LIVER CIRRHOSIS COMPLICATIONS

Cirrhosis of the liver is a chronic disease that causes cell destruction and fibrosis (scarring) of hepatic tissue. Fibrosis alters normal liver structure and vasculature, impairing blood and lymph flow and resulting in hepatic insufficiency and hypertension in the portal vein. Complications include hyponatremia, water retention, bleeding esophageal varices. Coagulopathy, spontaneous bacterial peritonitis, and hepatic encephalopathy.

Cirrhosis is a potentially life-threatening condition that occurs when scarring damages the liver. This scarring replaces healthy tissue and prevents the liver from
working normally. Cirrhosis usually develops after years of liver inflammation. When chronic diseases cause the liver to become permanently injured and scarred, the condition is called Cirrhosis. Cirrhosis harms the structure of the liver and blocks the flow of blood. The loss of normal liver tissue slows the processing of nutrients, hormones, drugs, and toxins by the liver. Also, the production of proteins and other substances made by the liver is suppressed. People with cirrhosis often have few symptoms at first. The person may experience fatigue, weakness, and exhaustion. Loss of appetite is usual, often with nausea and weight loss. As liver function declines, water may accumulate in the legs and the abdomen (ascites). A decrease in proteins needed for blood clotting makes it easy for the person to bruise, bleeding or infection. In the later stages of cirrhosis, jaundice (yellow skin) may occur, caused by the buildup of bile pigment that is passed by the liver into the intestines. The liver of a person with cirrhosis also has trouble removing toxins, which may build up in the blood. Drugs taken usually are filtered out by the liver, and this cleansing process also is slowed down by cirrhosis. 

People with cirrhosis often are very sensitive to medications and their side effects. The doctor often can diagnose cirrhosis from the patient’s symptoms and from laboratory tests. During a physical exam, the doctor could notice a change in how your liver feels or how large it is. If the doctor suspects Cirrhosis, you will be given blood tests. The purpose of these tests is to find out if liver disease is present. In some cases, other tests that take pictures of the liver are performed such as the computerized axial tomography (CAT) scan, and ultrasound. The doctor may decide to confirm the diagnosis by putting a needle through the skin (biopsy) to take a sample of tissue from the liver. In some cases, cirrhosis is diagnosed during surgery when the doctor is able to see the entire liver.

ANATOMY AND PHYSIOLOGY:

The liver is located in the upper right-hand portion of the abdominal cavity, beneath the diaphragm and on top of the stomach, right kidney and intestines. The liver, a dark reddish-brown organ that weighs about 3 pounds, has multiple functions.

There are two distinct sources that supply blood to the liver:

• oxygenated blood flows in from the hepatic artery
• nutrient-rich blood flows in from the portal vein

The liver holds about one pint (13 percent) of the body’s blood supply at any given moment.

The liver consists of two main lobes, both of which are made up of thousands of lobules. These lobules are connected to small ducts that connect with larger ducts to ultimately form the hepatic duct. The hepatic duct transports the bile produced by the liver cells to the gallbladder and duodenum (the first part of the small intestine).

The liver regulates most chemical levels in the blood and excretes a product called “bile,” which helps carry away waste products from the liver. All the blood leaving the stomach and intestines passes through the liver. The liver processes this blood and breaks down the nutrients and drugs into forms that are easier to use for the rest of the body. More than 500 vital functions have been identified with the liver. Some of the more well-known functions include the following:

Production of bile, which helps carry away waste and break down fats in the small intestine during digestion.

Production of certain proteins for blood plasma.

Production of cholesterol and special proteins to help carry fats through the body.

Conversion of excess glucose into glycogen for storage. (This glycogen can later be converted back to glucose for energy.)

Regulation of blood levels of amino acids, which form the building blocks of proteins.

Processing of hemoglobin for use of its iron content. (The liver stores iron.)

Conversion of poisonous ammonia to urea. (Urea is one of the end products of protein metabolism that is excreted in the urine.)

Clearing the blood of drugs and other poisonous substances.

Regulating blood clotting.

Resisting infections by producing immune factors and removing bacteria from the blood stream.

When the liver has broken down harmful substances, its by-products are excreted into the bile or blood. Bile by-products enter the intestine and ultimately leave the body in the feces. Blood by-products are filtered out by the kidneys, and leave the body in the form of urine.

PREDISPOSING FACTORS:

Chronic Alcoholism

Malnutrition – decrease Vitamin B, thiamin – main cause

Virus

Toxicity – e.g. carbon tetrachloride

Use of hepatotoxic agents

SIGNS AND SYMPTOMS:

Early Signs

Weakness, fatigue

Anorexia

Stomatitis

Urine – tea color

Stool – clay color

Amenorrhea

Decrease sexual urge

Loss of puic hair, axilla hair

Hepatomegaly

Jaundice

Pruritus or urticaria

Late Signs

Hematological changes – all blood cells decrease

Leukopenia – decrease

Thrombocytopenia – decrease

Anemia – decrease

Endocrine changes

Spider angiomas, Gynecomastia

Caput medusa, Palmar errythema

GIT changes

Ascitis, bleeding esophageal varices – due to portal Hypertension

Neurological Changes

PATHOPHYSIOLOGY:

Cirrhosis is characterized by diffuse fibrotic bands of connective tissue that distort the liver’s normal architecture. Inflammation caused by either toxins or disease results in extensive degeneration and destruction of hepatocytes ( liver cells ). As cirrhosis develops, the tissue becomes nodular. These nodules can block lile ducts and normal blood flow throughout the liver. Flow alterations in the vascular system and lymphatic bile duct channels result from compression caused by the proliferation of fibrous tissue. In early disease, the liver is usually enlarged, firm and hard. As the pathologic process continues, the liver shrinks in size.

COMPLICATIONS:

Cirrhosis is the eleventh leading cause of death by disease in the United States, killing more than 25,000 people each year. A damaged liver affects almost every bodily process, including the functions of the digestive, hormonal, and circulatory systems. The most serious complications are those associated with so-called decompensation, which occur when cirrhosis progresses. They include the following:

Bleeding and fluid buildup (ascites).

Infections.

Damage to the brain (encephalopathy). Impaired brain function occurs when the liver cannot detoxify harmful substances.

Liver cancer is also a long-term risk with cirrhosis.

Cirrhosis is irreversible, but the rate of progression can be very slow, depending on its cause and other factors. Five-year survival rates are about 85% and can be lower or higher depending on severity.

For example, alcoholics with cirrhosis who abstain can have a 5-year or more survival rate of as high as 85%. For those who continue drinking, the chance for living beyond 5 years is no higher than 60%.

In patients with hepatitis B or C, the 5-year survival rate after a diagnosis of cirrhosis ranges between 71 – 85%.

About two-thirds of patients with primary biliary cirrhosis never develop symptoms and can have a normal life span. Once symptoms of liver damage, such as jaundice, occur, however, the average survival time declines. In one study of women diagnosed with primary biliary cirrhosis, about 36% developed symptoms over an 11-year period, and 11% either died or required liver transplantation.