cirrhosis

Quick Overview

• Description: In liver cirrhosis (shrinking liver), increasingly healthy tissue is transformed into functionless connective tissue (scar tissue). The liver is less and less able to fulfill its important tasks.
• symptoms: general symptoms (such as tiredness, lack of appetite, weight loss), liver signs (reddened palms and soles, itching, yellowing of the skin and white dermis in the eye, etc.), often complications (ascites, etc.)
• Causes: usually alcohol abuse or virus-induced liver inflammation (hepatitis). Sometimes other diseases of the liver, biliary tract, heart, metabolic diseases etc. or medications or toxins
• Treatment: Cause must be eliminated / treated. This way, the progression of the disease can be stopped. Already existing liver damage can not be undone.
• Forecast: It depends on how advanced the liver cirrhosis already is and whether the cause can be eliminated / treated.

What is liver cirrhosis?

Liver cirrhosis (shrinking liver) is the cause of liver tissue and gradually transforms into connective tissue (scarring). Possible trigger is a liver damage such as alcohol abuse, liver inflammation (hepatitis) or other diseases.

Due to the increasing remodeling of the liver tissue organ function decreases. Finally, in liver cirrhosis, the liver can no longer adequately fulfill its role as a central metabolic organ. The collapse of all liver functions (acute liver failure) causes the patient to die.

In Germany, about 250 out of every 100,000 people develop liver cirrhosis every year. However, experts suspect a high number of unreported cases: the actual number of illnesses may be much higher. Cirrhosis affects and kills approximately twice as many men as women. Mortality has increased in recent years.

Cirrhosis: symptoms

Cirrhosis causes several common symptoms, such as tiredness, poor appetite or nausea. There are also signs of the underlying disease. More advanced liver damage also causes specific cirrhosis symptoms.

General cirrhosis symptoms

The cirrhosis of the liver initially shows no symptoms or manifests itself with general disease symptoms such as:

• Fatigue and poor performance
• anorexia
• nausea
• loss in weight
• Fullness in the upper abdomen

Cirrhosis: symptoms of the underlying disease

In addition, often symptoms of the underlying disease, so the actual cause of cirrhosis. Signs of the copper storage disease Wilson, for example, are memory disorders, tremor and psychosis.

Specific cirrhosis symptoms

Liver cirrhosis in later stages is associated with specific signs of liver damage: the Liver can be enlarged or reduced, or bumpy by the scar tissue that forms. The majority of patients also have one enlarged spleen, A concomitant enlargement of the spleen and liver is called hepatosplenomegaly.

Other signs of liver cirrhosis are the so-called Liver skin sign:

• Yellowing of the dermis of the eyes and the skin (jaundice = jaundice)
• “Vascular spider” (Spider naevi): small, visible vascular branches that spread in a star or spider form (especially on the face and décolleté)
• Redness of palms (palmar erythema) and soles (plantar erythema)
• Rampart of the mouth (painful cracks in the corners of the mouth) and lacquered lips (striking red-glossy lips)
• itching

Also hormonal disorders Occur: The liver can cause damage, among other things, the female sex hormones (estrogens) no longer properly. This can cause the following cirrhosis symptoms:

• Men: Breast development, loss of abdominal hair, shrinkage of the testicles, decrease in sexual desire or potency
• Women: absence or irregularity of the menstrual period

Cirrhosis: signs of complications

With advanced cirrhosis, the liver can no longer compensate for the large loss of functioning cells. These decompensated liver cirrhosis can cause various complications. These include, for example ascites, portal hypertension, liver cell cancer and a liver-related brain disease (hepatic encephalopathy). Often also develop varicose veins in the esophagus (esophageal varices).

Such complications cause additional symptoms in cirrhosis:

Ascites: Ascites often occur in advanced cirrhosis of the liver. The accumulation of fluid increases the size of the abdomen, and the abdomen bulges out. When lying down, the fluid in the abdomen expands towards the sides. If she presses on the diaphragm, breathing problems can be added.

portal hypertension: The portal vein collects the blood of various abdominal organs (stomach, intestine, spleen, etc.) and brings it to the liver. In patients with liver cirrhosis, this blood may build up in front of the scarred liver. Then there is a portal hypertension (portal hypertension). Possible consequences include varicose veins in the esophagus (esophageal varices: see below) or in the stomach, which can burst and cause dangerous bleeding.

Hepatocellular cancer: Hepatocellular carcinoma (hepatocellular carcinoma) can be manifested by pressure pain in the right upper abdomen. In early stages, but not always complaints. Therefore, all cirrhotic patients are screened for liver cancer as a precautionary measure.

Hepatic encephalopathy: Hepatic encephalopathy is the main complication of cirrhosis. About 70 percent of those affected show signs of a disruption of brain metabolism. The cause is above all an increase of toxins such as ammonia in the blood, since the detoxification function of the liver is too weak. Depending on the symptoms, hepatic encephalopathy is divided into four stages:

• Stage 1: The patients are somewhat drowsy, slightly slowed in their reactions and slightly confused. There are also mood swings, lack of concentration and slurred speech.
• Stage 2: Drowsiness increases. In addition, the patients appear impassive (apathetic), have tremulous hands (tremor), and their writing changes.
• Stage 3: Patients sleep a lot, but wake up. Agitation, aggression, and changes in electrical brain activity (EEG changes) are further signs at this stage.
• Stage 4: Due to the failure of the liver, the patients fall into a coma (coma hepaticum). They no longer respond to pain stimuli, show no more reflexes, and the breathing air has a typical sweetish smell (Fetor hepaticus).

esophageal varices

Cirrhosis of the liver can cause varicose veins to form in the esophagus. Because the veins in the esophagus then serve as a substitute for large amounts of venous blood on the way from the abdomen to the heart. Initially, these esophageal varices do not cause any symptoms.

It is dangerous, however, when the esophageal varicose veins burst. The so-called oesophageal variceal bleeding can lead to life-threatening blood loss and manifest itself among other things in hemoptysis (hemoptysis). If the patient aspirates this blood into the respiratory tract, suffocation or severe pneumonia is imminent. In addition, the blood can pass through the stomach into the intestine and stain the stool black. Doctors speak of a tarry chair.

A variceal bleeding in the esophagus is life-threatening and must be treated immediately!

Read more in the article Esophageal varices.

Cirrhosis: therapy

The progression of liver cirrhosis can be stopped if the cause is corrected in time. With the right treatment can also relieve the symptoms. Already incurred damage remains – you can not undo it.

Cirrhosis therapy consists of several building blocks:

The patient must Avoid liver-damaging substances, This counts in the first place alcohol, The renunciation of alcohol is not only for patients with alcoholic cirrhosis, but for all others! The doctor can give tips and options for alcohol withdrawal (advice centers, therapy centers, etc.). In addition, patients should be supported by relatives, friends, and / or support groups (such as Alcoholics Anonymous).

Also drugs damage the liver: They should therefore be taken in liver cirrhosis only if it is medically necessary. In addition, patients should always consult their doctor first before using on their own any preparations – even over-the-counter medicines and supplements.

It also belongs to every liver cirrhosis therapy, the triggering one To treat underlying disease (as much as possible). For example, the doctor prescribes certain medicines for liver inflammation (hepatitis).

Very important is also the targeted treatment of complications, For example, help Ascites diuretic drugs (diuretics) to flush out the accumulated fluid. In addition, those affected should eat low sodium. In severe cases of ascites, a so-called puncture may be necessary: ​​In doing so, the doctor pricks with a thin needle into the abdomen to drain the fluid through a hose.

In severe, advanced cirrhosis is one liver transplantation often the last chance of the patient.

Liver cirrhosis & nutrition

Generally, doctors recommend liver cirrhosis balanced, vitamin-rich diet, If there are no complications and the patient’s nutritional status is normal (neither overweight nor underweight), a special “Liver Diet “ not useful. If a special diet is needed, the attending physician will discuss this with the patient.

For example, overweight patients should be fed on a low-fat and low-calorie fatty liver. This helps with weight loss (along with regular exercise).

If liver damage already interferes with brain function (hepatic encephalopathy), it is particularly important to reduce toxins in the blood. For this purpose, sufferers should eat less protein – then also produces less toxic ammonia in the body. In addition, the excretion of this toxin can be promoted with lactulose, a mild laxative.

Also for all other cirrhotic patients: you should go to one controlled bowel movement take care to encourage the excretion of toxins via the intestine. This high-fiber diet and an adequate supply of liquid help. Which amount of water per day makes sense and is advisable, patients should discuss with the attending physician. In certain cases, you should not take too much fluid, for example, when ascites.

Cirrhosis: causes and risk factors

Different diseases can lead to liver cirrhosis as a late consequence. In industrialized countries, alcohol abuse is present in more than half of all cases of cirrhosis. In the other patients, liver cirrhosis can be attributed to liver inflammation (hepatitis B or hepatitis C) or (less commonly) to another disease. Sometimes it is also caused by medication.

Cirrhosis due to alcohol

Long-term alcohol abuse is one of the main causes of cirrhosis in Germany. Doctors also refer to this as Ethyltoxic liver cirrhosis.

As a central metabolic organ, the liver is responsible for the breakdown of many alcohol. There are more and more toxins. Initially, they cause the liver to store a lot of fat – so-called fatty liver, At this stage, the changes in liver tissue are still partially reversible.

If the excessive consumption of alcohol continues, the fat-overloaded cells are destroyed. They are replaced by connective tissue (scar tissue). Doctors then speak of one liver fibrosis, The development of the scar and connective tissue is irreversible. If the fibrosis continues, it eventually leads to cirrhosis of the liver.

The amount of alcohol that causes cirrhosis of the liver varies greatly between individuals. In general, the daily consumption of about 40 grams of alcohol in men can irreparably damage the liver. Women are more sensitive to the pleasure poison. Therefore, 20 grams of alcohol per day can cause permanent liver damage.

Cirrhosis due to viral hepatitis

More than 30 percent of all cirrhosis cases in Germany are caused by chronic hepatitis B or C. Both types of disease – hepatitis B and hepatitis C – are each triggered by a specific type of virus. These viruses are found in infected people in virtually all body fluids such as blood, semen, urine or saliva.

Due to the chronic inflammation, the liver cells can be damaged with time so that they die and scar – a liver cirrhosis arises.

Other cirrhosis causes

Other causes of liver cirrhosis can be:

• Hepatobiliary disorders: e.g. immune-induced hepatitis (autoimmune hepatitis), chronic inflammation of the small bile ducts in the liver (primary biliary cirrhosis / cholangitis, PBC), chronic inflammation and scarring of the middle and greater bile ducts (primary sclerosing cholangitis, PSC)
• Metabolic Diseases: Iron storage disease (hemochromatosis), copper storage disease (Wilson’s disease), cystic fibrosis, etc.
• tropical diseases like schistosomiasis or liver fluke infestations
• heart disease like chronic right heart failure (right heart failure)
• toxins such as carbon tetrachloride or arsenic
• drugs like methotrexate (in cancer and autoimmune diseases)

In some cases, no cause for the disease can be detected. Then there is a so-called Cryptogenic cirrhosis.

Cirrhosis: examinations and diagnosis

The doctor will first discuss it with the patient Medical history (medical history), He can describe the symptoms exactly and asks for any pre- or underlying diseases. Particularly important is a possible hepatitis infection. In addition, the doctor asks if the patient is using any medications and how much alcohol he is consuming.

Physical examination

The next step is a physical examination if you suspect cirrhosis of the liver. The doctor will feel the size of the liver and spleen and the edge of the liver. In addition, he taps the abdomen to see if there is any fluid in the abdominal cavity (ascites = ascites).

An important indication of liver cirrhosis are also the so-called liver membrane signs. The doctor checks, for example, whether the palms are red (palmar erythema), “vascular spider” (Spider naevi) or the patient has jaundice (jaundice).

blood test

By a blood test, the extent of liver damage can be determined. If the following values ​​are reduced, this indicates that the liver is not working as well:

• albumin
• Cholinesterase (CHE)
• Coagulation factors II, VII, IX, X (this lowers the Quick value, meaning it takes longer for the blood to clot)

The following values ​​may be increased in liver cirrhosis:

• bilirubin
• Ammonia (in hepatic encephalopathy)
• the liver enzymes GOT (ASAT), GPT (ALAT), GLDH and gamma-GT

Imaging methods

Using ultrasound (sonography), the doctor can estimate the size and condition of the liver. Even a portal hypertension can thus be determined. Sometimes the doctor also uses a special ultrasound technique – Doppler sonography. Another special form of ultrasound (fibroscan) shows how heavily the liver is already scarred.

A computed tomography (CT) is only necessary if the ultrasound findings are unclear.

In order to demonstrate the structural change in scarred connective tissue, the doctor takes a tissue sample (biopsy) of the liver and sends it to the laboratory for analysis.

Further investigations

Sometimes further investigations are indicated. For example, gastroscopy (gastroscopy) is often recommended for newly discovered liver cirrhosis. The doctor can detect varicose veins in the esophagus or in the stomach.

To clarify a slight brain damage caused by cirrhosis (hepatic encephalopathy), so-called psychometric tests can be performed.

Stages of cirrhosis: Child-Pugh score

Cirrhosis of the liver can be divided into different stages. Physicians use the so-called Child-Pugh-Score: It takes into account five criteria that indicate how advanced the shrinking liver is. The Child-Pugh criteria are:

• Ascites, assessed by ultrasound
• Brain damage due to liver disease (hepatic encephalopathy)

• Albumin concentration in the blood: Albumin is a protein (protein) that is produced in the liver. Liver cirrhosis produces less albumin.
• Bilirubin concentration in the blood: Bilirubin is a degradation product of the blood pigment hemoglobin. Normally, it is broken down in the liver. In liver cirrhosis, it accumulates in the blood.
• Quick Value: This coagulation marker is dependent on coagulation factors produced in the liver. In liver cirrhosis, fewer coagulation factors are formed. This reduces the quick value. Alternatively, today’s blood clotting is often described by the INR value: it behaves inversely to the Quick value (e.g., high Quick value, low INR).

The doctor examines each criterion in the patient and awards points:

criteria	1 point	2 points	3 points
Albumin (g / dl)	> 3,5	2,8 – 3,5	< 2,8
Ascites	none	little	pronounced
Bilirubin (mg / dl)	< 2,0	2,0 – 3,0	> 3,0
hepatic encephalopathy	none	moderate	pronounced
Quick value (%) or INR	> 70% or <1.7	40-70% and 1.7-2.3, respectively	2.3

If cirrhosis of the liver is caused by primary biliary cirrhosis, the bilirubin value is assessed differently: 1 point is given for readings below 4 mg / dl. If the bilirubin value is between 4 and 10 mg / dl, there are 2 points. For bilirubin levels above 10 mg / dl, the doctor awards 3 points.

Cirrhosis stadiums

All points scored together give the Child-Pugh score, It is between 5 and 15 points: a liver cirrhosis of the slightest expression gives the value 5. At the strongest liver damage, however, a total score of 15 is reached.

The individual point scores are associated with different stages of cirrhosis: with a total score of 5 to 6 there is a cirrhosis Child A – the easiest stage of cirrhosis. Child B corresponds to a Child Pugh score of 7 to 9. By contrast, scores 10 to 15 represent the highest stage of cirrhosis: Child C.

Based on the stage, the doctor can estimate how high the risk of death of the patient for the following twelve months:

Child-Pugh score	stage	1-year mortality
5 – 6	Child A	3 to 10%
7 – 9	Child B	10 to 30%
10 – 15	Child C	50 to 80%

As the table shows, first-year mortality at Child A stage is still fairly low. However, it increases significantly with further progression of cirrhosis.

Cirrhosis: disease course and prognosis

The earlier a liver cirrhosis is detected and treated, the better the prognosis. An effective treatment includes eliminating or treating the cause of the disease (alcoholism, hepatitis, etc.). For example, alcoholics who stop drinking permanently have a relatively good prognosis for liver cirrhosis. However, the already incurred damage is not curable. Only the progression of cirrhosis can be stopped.

The prospects are much worse when people with alcoholic cirrhosis continue to drink alcohol. Every second person dies within five years. However, complications of liver cirrhosis can additionally worsen the life expectancy of patients.

The most common causes of death in cirrhotic patients are liver failure, esophageal or gastric variceal hemorrhage, and liver cancer.

Cirrhosis: prevention

If you want to prevent liver cirrhosis, you should first and foremost Avoid alcohol or at least consume only in moderation: Healthy men can drink up to 0.75 liters of beer or three eighths of a liter of wine a day. Healthy women are recommended a maximum of 0.5 liters of beer or a quarter liter of wine. For both sexes: This “allowed” amount of alcohol should not be allowed every day!

With a Hepatitis vaccination you can prevent the second most common cause of cirrhosis of the liver. Such a vaccination is advisable especially before planned trips abroad.

Watch out for toxic chemicals in the workplace (Carbon tetrachloride, benzene, etc.): Company doctors or occupational physicians clarify about possible hazards and occupational safety measures.

Take Medicines and vitamin supplements only one if necessary. As a central metabolic organ, the liver has to degrade and detoxify all foreign substances. Ask your doctor or pharmacist in advance how liver damage is a drug – perhaps there is a better tolerated drug, which increases the risk of liver damage and cirrhosis not increased.

Additional information

guidelines:

S3_Guide “Ascites, spontaneous bacterial peritonitis, hepatorenal syndrome” of the German Society for Digestive and Metabolic Diseases (2011)

Support Groups:

• German Liver Assistance e.V.