Cirrhosis (cont.)
What are the symptoms and signs of cirrhosis?
Patients 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.
Patients with cirrhosis also develop symptoms and signs from the complications
of cirrhosis that are discussed next.
What are the 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 accumulates 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 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 release of the pressure. Actually, any type of
pressure, such as from the elastic band of a sock, may be enough to cause
pitting.) The swelling often is worse at the end of a day after standing or
sitting and may lessen overnight as a result of the loss of the effects of
gravity 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. This accumulation of fluid
(called ascites) causes 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 is able to 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. Therefore, infection within the
abdomen and the ascites, referred to as 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 fever, chills,
abdominal pain and tenderness, diarrhea, and worsening ascites.
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 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 usually is severe and, without immediate treatment, can be
fatal. Symptoms of bleeding from varices include vomiting blood (the vomitus can
be red blood mixed with clots or "coffee grounds" in appearance, the latter due to
the effect of acid on the blood), passing stool that is black and tarry 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 also may occur from varices that form elsewhere
in the intestines, for example, the colon, but this is rare. For reasons yet unknown, patients
hospitalized because of actively bleeding esophageal varices have a high risk of
developing spontaneous bacterial peritonitis.
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. These substances then can be absorbed into the body. Some of these
substances, for example, 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.
As previously discussed, 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, the
toxic substances 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 among the earliest symptoms of hepatic encephalopathy.
Other symptoms include irritability, inability to concentrate or perform
calculations, loss of memory,
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 that normally are detoxified by the liver have to be reduced to
avoid a toxic buildup in cirrhosis, particularly sedatives and drugs that are
used to promote sleep. Alternatively, drugs may be used that do not need to be
detoxified or eliminated from the body by the liver, for example, drugs that are
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,
that is, 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 even though some 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. This suggests
that the reduced function of the kidneys is the result of the accumulation of
toxic substances in the blood 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 the 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.
Hypersplenism
The spleen normally acts as a filter to remove older red blood cells, white
blood cells, and platelets (small particles that are 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"
and accumulates in the spleen, and the spleen swells in size, a condition
referred to as splenomegaly.
Sometimes, the spleen is so swollen that 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 (leucopenia), and/or a low
platelet count (thrombocytopenia). The anemia can cause weakness, the leucopenia
can lead to infections, and the thrombocytopenia can impair the clotting of
blood and result in prolonged bleeding.
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. A 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 increased in red blood cell count
(erythrocytosis), low blood sugar (hypoglycemia), and high blood calcium (hypercalcemia).
For more, please read the Liver
Cancer article.
Next: What are the common causes of cirrhosis? »
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