on the one hand by specific liver values.
The so-called transaminases (ALT and AST) are increased.
GLDH, alkaline phosphatase and gamma-GT are also usually elevated.
Due to the biliary blockage, the blood pigments cannot be excreted sufficiently, so that the bilirubin in the blood count is increased.
If the detoxification via the liver is no longer sufficient, the ammonia level in the blood can also rise.
In addition, the synthesis disturbance in the liver becomes noticeable through reduced coagulation values.
The total protein in the blood, especially the albumin, decreases.
For more information about changes in blood values in cirrhosis of the liver, see:
This is how the blood values change in liver cirrhosis
What do you see in the ultrasound?
On the ultrasound, the liver appears bumpy and knotty.
In addition, the shape of the organ changes so that the otherwise acute angle of the liver is rounded.
The liver tissue itself shows up with connective tissue changes, which are shown by inhomogeneities (different echo-density structures).
In cirrhosis, the liver is usually enlarged at first, later the organ contracts, so that the liver becomes smaller.
In the late stages, complications of liver cirrhosis can also be seen on ultrasound.
This leads to a reduced number of small hepatic veins, while the largest hepatic vessel (portal vein) appears enlarged.
In addition, water retention in the abdomen (ascites) can be diagnosed well with the help of ultrasound.
Can you feel cirrhosis of the liver?
Cirrhosis of the liver can be felt well in the physical examination.
The liver is usually hidden under the right costal arch and is maximally palpable at the edge when fully exhaling.
The cirrhosis of the liver initially enlarges the organ so that the liver is easier to feel.
The liver also feels knotty and bumpy due to the connective tissue remodeling.
A hardening of the surface can also become noticeable.
In the later stages, the liver shrinks again, making it difficult to feel the organ.
Therapy / treatment of cirrhosis of the liver
General therapy for cirrhosis of the liver initially consists of reducing the risk factors.
Liver-damaging drugs should be discontinued.
Harmful substances such as alcohol are also forbidden in cirrhosis of the liver.
If there is already increased pressure in the liver vessels, diuretic therapy with water tablets can lower the pressure.
Beta blockers can also be used to treat pressure.
In addition, coagulation factors should be administered medically to prevent excessive bleeding.
This also includes a substitution of vitamin K, which is required for the formation of some coagulation factors.
Interventionally, the accumulation of water in the abdomen can be relieved by means of a puncture.
Complications such as bleeding in the bypass circuits must also be treated interventionally.
Read more on the subject at: Puncture water in the abdomen
These varices can, for example, bleed in the esophagus and cause life-threatening blood loss.
It may be necessary to stop the bleeding by means of interventional therapy.
The last option for treating the disease is a liver transplant.
Also learn how to get on the waiting list for a liver transplant:
The liver transplant - indications, costs & the waiting list
Life expectancy in cirrhosis of the liver
Life expectancy depends on the stage of liver cirrhosis.
In stage A with only minor failures in liver function, the survival rate is almost normal.
In the highest stage, stage C (end stage of liver cirrhosis), only about every third affected person survives a full year.
The exception are those who can be cured with a liver transplant.
Read everything about liver transplantation in the following article:
The liver transplant - indications, costs & the waiting list
Consequences of cirrhosis of the liver
The consequences of liver cirrhosis are initially noticeable through an accumulation of various toxins and a reduced synthesis capacity of the liver and the resulting coagulation disorders.
Two serious consequences of cirrhosis of the liver are hepatic encephalopathy (the brain is affected) and hepatorenal syndrome (the kidney is affected).
In hepatic encephalopathy, toxins such as ammonia build up in the brain.
Disturbances in consciousness and even coma can occur, which can be aggravated by a deterioration in liver function as well as indigestion, loss of fluids and infections.
The therapy consists in the administration of ornithine aspartate, which can increase the ammonia detoxification.
In the case of hepatorenal syndrome, a kidney dysfunction occurs, which is caused by the poor blood flow to the kidneys due to the liver dysfunction.
Here, too, loss of fluids, digestive disorders and infections are the most common causes of acute deterioration.
Typically, kidney values, such as creatinine, rise, leading to acute kidney failure with significantly reduced or no urinary excretion.
Can cirrhosis of the liver be cured?
Cirrhosis of the liver itself is usually no longer curable.
However, preliminary stages of the disease (fatty liver) can still be reversed.
The first remodeling processes are caused by substances that damage the liver such as medication, drugs, alcohol and excessive fat consumption.
The resulting fatty liver is a reversible (reversible) change in the liver tissue and can be cured by doing without the substances mentioned.
As soon as the connective tissue remodeling of the tissue takes place, the process is no longer reversible and one speaks of liver cirrhosis.
The only "cure" is a liver transplant.
When do you need a liver transplant?
A liver transplant is the only way to cure cirrhosis and is done in the most advanced stages of cirrhosis if an organ is available.
A point value, the so-called MELD score, is used for this.
This calculates an approximation for the residual function of the liver from the concentration of bilirubin, creatinine (kidney value) and INR (coagulation value) and can use this to assess the urgency of a liver transplant.
You can find more information about liver transplantation at:
Liver transplantation - indication, procedure & costs
This is what end-stage liver cirrhosis looks like
In the final stage, liver cirrhosis is characterized by a multitude of complaints.
There is a significantly reduced amount of protein that is still produced in the liver.
This results in a strong tendency to edema with water retention in the extremities (especially the legs) and the abdomen (ascites).
In addition, the concentration of blood breakdown products increases continuously.
There is an accumulation of bilirubin, so that the skin turns yellow (so-called jaundice).
This often leads to symptoms such as itching.
In addition, the synthesis capacity of the liver decreases in the end stage so that the coagulation factors are no longer available in sufficient quantities.
This quickly leads to extensive bleeding.
In addition, since the vessels in the liver are congested and large environmental circuits are formed as a result, damage to these vessels in combination with poor coagulation can lead to life-threatening bleeding.
In addition, toxins such as ammonia accumulate due to the poor metabolism.
These get into the brain and lead to hepatic encephalopathy.
What are liver skin signs?
In cirrhosis of the liver, the loss of function of the liver causes so-called liver skin signs.
These include the lacquer lip and the lacquer tongue, where the affected areas shine particularly well.
Superficial thin vessels appear on the trunk, one speaks of telangiectasia and spider naevi.
Around the navel, the superficial veins can enlarge as bypass circuits; in its pronounced form, this shows up as the caput medusae.
A rash develops on the palms of the hands, the fingernails become milky white.
What is gynecomastia?
Gynecomastia is an enlarged breast in men.
In the context of cirrhosis of the liver, female hormones are also frequently produced in men.
This can be noticeable, among other things, in breast growth.
Typically, gynecomastia occurs on both sides because it is hormonally triggered and not based on local functional disorders.
You can find out how gynecomastia is treated here:
Gynecomastia - How It's Treated!
Jaundice in cirrhosis of the liver
Jaundice (icterus) is one of the first signs of liver dysfunction.
The accumulation of breakdown products of the blood pigment hemoglobin turns the eyes (sclera) and skin yellow.
Jaundice is typically accompanied by itching, which is also due to the accumulation of bilirubin.
Coagulation disorder in cirrhosis of the liver
The coagulation disorder in liver cirrhosis is due to a reduced production of the coagulation factors.
In particular, the vitamin K-dependent coagulation factors II, VII, IX and X are formed in the liver.
If there is a reduced synthesis capacity due to liver cirrhosis, the concentration of these coagulation factors in the blood falls and a coagulation disorder occurs. This can be noticeable through extensive bleeding as a result of only minor trauma.
How high is the risk that cirrhosis of the liver will develop into liver cancer?
Cirrhosis of the liver is a chronic irritation of the liver cells.
Typically, this initially leads the liver to try to regenerate by making new cells.
The more often the cells need to be regenerated and / or repaired, the more likely it is that something will go wrong.
This can lead to a liver cancer cell that develops into a full-blown tumor.
The more advanced the liver cirrhosis, the higher the risk that liver cirrhosis will develop into liver cancer.
What are the symptoms of liver cancer? Read our article on this:
Liver cancer symptoms
history
The first description of a cirrhotic liver appeared in a drawing by Leonardo Da Vinci from 1508 in Florence. The drawing was based on an autopsy in which the vascular anatomy of the liver was to be emphasized.
Disease emergence
As mentioned above, the causes of liver cirrhosis are very diverse. The most common cause in industrialized countries, with around 50% of cirrhosis, is alcohol abuse.
The second most common cause of cirrhosis is reserved for hepatitis. The frequency here is around 20-25%. Hepatitis C is the form of hepatitis that most frequently leads to liver cirrhosis, as hepatitis C is chronic in 85% of cases and thus the liver tissue is destroyed over decades.
In developing countries, the causes of cirrhosis are clearly reversed. Here, over 90% of cirrhosis is the result of hepatitis.
This can mainly be explained by the poor hygiene. At the cellular level there is what is known as necrosis of the liver cells.
Necrosis describes a process in which cells are irreversibly damaged.
These cell necrosis are caused by viruses or poisons. The destruction of the liver cells causes the immune system, with its many cells, to be activated via messenger substances and the constant immune reaction leads to a connective tissue remodeling of the liver.
This leads to tissue necrosis with the formation of so-called regenerated nodes and connective tissue septa. These remodeling processes interrupt the natural flow of blood and bile through the liver. The interruption of the blood and biliary tract causes blood and bile congestion in the liver, which in severe cases can spread to the body. The high pressure created by the congestion of blood in the liver is called portal hypertension (high blood pressure in the liver). With portal hypertension, the blood backs up in the abdominal organs of the body and in the so-called collateral vessels (bypass circuits).
The most feared complication of liver cirrhosis is esophageal variceal bleeding (varicose veins in the esophagus). The varices arise when the congested blood in the liver looks for other ways to get back to the right ventricle.
These varicose veins are under high pressure and can tear, for example, if you cough too hard. The tearing of these varicose veins is one of the most serious emergencies in medicine, as a lot of blood can be lost very quickly.
Liver cirrhosis is now one of the preliminary stages of liver cancer, the so-called hepato-cellular carcinoma (HCC).
