Chronic damage to the liver over a long period of time can lead to parts of it becoming scarred and shrunken, while other parts, trying to compensate, grow in the form of nodules (or lumps). So the whole liver, which is normally soft and has a smooth surface, becomes quite hard and lumpy. This is called cirrhosis.
Alcohol abuse in the best-known cause of cirrhosis, but cirrhosis can also develop due to lots of other reasons. Chronic viral hepatitis B and C can lead to cirrhosis. So can autoimmune conditions like primary biliary cirrhosis or primary sclerosing cholangitis (these are diseases where one’s own immune system ends up attacking the liver or the bile ducts). Long-term obstruction to the flow of bile can cause secondary biliary cirrhosis. There are several other possible causes of cirrhosis, which we have not listed here.
Cirrhosis can lead to one or more of the following scenarios:
- Liver failure: End-stage liver disease may show up as jaundice, with abnormal liver function tests and deranged clotting.
- Portal hypertension: The pressure in the portal vein, which brings blood into the liver from the gut, is raised. This leads to enlargement of the spleen (splenomegaly), and opening up of parallel channels of blood flow in the gut (collaterals). The latter may lead to swelling of veins in the lower part of the gullet and in the stomach - these are known as oesophageal or gastric varices. These veins can burst, and bleed into the gut. In the short term , acute bleeding may be dealt with by blood transfusion, medicines to improve the clotting process (clotting factors, plasma, Vitamin K), medicines that may lower the pressure in the portal vein (somatostatin, glypressin etc), compression of the bleeding veins by a tube placed in the gullet (Sengstaken tube), endoscopy to tie off or cauterise the bleeding vein, radiological measures to reduce the pressure in the portal vein (a procedure called TIPPS) or surgery to either decompress the portal vein (a shunt operation) or tie off the bleeding collateral veins (devascularisation, which may involve removal of the spleen and/or division and rejoining of the gullet).
- Ascites: The combination of raised portal pressure and low levels of albumin in the blood can lead to watery fluid collecting in the abdominal cavity. This is called ascites. Treatment involves salt restriction in the diet, and water tablets (diuretics). In some instances, drawing out the fluid (abdominal tap or paracentesis) gives temporary relief. Shunting the blood flow away from the portal vein and reducing the high pressure within it reduces the formation of ascites. This can be done by a surgical shunt operation, a radiological procedure called TIPSS, or a liver transplant.
- Encephalopathy: Chronic liver damage can affect the brain and lead to subtle behavioural changes at first, followed by confusion, delirium and even coma. Treatment of this involves a low-protein diet, and medications (lactulose, lactitol) that change the types of bacteria normally present in the gut.
The severity of liver damage in cirrhosis is often measured by Child’s criteria, and patients are grouped into Child’s Stages A, B and C, with A representing mild liver damage, and C very severe damage.