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  • Julio Alejandro Murra Saca, MD

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  • San Salvador, El Salvador


Liver Cirrhosis: Not always due to a alcohol abuse

Cirrhosis represents the final common histologic pathway for a wide variety of chronic liver diseases. The term cirrhosis was first introduced by Laennec in 1826.

Cirrhosis is defined histologically as a diffuse hepatic process characterized by fibrosis and the conversion of normal liver architecture into structurally abnormal nodules. The progression of liver injury to cirrhosis may occur over weeks to years. Indeed, patients with hepatitis C may have chronic hepatitis for as long as 40 years before progressing to cirrhosis.

Many forms of liver injury are marked by fibrosis, which is defined as an excess deposition of the components of the extracellular matrix (ie, collagens, glycoproteins, proteoglycans) within the liver. This response to liver injury potentially is reversible. In contrast, in most patients, cirrhosis is not a reversible process.

In addition to fibrosis, the complications of cirrhosis include, but are not limited to, portal hypertension, ascites, hepatorenal syndrome, and hepatic encephalopathy.

Often a poor correlation exists between histologic findings in cirrhosis and the clinical picture. Some patients with cirrhosis are completely asymptomatic and have a reasonably normal life expectancy. Other individuals have a multitude of the most severe symptoms of end-stage liver disease and have a limited chance for survival. Common signs and symptoms may stem from decreased hepatic synthetic function (eg, coagulopathy), decreased detoxification capabilities of the liver (eg, hepatic encephalopathy), or portal hypertension (eg, variceal bleeding

Cirrhosis represents a late stage of progressive hepatic fibrosis characterized by distortion of the hepatic architecture and the formation of regenerative nodules. It is generally considered to be irreversible in its advanced stages at which point the only option may be liver transplantation. Patients with cirrhosis are susceptible to a variety of complications and their life expectancy is markedly reduced.
Patients with cirrhosis may present in a variety of ways. They may have stigmata of chronic liver disease discovered on routine physical examination. They may have undergone laboratory or radiologic testing or an unrelated surgical procedure that incidentally uncovered the presence of cirrhosis. They may present with decompensated cirrhosis, which is characterized by the presence of dramatic and life-threatening complications, such as variceal hemorrhage, ascites, spontaneous bacterial peritonitis (SBP), or hepatic encephalopathy.Some patients never come to clinical attention. IAll patients with cirrhosis should undergo diagnostic endoscopy to document the presence of varices and to determine their risk for variceal hemorrhage. Patients at high risk for development of variceal hemorrhage should be considered for primary prophylaxis. I like Variceal Banding.

Much to often Liver Cirrhosis is being related to excessive alcohol ingestion. Even though alcoholism is a common cause of this entity, it is by far not the only cause of this often deadly disease. Liver cirrhoses is not curable, but it is definitely preventable in many instances, if one recognizes and minimizes certain risk factors.
The liver, the largest of our organs, is a real laboratory. With many many functions, essential for the human body. Within the liver cell carry out, complex enzymatic processes take place and many essential nutrients as well as glycogen, proteins, fat and vitamins are stored. Generally speaking, it is a very resistant organ that rarely ever fails to perform, contrary to the teachings and beliefs of many naturist, quacks and charlatans, who readily blame the liver for many diverse symptoms, without any scientific basis.

In this photograph can see a liver with macronodular cirrhosis,
which is being observed in a surgery

Causes of Cirrhosis
Although most often associated with alcohol abuse, cirrhosis of the liver can result from many causes. Almost any chronic liver disease can lead to cirrhosis. This list gives some of the many causes: 
Alcoholic liver disease most common cause.
Chronic viral hepatitis B, C and D Postnecrotic cirrhosis: Hepatitis, a viral infection of the liver, usually causes this disease, although poisonous substances may also cause it. Two types of hepatitis, hepatitis B or hepatitis C, cause 25-75% of these cases. Large areas of scar tissue mix with large areas of healing nodules. 
Chronic autoimmune hepatitis 
Non-alcoholic Steatohepatitis, Malnutrition and Diabetes: Steatohepatitis is the medical term for an enlarged, fatty liver. The condition is usually caused by alcoholism, but can also be the result of malnutrition, obesity and diabetes. Nonalcoholic steatohepatitis (liver inflammation that can be caused by fatty liver)
Inherited metabolic diseases (e. g. hemochromatosis, Wilson disease, Galactosemia) 
Chronic bile duct diseases (e. g. primary biliary cirrhosis) When small tubes that help you digest food become blocked, your body mistakenly turns on itself and reacts against these bile tubes. Gallstones often block tubes and cause this type of cirrhosis. The disease usually affects women aged 35-60 years
Chronic congestive heart failure Your heart is a pump that pushes blood throughout your body. When your heart doesn't pump well, blood "backs up" into the liver. This congestion causes damage to your liver. It may become swollen and painful. Later it becomes hard and less painful. The cause of the heart failure may be from heart valve problems, smoking, or infection of the heart muscle or the sac around the heart
Parasitic infections (e. g. schistosomiasis) 
Long term exposure to toxins or drugs.
Alpha-1-antitrypsin Deficiency: This is a hereditary disorder that prevents the body from properly utilizing the alpha-1-antitrypsin protein. In some cases, alpha-1-antitrypsin builds up in the liver, where excess amounts can lead to tissue scarring.


Liver Cirrhosis is a disease of this noble organ,
which is not easily understood by the lay person. This disease comprises the destruction (necrosis) of the individual liver cells and its substitution for scar tissue, a process which is irreversible. Often this is consequence of chronic alcohol abuse, but may also be the result of previous infection with hepatitis B,C,D . Specially hepatitis C which can develop in chronic viral hepatitis is frequently related to liver cirrhosis.

Other causes of liver cirrhosis are diseases of metabolic origin. Metabolic defects may cause the deposition of cirrhosis inducing substances into the liver cells. Wilson´s disease as well as Galactosemia are such entities. In Wilson´s disease, a specific enzyme deficiency causes the deposition of copper particles in liver tissue. In Galactosemia , the deficiency of the enzyme Galactose 1 Uridiltransferase , necessary for metabolism of galactose, is responsible for the abnormal deposition of galactose in the tissues, leading to mental retardation, cataracts and liver cirrhosis.Liver injury that results in cirrhosis also may be caused by a number of inherited diseases such as cystic fibrosis, alpha-1 antitrypsin deficiency, hemochromatosis and glycogen storage diseases others causes of liver cirrhosis are prolonged exposure to environmental toxins, and repeated bouts of heart failure with liver congestion. 

Prescription Drug abuse or even the prolonged or simultaneous ingestion of some Over the Counter remedies,
may cause liver cirrhosis. Special attention should be given to the abuse of acetaminophen and paracetamol, which is widespread here in El Salvador as well as in many other countries, and is being self-medicated for a diverse variety of symptoms including "hangovers", since liver cirrhosis may be a consequence of this abuse. Specially the ingestion of acetaminophen during "hangovers" should be avoided since the alcohol toxicity and the acetaminophen liver toxicity are a dangerous combination for the liver. In normal persons large doses of acetaminophen are needed to damage liver cells while patients with chronic alcoholism may suffer massive liver damage when exposed to small therapeutic doses of this drug. For this reason acetaminophen should be avoided in chronic alcoholic patients. 

What Are the Symptoms of Cirrhosis? 
People with cirrhosis often have few symptoms at first. At the beginning
The person may experience fatigue, weakness, and exhaustion. Loss of appetite is usual, often with nausea and weight loss. As liver function declines, less protein is made by the organ. For example, less of the protein albumin is made, which results in water accumulating in the legs (edema) or abdomen (ascites). A decrease in proteins needed for blood clotting makes it easy for the person to bruise or to bleed.
With respect to the clinical signs and symptoms of liver cirrhosis In the later stages this entity may present with uncharacteristic clinical features over a long period of time and go undiagnosed over many years. Symptoms and observable symptoms may appear late in the disease and may include loss of libido, nausea, anorexia, vomiting, ocular or total body jaundice, itching, reddening (erythema) of the palms, spider naevi on the chest, gynaecomastia, abdominal swelling, hepatomegaly, splenomegaly, pubic and axillary hair loss, swelling of ankles, abdominal pain, or mores severe manifestations such as encephalopathy, upper G.I. Tract bleeding due to esophageal varices or gastric ulcers or patient may even fall into a comatose state. Due to this diversity of manifestations, special classifications exist that classify a patient according to his or hers clinical features, which range from an asymptomatic state to an advanced life threatening condition.

The definite diagnosis of liver cirrhosis can only be obtained through liver biopsy.
Other diagnostic methods such as ultrasound, CT Scan, MRI can detect certain morphologic abnormalities associated with cirrhosis, although these changes are usually seen in advanced disease only.

Liver cirrhosis
in its initial stages can most often not be diagnosed by diagnostic imaging methods. Endoscopy is useful to document the presence of esophageal varices, as well as gastric or duodenal ulcers, often associated with cirrhosis. 

What Are the Treatments for Cirrhosis? 
As Liver cirrhoses is not curable the Treatment of cirrhosis is aimed at stopping or delaying its progress, minimizing the damage to liver cells, and reducing complications. 
The major goals of treating the cirrhotic patient include:

Slowing or reversing the progression of liver disease.
2. Preventing superimposed insults to the liver.
3. Preventing and treating the complications
4. Determining the appropriateness and optimal timing for liver transplantation

Slowing or reversing the progression of liver disease
 Although cirrhosis is generally considered to be irreversible in its advanced stages, the exact point at which it becomes irreversible is unclear . Some chronic liver diseases respond to treatment even when the liver disease has progressed to cirrhosis. Thus, specific therapies directed against the underlying cause of the cirrhosis should be instituted. As examples:
The 10-year survival rate in patients with cirrhosis from autoimmune hepatitis who are treated with steroids or immunosuppressive agents approaches 90 percent. This number is similar to survival rates of treated patients with autoimmune hepatitis who do not have cirrhosis.
Abstinence from alcohol improves survival in alcoholic cirrhosis.
Interferon therapy slows the progression of cirrhosis in patients with chronic hepatitis C virus infection, and may also decrease fibrosis and the risk of hepatocellular carcinoma 
Treatment of patients with chronic hepatitis B with lamivudine may result in significant improvement in liver function and histology. 
Cirrhosis of the liver is irreversible but treatment of the underlying liver disease may slow or stop the progression. Such treatment depends upon the underlying etiology. Termination of alcohol intake will stop the progression in alcoholic cirrhosis and for this reason, it is important to make the diagnosis early in a chronic alcohol abuser.

Risk Factors for Developing Cirrhosis from Hepatitis C.

Between 20% and 30% of people with Hepatitis C develop cirrhosis after twenty years. (It should be noted that even in patients with cirrhosis, survival rates in one study were nearly 80% at 10 years in these patients.) The following conditions put people with hepatitis C at higher risk for liver damage: 

Gastrointestinal hemorrhage due to esofageal variceal bleeding.
This endoscopic image displays the exactly site of the bleeding at the cardias, actve variceal bleeding is appreciated at the esophageal cardias.
DIAGNOSIS OF THE BLEEDING SOURCE, Endoscopy is an essential step in the diagnosis and treatment of acute variceal bleeding.

The endoscopic image display 2 esofageal varices that have been ligated.

The image displays a person with advanced liver cirrhosis with bulking abdomen due to ascites.
Ascites is the accumulation of fluid in the peritoneal cavity.

Another image of the same patient.

The presence of ascites in cirrhotic patients is indicative of significant liver impairment. Its cause is multifactorial.

Grading — A grading system for ascites has been proposed by the International Ascites Club.

Grade 1 — mild ascites detectable only by ultrasound examination

Grade 2 — moderate ascites manifested by moderate symmetrical distension of the abdomen

Grade 3 — large or gross asites with marked abdominal distension.
Alcoholic hepatitis regularly causes ascites with or without cirrhosis. 

Encephalopathy. is a syndrome observed in patients with cirrhosis. Hepatic encephalopathy is defined as a spectrum of neuropsychiatric abnormalities in patients with liver dysfunction, after exclusion of other known brain disease. Hepatic encephalopathy is characterized by personality changes, intellectual impairment, and a depressed level of consciousness. An important prerequisite for the syndrome is diversion of portal blood into the systemic circulation through portosystemic collateral vessels. Hepatic encephalopathy is also described in patients without cirrhosis with either spontaneous or surgically created portosystemic shunts. The development of hepatic encephalopathy is explained, to some extent, by the effect of neurotoxic substances, which occurs in the setting of cirrhosis and portal hypertension.

Subtle signs of hepatic encephalopathy are observed in nearly 70% of patients with cirrhosis. Symptoms may be debilitating in a significant number of patients. Overt hepatic encephalopathy occurs in about 30-45% of patients with cirrhosis. It is observed in 24-53% of patients who undergo portosystemic shunt surgery.

The development of hepatic encephalopathy negatively impacts patient survival. The occurrence of encephalopathy severe enough to lead to hospitalization is associated with a survival probability of 42% at 1 year of follow-up and 23% at 3 years.

Approximately 30% of patients dying of end-stage liver disease experience significant encephalopathy, approaching coma.

The economic burden of hepatic encephalopathy is substantial. After ascites, hepatic encephalopathy is the second most common reason for hospitalization of cirrhotic patients in the United States. Hepatic encephalopathy is also the most common, possibly preventable, cause for readmission

The main recommendation to prevent cirrhosis is to avoid drinking and if it does not exceed the amounts, is recommended for these people who are drinking when consuming foods to avoid further damage. Also, avoid excessive intake of medicines containing acetaminophen especially and most emphatically, in alcoholics. In the same way, people who have had liver disease should eliminate the use of contraceptives.

Vaccination against hepatitis B is recommended for persons at risk such as those working in hospitals must be aware that cirrhosis is an incurable disease the patient can be kept for years depending on the state of progress "The best cure is prevention."