Cirrhosis (Liver): Life Expectancy, Symptoms, Causes, Stages & Treatment

Cirrhosis is a complication of liver disease that involves loss of liver cells and irreversible scarring of the liver.Source: Getty Images

Things to know about cirrhosis of the liver

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Cirrhosis is a complication of liver disease that involves loss of liver cells and irreversible scarring of the liver. Alcohol and viral hepatitis B and C are common causes of cirrhosis, although there are many other causes.

• Cirrhosis can cause weakness, loss of appetite, easy bruising, yellowing of the skin (jaundice), itching, and fatigue.
• Diagnosis of cirrhosis can be suggested by history, physical examination, and blood tests, and can be confirmed by liver biopsy.
• Complications of cirrhosis include:
  • Swelling of the abdomen (ascites) and/or in the hip, thigh, leg, ankle, and foot
  • Spontaneous bacterial peritonitis
  • Bleeding from varices
  • Hepatic encephalopathy
  • Hepatorenal syndrome
  • Hepatopulmonary syndrome
  • Hypersplenism
  • Liver cancer
• Treatment of cirrhosis is designed to prevent further damage to the liver, treat complications of cirrhosis, and prevent or detect liver cancer early.
• Transplantation of the liver is an important option for treating patients with advanced cirrhosis.
• There is no cure for cirrhosis of the liver, and for some people the prognosis is poor. The life expectancy for advanced cirrhosis is 6 months to 2 years depending on complications of cirrhosis, and if no donor is available for liver transplantation The life expectancy for people with cirrhosis and acholic hepatitis can be as high as 50%.
• The life expectancy is more than 12 years for a person with cirrhosis and no major complications.

Symptoms of Cirrhosis of the Liver

Individuals with cirrhosis may have few or no symptoms and signs of liver
disease. Some of the symptoms may be nonspecific, that is, they don’t suggest
that the liver is their cause. Some of the more common symptoms and signs of
cirrhosis include:

• Yellowing of the skin (jaundice) due to the accumulation of bilirubin in
  the blood
• Fatigue
• Weakness
• Loss of appetite
• Itching
• Easy bruising from decreased production of blood clotting factors by the
  diseased liver.

Individuals with cirrhosis also develop symptoms and signs from the
complications of cirrhosis.

There are many causes of cirrhosis including chemicals (such as alcohol, fat, and certain medications), viruses, toxic metals, and autoimmune liver disease in which the body’s immune system attacks the liver.Source: MedicineNet

What is cirrhosis?

Cirrhosis is a complication of many liver diseases characterized by abnormal structure and function of the liver. The diseases that lead to cirrhosis do so because they injure and kill liver cells, after which the inflammation and repair that is associated with the dying liver cells cause scar tissue to form. The liver cells that do not die multiply in an attempt to replace the cells that have died. This results in clusters of newly-formed liver cells (regenerative nodules) within the scar tissue. There are many causes of cirrhosis including chemicals (such as alcohol, fat, and certain medications), viruses, toxic metals (such as iron and copper that accumulate in the liver as a result of genetic diseases), and autoimmune liver disease in which the body's immune system attacks the liver.

The relationship of the liver to the blood is unique.Source: MedicineNet/iStock

Why does cirrhosis cause problems?

The liver is an important organ in the body. It performs many critical functions, two of which are producing substances required by the body, for example, clotting proteins that are necessary in order for blood to clot, and removing toxic substances that can be harmful to the body, for example, such as drugs. The liver also has an important role in regulating the supply of glucose (sugar) and lipids (fat) that the body uses as fuel. In order to perform these critical functions, the liver cells must be working normally, and they must have close proximity to the blood because the substances that are added or removed by the liver are transported to and from the liver by the blood.

The relationship of the liver to the blood is unique. Unlike most organs in the body, only a small amount of blood is supplied to the liver by arteries. Most of the liver's supply of blood comes from the intestinal veins as the blood returns to the heart. The main vein that returns blood from the intestines is called the portal vein. As the portal vein passes through the liver, it breaks up into increasingly smaller and smaller veins. The tiniest veins (called sinusoids because of their unique structure) are in close contact with the liver cells. Liver cells line up along the length of the sinusoids. This close relationship between the liver cells and blood from the portal vein allows the liver cells to remove and add substances to the blood. Once the blood has passed through the sinusoids, it is collected in increasingly larger and larger veins that ultimately form a single vein, the hepatic vein, which returns the blood to the heart.

In cirrhosis, the relationship between blood and liver cells is destroyed. Even though the liver cells that survive or are newly formed may be able to produce and remove substances from the blood, they do not have a normal, intimate relationship with the blood, and this interferes with the liver cells' ability to add or remove substances from the blood. In addition, the scarring within the cirrhotic liver obstructs the flow of blood through the liver and to the liver cells. As a result of the obstruction to the flow of blood through the liver, blood "backs up" in the portal vein, and the pressure in the portal vein increases, a condition called portal hypertension. Because of the obstruction to flow and high pressures in the portal vein, blood in the portal vein seeks other veins in which to return to the heart, veins with lower pressures that bypass the liver. Unfortunately, the liver is unable to add or remove substances from the blood that bypasses it. It is a combination of reduced numbers of liver cells, loss of the normal contact between blood passing through the liver and the liver cells, and blood bypassing the liver that leads to many of the signs of cirrhosis.

A second reason for the problems caused by cirrhosis is the disturbing relationship between the liver cells and the channels through which bile flows. Bile is a fluid produced by liver cells that has two important functions: to aid in digestion and to remove and eliminate toxic substances from the body. The bile produced by liver cells is secreted into very tiny channels that run between the liver cells that line the sinusoids, called canaliculi. The canaliculi empty into small ducts which then join together to form larger and larger ducts. All of the ducts combine into one duct that enters the small intestine which can help with the digestion of food. At the same time, toxic substances contained in the bile enter the intestine and then are eliminated in the stool. In cirrhosis, the canaliculi are abnormal and the relationship between liver cells and canaliculi is destroyed, just like the relationship between the liver cells and blood in the sinusoids. As a result, the liver is not able to eliminate toxic substances normally, and they can accumulate in the body. To a minor extent, digestion in the intestine also is reduced.

Common symptoms and signs of cirrhosis include jaundice, fatigue, weakness, loss of appetite, itching, and easy bruising.Source: Getty Images/iStock/Bigstock

What are the signs and symptoms of cirrhosis?

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People with cirrhosis may have few or no symptoms and signs of liver disease. Some of the symptoms may be nonspecific and don't suggest the liver is their cause. Common symptoms and signs of cirrhosis include:

• Yellowing of the skin (jaundice) due to the accumulation of bilirubin in the blood
• Fatigue
• Weakness
• Loss of appetite
• Itching
• Easy bruising from decreased production of blood clotting factors by the diseased liver.

People with cirrhosis of the liver also develop symptoms and signs from the complications of the disease.

What are the stages of cirrhosis of the liver?

Cirrhosis in itself is already a late stage of liver damage. In the early stages of liver disease, there will be inflammation of the liver. If this inflammation is not treated it can lead to scarring (fibrosis). At this stage, it is still possible for the liver to heal with treatment.

If fibrosis of the liver is not treated, it can result in cirrhosis. At this stage, the scar tissue cannot heal, but the progression of the scarring may be prevented or slowed. People with cirrhosis who have signs of complications may develop the end-stage liver disease (ESLD) and the only treatment at this stage is liver transplantation.

• Stage 1 cirrhosis involves some scarring of the liver, but few symptoms. This stage is considered compensated cirrhosis, where there are no complications.
• Stage 2 cirrhosis includes worsening portal hypertension and the development of varices.
• Stage 3 cirrhosis involves the development of swelling in the abdomen and advanced liver scarring. This stage marks decompensated cirrhosis, with serious complications and possible liver failure.
• Stage 4 cirrhosis can be life-threatening and people have developed the end-stage liver disease (ESLD), which is fatal without a transplant.

QUESTION

Liver disease refers to any abnormal process that affects the liver.
See Answer

Edema, ascites, and spontaneous bacterial peritonitis (SBP) complicationsSource: MedicineNet

Edema, ascites, and bacterial peritonitis complications of cirrhosis

Edema and ascites

As cirrhosis of the liver becomes severe, signals are sent to the kidneys to retain salt and water in the body. The excess salt and water first accumulate in the tissue beneath the skin of the ankles and legs because of the effect of gravity when standing or sitting. This accumulation of fluid is called peripheral edema or pitting edema. (Pitting edema refers to the fact that pressing a fingertip firmly against an ankle or leg with edema causes an indentation in the skin that persists for some time after the release of the pressure. Any type of pressure, such as from the elastic band of a sock, maybe enough to cause pitting.) The swelling often is worse at the end of a day after standing or sitting and may lessen overnight when lying down. As cirrhosis worsens and more salt and water are retained, fluid also may accumulate in the abdominal cavity between the abdominal wall and the abdominal organs (called ascites) causing swelling of the abdomen, abdominal discomfort, and increased weight.

Spontaneous bacterial peritonitis (SBP)

Fluid in the abdominal cavity (ascites) is the perfect place for bacteria to grow. Normally, the abdominal cavity contains a very small amount of fluid that can resist infection well, and bacteria that enter the abdomen (usually from the intestine) are killed or find their way into the portal vein and to the liver where they are killed. In cirrhosis, the fluid that collects in the abdomen is unable to resist infection normally. In addition, more bacteria find their way from the intestine into the ascites. Infection within the abdomen and the ascites, called spontaneous bacterial peritonitis or SBP, is likely to occur. SBP is a life-threatening complication. Some patients with SBP have no symptoms, while others have a fever, chills, abdominal pain and tenderness, diarrhea, and worsening ascites.

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Bleeding and spleen complicationsSource: iStock

Bleeding and spleen complications of cirrhosis

Bleeding from esophageal varices

In the cirrhotic liver, the scar tissue blocks the flow of blood returning to the heart from the intestines and raises the pressure in the portal vein (portal hypertension). When the pressure in the portal vein becomes high enough, it causes blood to flow around the liver through veins with lower pressure to reach the heart. The most common veins through which blood bypasses the liver are the veins lining the lower part of the esophagus and the upper part of the stomach.

As a result of the increased flow of blood and the resulting increase in pressure, the veins in the lower esophagus and upper stomach expand and then are referred to as esophageal and gastric varices; the higher the portal pressure, the larger the varices and the more likely a patient is to bleed from the varices into the esophagus or stomach.

Bleeding from varices is severe and without immediate treatment can be fatal. Symptoms of bleeding from varices include vomiting blood (it may appear as red blood mixed with clots or "coffee grounds"), passing stool that is black and tarries due to changes in the blood as it passes through the intestine (melena), and orthostatic dizziness or fainting (caused by a drop in blood pressure, especially when standing up from a lying position).

Bleeding may rarely occur from varices that form elsewhere in the intestines, for example, the colon. Patients hospitalized because of actively bleeding esophageal varices have a high risk of developing spontaneous bacterial peritonitis, though the reasons for this are not yet understood.

Hypersplenism

The spleen normally acts as a filter to remove older red blood cells, white blood cells, and platelets (small particles important for the clotting of blood.). The blood that drains from the spleen joins the blood in the portal vein from the intestines. As the pressure in the portal vein rises in cirrhosis, it increasingly blocks the flow of blood from the spleen. The blood "backs up," accumulating in the spleen, and the spleen swells in size, a condition referred to as splenomegaly. Sometimes, the spleen is so enlarged it causes abdominal pain.

As the spleen enlarges, it filters out more and more of the blood cells and platelets until their numbers in the blood are reduced. Hypersplenism is the term used to describe this condition, and it is associated with a low red blood cell count (anemia), low white blood cell count (leukopenia), and/or a low platelet count (thrombocytopenia). Anemia can cause weakness, leucopenia can lead to infections, and thrombocytopenia can impair the clotting of blood and result in prolonged bleeding

IMAGES

Cirrhosis (Liver)
See a medical illustration of the liver plus our entire medical gallery of human anatomy and physiology
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Liver (hepatic) complicationsSource: iStock

Liver (cancer and hepatic) complications of cirrhosis

Liver cancer (hepatocellular carcinoma)

Cirrhosis due to any cause increases the risk of primary liver cancer (hepatocellular carcinoma). Primary refers to the fact that the tumor originates in the liver. Secondary liver cancer is one that originates elsewhere in the body and spreads (metastasizes) to the liver.

The most common symptoms and signs of primary liver cancer are abdominal pain and swelling, an enlarged liver, weight loss, and fever. In addition, liver cancers can produce and release a number of substances, including ones that cause an increase in red blood cell count (erythrocytosis), low blood sugar (hypoglycemia), and high blood calcium (hypercalcemia).

Hepatic encephalopathy

Some of the protein in food that escapes digestion and absorption is used by bacteria that are normally present in the intestine. While using the protein for their own purposes, the bacteria make substances that they release into the intestine to then be absorbed into the body. Some of these substances, such as ammonia, can have toxic effects on the brain. Ordinarily, these toxic substances are carried from the intestine in the portal vein to the liver where they are removed from the blood and detoxified.

When cirrhosis is present, liver cells cannot function normally either because they are damaged or because they have lost their normal relationship with the blood. In addition, some of the blood in the portal vein bypasses the liver through other veins. The result of these abnormalities is that toxic substances cannot be removed by the liver cells, and instead accumulate in the blood.

When the toxic substances accumulate sufficiently in the blood, the function of the brain is impaired, a condition called hepatic encephalopathy. Sleeping during the day rather than at night (reversal of the normal sleep pattern) is an early symptom of hepatic encephalopathy. Other symptoms include irritability, inability to concentrate or perform calculations, memory loss, confusion, or depressed levels of consciousness. Ultimately, severe hepatic encephalopathy causes coma and death.

The toxic substances also make the brains of patients with cirrhosis very sensitive to drugs that are normally filtered and detoxified by the liver. Doses of many drugs may have to be reduced to avoid a toxic buildup in cirrhosis, particularly sedatives and drugs used to promote sleep. Alternatively, drugs may be used that do not need to be detoxified or eliminated from the body by the liver, such as drugs eliminated by the kidneys.

Hepatorenal syndrome

Patients with worsening cirrhosis can develop the hepatorenal syndrome. This syndrome is a serious complication in which the function of the kidneys is reduced. It is a functional problem in the kidneys, meaning there is no physical damage to the kidneys. Instead, the reduced function is due to changes in the way the blood flows through the kidneys themselves. The hepatorenal syndrome is defined as progressive failure of the kidneys to clear substances from the blood and produce adequate amounts of urine while other important functions of the kidney, such as retention of salt, are maintained. If liver function improves or a healthy liver is transplanted into a patient with hepatorenal syndrome, the kidneys usually begin to work normally again. This suggests that the reduced function of the kidneys is the result of either the accumulation of toxic substances in the blood or abnormal liver function when the liver fails. There are two types of hepatorenal syndrome. One type occurs gradually over months. The other occurs rapidly over a week or two.

Hepatopulmonary syndrome

Rarely, some patients with advanced cirrhosis can develop hepatopulmonary syndrome. These patients can experience difficulty breathing because certain hormones released in advanced cirrhosis cause the lungs to function abnormally. The basic problem in the lung is that not enough blood flows through the small blood vessels in the lungs that are in contact with the alveoli (air sacs) of the lungs. Blood flowing through the lungs is shunted around the alveoli and cannot pick up enough oxygen from the air in the alveoli. As a result, the patient experiences shortness of breath, particularly with exertion.

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There are 12 common causes of cirrhosis.Source: iStock

What are common causes of cirrhosis?

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Common causes of cirrhosis of the liver include:

1. Alcohol
2. Nonalcoholic fatty liver disease
3. Cryptogenic causes
4. Chronic viral hepatitis (A, B, and C)
5. Autoimmune hepatitis
6. Inherited (genetic) disorders
7. Primary biliary cirrhosis (PCB)
8. Primary sclerosing cholangitis (PSC)
9. Infants born without bile ducts

Less common causes of cirrhosis include:

1. Unusual reactions to some drugs
2. Prolonged exposure to toxins
3. Chronic heart failure (cardiac cirrhosis).

In certain parts of the world (particularly Northern Africa), infection of the liver with a parasite (schistosomiasis) is the most common cause of liver disease and cirrhosis.

Alcohol and nonalcoholic fatty liver disease are common causes of cirrhosis.Source: iStock

Alcohol and nonalcoholic fatty liver disease

Alcohol

Alcohol is a very common cause of cirrhosis, particularly in the Western world. Chronic, high levels of alcohol consumption injure liver cells. Thirty percent of individuals who drink daily at least eight to sixteen ounces of hard liquor or the equivalent for fifteen or more years will develop cirrhosis. Alcohol causes a range of liver diseases, which include simple and uncomplicated fatty liver (steatosis), more serious fatty liver with inflammation (steatohepatitis or alcoholic hepatitis), and cirrhosis.

Nonalcoholic fatty liver disease (NAFLD)

Nonalcoholic fatty liver disease (NAFLD) refers to a wide spectrum of liver diseases that, like alcoholic liver disease, range from simple steatosis to nonalcoholic steatohepatitis (NASH), to cirrhosis. All stages of NAFLD have in common the accumulation of fat in liver cells. The term nonalcoholic is used because NAFLD occurs in individuals who do not consume excessive amounts of alcohol, yet in many respects, the microscopic picture of NAFLD is similar to what can be seen in liver disease that is due to excessive alcohol. NAFLD is associated with a condition called insulin resistance, which, in turn, is associated with metabolic syndrome and diabetes mellitus type 2. Obesity is the main cause of insulin resistance, metabolic syndrome, and type 2 diabetes. NAFLD is the most common liver disease in the United States and is responsible for up to 25% of all liver diseases. The number of livers transplanted for NAFLD-related cirrhosis is on the rise. Public health officials are worried that the current epidemic of obesity will dramatically increase the development of NAFLD and cirrhosis in the population.

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The prognosis and life expectancy for cirrhosis of the liver varies and depends on the cause, the severity, any complications, and any underlying diseases.Source: iStock

Prevention and early detection for liver cancer, and liver transplantation

Prevention and early detection of liver cancer

Several types of liver disease that cause cirrhosis (such as hepatitis B and C) are associated with a high incidence of liver cancer. It is useful to screen for liver cancer in patients with cirrhosis, as early surgical treatment or transplantation of the liver can cure the patient of cancer. The difficulty is that the methods available for screening are only partially effective, identifying at best only half of patients at a curable stage of their cancer. Despite the partial effectiveness of screening, most patients with cirrhosis, particularly hepatitis B and C, are screened yearly or every six months with ultrasound examination of the liver and measurements of cancer-produced proteins in the blood, for example, alpha-fetoprotein.

Liver transplantation

Cirrhosis is irreversible. Liver function usually gradually worsens despite treatment, and complications of cirrhosis increase and become difficult to treat. When cirrhosis is far advanced liver transplantation often is the only option for treatment. Recent advances in surgical transplantation and medications to prevent infection and rejection of the transplanted liver have greatly improved survival after transplantation. On average, more than 80% of patients who receive transplants are alive after five years. Not everyone with cirrhosis is a candidate for transplantation. Furthermore, there is a shortage of livers to transplant, and they're usually is a long (months to years) wait before a liver for transplanting becomes available. Measures to slow the progression of liver disease, and treat and prevent complications of cirrhosis are vitally important.

What is the prognosis and life expectancy for cirrhosis of the liver?

The prognosis and life expectancy for cirrhosis of the liver varies and depends on the cause, the severity, any complications, and any underlying diseases.

• In compensated cirrhosis, patients have not developed any major complications and the average survival rate is more than 12 years.
• The prognosis is worse for patients who have decompensated cirrhosis and have developed complications such as ascites, variceal hemorrhage, spontaneous bacterial peritonitis, hepatocellular carcinoma, hepatorenal syndrome, or hepatopulmonary syndrome.
• Patients with decompensated cirrhosis often require liver transplantation and in those who are unable to receive an organ transplant, life expectancy may be less than 6 months.

What research is ongoing to prevent and treat cirrohsis of the liver?

Progress in the management and prevention of cirrhosis continues. Research is ongoing to determine the mechanism of scar formation in the liver and how this process of scarring can be interrupted or even reversed. Newer and better treatments for viral liver disease are being developed to prevent the progression to cirrhosis. Prevention of viral hepatitis by vaccination, which is available for hepatitis B, is being developed for hepatitis C. Treatments for the complications of cirrhosis are being developed or revised, and tested continually. Finally, research is being directed at identifying new proteins in the blood that can detect liver cancer early or predict which patients will develop liver cancer.