Liver Cirrhosis: Causes, Symptoms, and Complications

• Liver diseases include hepatitis, metabolic dysfunction-associated steatotic liver disease (MASLD), hepatocellular carcinoma (HCC), and liver failure.
• Complications from liver disease include cirrhosis, portal hypertension, esophageal varices, and hepatic encephalopathy.

Cirrhosis

• Cirrhosis involves the irreversible replacement of normal liver tissue with non-functional scar tissue.
• The most common cause is alcoholic hepatitis, followed by viral hepatitis (Hep B and Hep C), and metabolic dysfunction – associated steatotic liver disease (MASLD).
• Cirrhosis is twice as common in males.
• Autopsies in the US reveal that 5% of the population has cirrhosis.
• Cirrhosis causes 25,000 deaths per year in the US.
• Without a transplant, a patient usually dies within 5 to 15 years after diagnosis.
• Complications of cirrhosis include portal hypertension, esophageal varices, rectal varices (hemorrhoids), ascites, kidney failure, and hepatic encephalopathy.
• Decreased bile production leads to poor vitamin D absorption (potentially causing osteoporosis) and poor vitamin K absorption (increasing bleeding tendency).
• Splenomegaly results in platelets getting trapped, leading to bleeding and anemia.
• Patients may be asymptomatic for several years.
• Symptoms can be related to declining liver function or portal hypertension.
• Common symptoms include weakness, malaise, fatigue, weight loss, ascites, and loss of appetite.
• Declining liver function leads to reduced bile production, decreased absorption of fat and fat-soluble vitamins, greasy and foul-smelling steatorrhea, fatigue, loss of appetite, weight loss, dark urine (bilirubin buildup), generalized edema, and malabsorption.
• Portal hypertension can cause jaundice, ascites, hepatomegaly, splenomegaly, digital clubbing, caput medusae, spider telangiectasia, and xanthelasma.
• Spider telangiectasia (spider angioma) pathogenesis may be related to elevated levels of vascular endothelial growth factor, fibroblast growth factor, or altered estrogen/testosterone ratio.
• Digital clubbing pathogenesis may be related to elevated levels of vascular endothelial growth factor or fibroblast growth factor, or an altered estrogen/testosterone ratio.
• Caput medusae involves swollen veins around the umbilicus due to portal hypertension, creating varicose veins in the abdominal region.
• Xanthelasma are benign yellow growths on or around the eyelids involving cholesterol deposits.
• Xanthelasma is linked to dyslipidemia, altered lipoprotein profiles, altered fat metabolism, and metabolic disease.
• Other signs and symptoms include sarcopenia, palmar erythema, gynecomastia, testicular atrophy, thinning of armpit hair (less testosterone, more estrogen), and Dupuytren's contracture (fibrosis of the palmar aponeurosis).
• Diagnosis involves medical history, signs and symptoms, physical exam, and blood tests.
• The liver may feel nodular and firm on palpation.
• Advanced imaging (US or CT) and biopsy can confirm the diagnosis.
• Blood tests include liver function tests (LFTs) showing elevated liver enzymes (AST and ALT), elevated bilirubin, and decreased albumin.
• A complete blood count (CBC) may show signs of anemia.
• Blood work can help find the underlying cause, such as Hep B and Hep C serology.
• Treatment includes eliminating alcohol, improving diet and activity (if caused by metabolic disease), and reviewing medications and supplements with a doctor.
• Diuretics and a low-sodium diet may be prescribed.
• A liver transplant may be necessary if liver failure occurs (80-90% liver destruction).
• Massage has no contraindications, but therapists may want to use less pressure to avoid easy bruising.

Portal Hypertension

• Portal hypertension is abnormally high blood pressure in the branches of the portal vein.
• Presentation includes an enlarged abdomen, abdominal discomfort, confusion, and internal bleeding.
• The most common cause is cirrhosis.
• Etiology includes cirrhosis, thrombosis in the portal vein, parasitic infection (schistosomiasis), and malignancy.
• Symptoms arise from the consequences of portal hypertension, such as ascites, telangiectasia, caput medusae, esophageal varices (potentially leading to mass hematemesis), splenomegaly, hepatic encephalopathy (causing drowsiness, confusion, and coma), and gastrointestinal bleeding.
• Diagnosis is based on symptoms, history, and physical exam, and confirmed with ultrasound.
• Most cases are irreversible due to cirrhosis.
• Treatment options include medications to reduce portal blood pressure such as beta blockers and managing complications.
• Emergency treatment, possibly surgery or a bypass shunt, is required if bleeding occurs.
• Massage has no contraindications, but any abdominal massage should be performed with very light pressure to avoid easy bruising and ensure patient comfort.

Esophageal Varices

• Esophageal varices are engorged, tortuous, and fragile varicose vessels of the lower esophagus.
• Etiology includes portal hypertension, where retrograde flow into the lower esophageal vessels causes distention, leading to varices.
• Signs and symptoms include hematemesis (mild to fatal), black, tarry, or bloody stools, and lightheadedness due to blood loss.
• Treatment involves beta-blockers to reduce blood pressure.
• In cases of bleeding, an endoscope is used to confirm bleeding is from varices and banding off/chemical injections of veins are preformed.
• Vasopressin may be given IV to constrict bleeding veins, and transfusions replace blood loss.
• Massage may be a contraindication depending on the severity of esophageal varices.

Hepatic Encephalopathy

• Hepatic encephalopathy is the deterioration of brain function due to the buildup of toxic substances (normally removed by the liver) reaching the brain.
• Ammonia, an end product of normal protein breakdown, plays a large role.
• Etiology lies in portal hypertension (blood bypasses the liver due to increased BP) and liver failure.
• It can be triggered by an alcohol binge, drug intake, or other liver stressors in those with longstanding liver disorders.
• Early stages include subtle changes in logical thinking, judgment, mood, personality, and behavior; late stages include drowsiness, confusion, disorientation, asterixis (flapping tremors), and sluggish movements and speech.
• Uncommon symptoms are agitation and seizures.
• Eventual loss of consciousness and coma are possible.
• Diagnosis is based on symptoms, history, and physical exam.
• CT scan and EEG (electroencephalogram) can be used.
• Blood tests assess liver function and measure ammonia levels.
• Treatment targets identifying and eliminating triggers, reducing protein intake and other dietary restrictions, and using lactulose sugar to decrease blood ammonia.
• Liver treatment addresses the underlying liver issues.
• Prognosis can be reversible with complete recovery possible, but chronic liver failure predisposes to future episodes.
• Acute hepatic encephalopathy is fatal in >50% of cases, and in 80% of people who fall into a coma.

Jaundice

• Jaundice is the presence of excess amounts of bilirubin circulating in the bloodstream, dissolving in subcutaneous fat and causing a yellowish appearance of the skin and whites of the eyes.
• In prehepatic jaundice conditions affect the blood's rate of breaking down blood cells, examples are sickle cell anemia and thalassemia.
• In intrahepatic jaundice, liver tissue becomes less effective at filtering out bilirubin from your blood for example conditions like hepatitis, cirrhosis and hepatocellular carcinoma
• In posthepatic jaundice (obstructive) bilirubin filtered from the blood cant drain properly into the bile ducts or digestive tract to be passed out of the body examples cholelithiasis, pancreatitis and pancreatic cancer
• Signs and symptoms include yellow skin, yellowing of the sclera, yellow color inside the mouth, dark or brown-colored urine, pale or clay-colored stools, and itching (pruritus).
• Massage treatment may or may not be indicated based on the cause and severity of jaundice.