Health Information

Summary/Definition

Cirrhosis of the liver is a pathological condition in which ordinary liver tissue is replaced by fibrous tissue, which disrupts the normal function of the organ. In the early stages of cirrhosis, symptoms may remain unnoticeable, and blood tests do not always reveal deviations from the norm. However, with the severe progression of liver damage, complications such as jaundice, ascites, hepatic encephalopathy, and varicose bleeding may occur. Therapy for cirrhosis of the liver includes the treatment of the underlying disease and the elimination of complications caused by cirrhosis of the liver.

1. Anatomy of the liver
   • The liver is the largest organ in our body, in adults it weighs from 1.2 to 1.5 kg. The liver has a wedge-shaped shape, it is located under the right diaphragm and is protected by ribs. The organ is mainly divided into two lobes: the right and the left, and both lobes consist of about 100,000 lobules. Bile produced in the liver accumulates in the gallbladder and is then released into the duodenum through the bile ducts inside the liver itself when food is consumed.
   • When liver cells are damaged for various reasons and fibrosis progresses in the liver tissue, the normal structure of the liver changes and is transformed into abnormal regenerative nodes. This phenomenon is accompanied by the formation of small lumps in the organ tissue. Cirrhosis of the liver is a disease in which these changes do not allow the liver to perform its original function and increase portal pressure in the liver, causing various problems in the body.
2. Liver function
   • The liver performs many important functions. First of all, it participates in the regulation of the metabolism of proteins, carbohydrates, and fats and the processing of nutrients, including vitamins. Secondly, it is responsible for the production of bile, which promotes the absorption of fats and fat-soluble vitamins. Bile accumulates in the gallbladder and is released into the intestines when eating, where it helps digest fats. Thirdly, the liver removes toxins from the body. It removes harmful toxins synthesized in the body or received from the outside, through bile or urine. Fourth, the liver performs the function of maintaining blood function. The old red blood cells in the blood are removed by the liver and spleen, and the iron contained in these red blood cells is processed to form new red blood cells in the bone marrow. In addition, the liver plays a key role in the development of blood clotting factors that ensure rapid cessation of bleeding when it occurs.

Micromorphologically, liver cirrhosis is divided into micronodular, macronodular, and mixed types, and clinically, into compensated cirrhosis without pronounced symptoms and decompensated cirrhosis with complications. Compensated cirrhosis of the liver refers to the stage at which cirrhosis of the liver begins, but normal function can be maintained without complications. In patients with compensated cirrhosis of the liver, clinical symptoms may be unclear, and blood tests may not reveal any special abnormalities. However, with the aggravation of cirrhosis of the liver, complications such as jaundice, ascites, hepatic encephalopathy, and varicose bleeding may occur, and eventually, with the onset of liver failure, death may occur. It also increases the risk of liver cancer. This condition is called decompensated cirrhosis.

Cirrhosis occurs due to ongoing inflammation of the liver caused by chronic hepatitis B or C, as well as due to excessive alcohol consumption, obesity, or exposure to toxic substances in the liver. Among Korean patients, the most common cause of liver cirrhosis is hepatitis B virus (48-70%), followed by alcohol damage and hepatitis C virus.

1. Chronic viral hepatitis
   • Chronic viral hepatitis, for example, hepatitis B or C, is the main cause of liver cirrhosis. Because chronic hepatitis lasts longer, it causes inflammation in liver cells, which ultimately leads to damage and destruction of liver cells, increasing the risk of liver cirrhosis. In approximately 10-15% of cases of chronic hepatitis C and 5-10% of cases of chronic hepatitis B, these diseases eventually progress to the stage of liver cirrhosis.
2. Alcoholic liver damage
   • Excessive alcohol consumption is one of the main risk factors for liver cirrhosis. Ethyl alcohol, formed during the metabolism of alcohol in the liver, is transformed into toxic metabolites, for example, acetaldehyde, which causes inflammation and damage to liver tissues. The damaged liver loses its ability to efficiently process fats, which leads to their accumulation and, eventually, to the development of fibrosis, which can lead to cirrhosis of the liver. Women have an increased risk of liver disease compared to men, even when drinking alcohol in small amounts. Even with an equal amount of alcohol consumed, women have a higher concentration of alcohol in their blood, and they metabolize alcohol more slowly than men, which leads to its prolonged presence in the body.
3. Non-alcoholic fatty liver disease
   • Recently, there has been a rapid increase in the number of people suffering from obesity and metabolic syndrome, which causes the accelerated spread of non-alcoholic fatty liver disease. It’s important to note that this condition can evolve from the buildup of fat in the liver to the onset of hepatitis, cirrhosis, and liver cancer, ultimately exhibiting clinical similarities to alcohol-induced fatty liver disease.
4. Autoimmune disease
   • Autoimmune liver diseases include autoimmune hepatitis and primary biliary cirrhosis. These diseases occur because of impaired function of the immune system, which begins to aggressively attack its cells and organs. Patients suffering from these liver pathologies often also face other autoimmune diseases, for example, systemic lupus erythematosus, rheumatoid arthritis, Sjogren’s syndrome, scleroderma, and chronic inflammatory bowel diseases.
5. Hemochromatosis and iron
   • Hemochromatosis is a violation of iron metabolism, which leads to excessive accumulation of iron in various tissues of the body, including the liver. This process can provoke the development of cirrhosis of the liver.

Cirrhosis is a condition in which there is a progression of fibrous changes in liver tissue due to damage to liver cells under the influence of various factors. This is associated with the development of irregular structural nodes encircled by fibrous scars. Due to the decline in liver cell function and heightened resistance to blood flow, there is an increase in the accumulation of toxic metabolites, a decrease in the synthesis of crucial proteins, and a rise in portal pressure. This can lead to the development of complications such as ascites, hepatic coma, and varicose bleeding.

Epidemiology and statistics

In the Republic of Korea, there is a high prevalence of liver diseases, and cirrhosis is a significant factor affecting the mortality of the population. According to the National Statistical Service, in 2019, the death rate from liver diseases was 12.7 cases per 100,000 people, which made them the eighth among all causes of death and the sixth among men. According to the frequency of liver cirrhosis, hepatitis B virus infection is the most common, accounting for 57% to 73% of cases. Alcohol and hepatitis C virus infection are in second and third places, respectively (from 7% to 31% and from 9% to 22%). Despite the decrease in the prevalence of hepatitis B virus infection due to vaccination, the incidence of alcoholic cirrhosis of the liver continues to increase, increasing from 7% in the 1980s to 31%. There is also an increase in the number of cases of cirrhosis of the liver caused by the hepatitis C virus, especially among the young population.

Symptoms

Symptoms of the initial stage include factors such as fatigue, loss of appetite, nausea, and abdominal discomfort, while with further progression, jaundice, arachnid angiomas on the skin, redness of the palms, gynecomastia, sexual dysfunction, and menstrual disorders may occur. If the condition worsens, ascites (accumulation of fluid in the abdominal cavity) and bloating may occur, and in severe cases, patients may experience shortness of breath. Edema of the lower extremities may be accompanied by spot edema, in which, after pressing with a finger, the skin condition cannot recover immediately. Varicose veins of the stomach and esophagus may also develop, as well as hepatic encephalopathy, and in the case of varicose veins, massive bleeding may develop.

Diagnostics

In patients with chronic liver diseases, it is important to prevent the progression of cirrhosis and the subsequent development of hepatocellular carcinoma. For this purpose, it is necessary to assess the degree of liver fibrosis and diagnose cirrhosis in the early stages. This is achieved by conducting a medical examination, appropriate blood tests, and imaging studies. The diagnosis of cirrhosis is usually based on the presence of complications such as ascites, varicose veins, and hepatic encephalopathy caused by portal hypertension, and is confirmed by the results of imaging studies and blood tests reflecting a decrease in liver function.

1. Medical examination
   • During a medical examination, the following symptoms may appear spider angioma, erythema of the palms, muscle atrophy, jaundice, and ascites. Men may experience hair loss on the chest and abdomen, as well as the appearance of gynecomastia and testicular atrophy. The liver may have a nodular structure and be dense to the touch when palpated in the abdominal cavity. Portal hypertension can lead to an increase in the size of the spleen and the formation of a “jellyfish head” on the abdomen, which is the expansion of blood vessels around the navel. However, it is worth noting that the above symptoms manifest themselves at later stages of the development of cirrhosis of the liver, and the absence of these signs does not exclude the presence of this disease.
2. Laboratory indicators
   • 1 – Blood test
   • The results indicate a decrease in the number of platelets, albumin, and blood clotting factors. Abnormal levels of liver enzymes and elevated bilirubin levels are often observed. However, in the early stages of the disease, these deviations may be absent or insignificant, which complicates their unambiguous definition. To diagnose liver cancer, it is recommended to perform abdominal ultrasound (if necessary, computed tomography of the abdominal cavity) and testing for alpha-fetoprotein (AFP) every 6 months. It is also recommended to check the causes of these changes by testing for antibodies to viral hepatitis (including hepatitis B and C), antibodies to autoimmune hepatitis, and, if necessary, to conduct additional serological studies for hereditary metabolic diseases.
   • 2 – Imaging studies and endoscopy of the upper gastrointestinal tract
   • Ultrasound of the abdominal cavity, computed tomography, and magnetic resonance imaging can confirm the diagnosis by detecting morphological changes (for example, a rough parenchymal echogram of the liver, nodular changes in the structure of the liver, etc.) in the liver, as well as identifying collateral vessels in the abdominal cavity, indicating splenomegaly, ascites, and portal hypertension. If an endoscopy of the upper gastrointestinal tract (hereinafter referred to as endoscopy) reveals varicose veins of the esophagus or stomach and there are clinical signs of liver cirrhosis, the diagnosis can be made without a liver biopsy. Usually, endoscopy is recommended for patients with mild to moderate cirrhosis of the liver to detect varicose veins of the esophagus or stomach, even if there are no symptoms.
   • 3 – Liver fibroscanning
   • Liver fibroscanning is a research method aimed at assessing the presence or progression of liver fibrosis. This method is based on measuring the stiffness (or elasticity) of the liver using vibration. It determines the rate of transmission of elastic waves of vibration from the surface of the skin to the liver tissues and their return. Liver fibroscanning differs from liver biopsy in that it is safe and painless, which makes it an important tool for predicting the degree of liver fibrosis.
   • 4 – Biopsy
   • This procedure involves collecting a sample of liver tissue, carried out by inserting a special needle into the liver and then analyzing this tissue under a microscope. Liver biopsy is a standard diagnostic technique aimed at directly determining the presence of fibrosis in liver tissue. This method allows you to assess the causes of the disease, choose an approach to treatment, determine the degree of damage, and predict long-term prospects, but it should be borne in mind that the invasive nature of this procedure may cause complications.

Treatment and course of the disease

The prognosis of liver cirrhosis is influenced by several factors, including the root cause, severity, presence of complications, and concomitant systemic diseases. The annual risk of decompensated cirrhosis of the liver in patients with compensated cirrhosis is 5-7%, while in patients with early cirrhosis, the probability of bleeding from varicose veins is 25%, and the probability of developing ascites within 10 years reaches 50%. When complications of cirrhosis occur, the prognosis is unfavorable, since the 5-year survival rate for all patients with cirrhosis in the Republic of Korea is 68%, and the 5-year survival rate since the onset of ascites, bleeding from varicose veins of the esophagus and hepatic encephalopathy is 32%, 21%, and 40%, respectively, which characterizes the prognosis is extremely unfavorable.

As cirrhosis progresses, restoring normal liver function becomes a difficult task. However, proper treatment of the underlying cause and prevention of factors contributing to further liver damage can prevent the progression of cirrhosis and its development into a serious disease. To prevent progression, the cause of cirrhosis should be actively treated and the effects of factors contributing to further liver damage should be avoided.

The most important thing is to refrain from drinking alcohol, which will help prevent ascites, minimizing additional damage to liver cells and contributing to blocking liver fibrosis. It also contributes to the control of ascites in patients who have already developed ascites. The primary approach to the treatment of cirrhosis of the liver is to combat the underlying disease that caused its development, while the secondary approach is focused on antifibrosis treatment aimed at blocking the processes of fibrosis in the liver. Many studies confirm that antiviral therapy improves liver function in patients with chronic hepatitis B. The use of antiviral agents can reduce the level of hepatitis B viral DNA, improve portal pressure, reduce histological inflammation and fibrosis, and reduce the likelihood of complications, including ascites. Liver transplantation is considered a treatment method for patients with cirrhosis of the liver, whose life expectancy is less than 1 year and there is a danger to their lives. Currently, the five-year survival rate after liver transplantation is about 80%, which indicates excellent results of this procedure in the Republic of Korea.

Complications

1. Prevention and treatment of bleeding from varicose veins of the stomach and esophagus:

1. Preventive treatment:
   • In the presence of small varicose veins that have not previously bled, the possibility of using non-selective beta-blockers for prevention can be considered. In the case of large varicose veins that have not previously bled, the use of non-selective beta-blockers or endoscopic ligation of varicose veins is recommended.
2. Treatment for bleeding:
   • Vasoconstrictors are used to stop bleeding and prevent its recurrence. In addition, endoscopic ligation of varicose veins and occlusion of these veins are often used to prevent further bleeding and stop the current bleeding.
3. If the bleeding doesn’t stop
   • If the bleeding does not stop, you can temporarily place a probe or a permanent transjugular intrahepatic portosystemic shunt (TIPS).

2. Treatment of ascites and intra-abdominal infections:

Treatment of ascites begins with the correction of the underlying disease, for example, through abstinence from alcohol and antiviral therapy, and includes limiting salt intake, and the use of diuretics. In the case of recurrent or refractory ascites, therapeutic paracentesis, and transjugular intrahepatic portosystemic bypass surgery may be required. If an infection is detected during the ascites analysis, antibiotic treatment is prescribed. For treatment with antibiotics, hospitalization is necessary. Antibiotics are administered intravenously for about 7-10 days.

3. Treatment of hepatic encephalopathy:

Hepatic encephalopathy is treated by eliminating the main cause of its development. Among the common causes of encephalopathy are hyperammonemia, bleeding, hypoxia, dehydration, infection, sedation, and constipation. Ammonia is considered the main toxin contributing to the development of encephalopathy in cirrhosis of the liver. Mild forms of encephalopathy can be treated by reducing the level of ammonia in the intestinal tract as follows:

• Regulating the consumption of animal protein and the inclusion of plant proteins such as soy in the diet.
• The use of drugs such as lactulose, which can reduce the concentration of ammonia in the blood and have an effective effect on mild encephalopathy.
• The use of enemas to cleanse the intestines, due to the potential effectiveness of this method.
• The use of antibiotics such as metronidazole and neomycin, as they can destroy ammonia-producing bacteria in the digestive tract.

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