Liver Cirrhosis: Symptoms, Course, Treatment

Brief overview

  • Symptoms: General complaints (e.g. tiredness, lack of appetite, weight loss), liver skin signs (reddened palms and soles, itching, jaundice), ascites
  • Causes: Usually alcohol abuse or liver inflammation caused by viruses (hepatitis); sometimes other diseases (e.g. of the bile ducts, heart or metabolism), medication and toxins
  • Diagnosis: Physical examination, blood tests, ultrasound, possibly biopsy and gastroscopy
  • Course of the disease: If left untreated, the disease progresses continuously. Suitable therapy can halt the scarring of the liver tissue.
  • Prognosis: Depends on how advanced the liver cirrhosis already is and whether the cause can be eliminated or treated
  • Prevention: Avoid harmful substances that damage the liver (especially alcohol), hepatitis vaccination

What is liver cirrhosis?

Due to the increasing remodeling of the liver tissue, the organ’s function continues to decline. In the final stage of liver cirrhosis, the liver is ultimately no longer able to adequately perform its tasks as a central metabolic organ. If all liver functions break down, doctors speak of acute liver failure. Liver failure is one of the most common causes of death in liver cirrhosis.

What are the symptoms of liver cirrhosis?

Liver cirrhosis causes various general symptoms such as tiredness, lack of appetite or nausea. There are also signs of the underlying disease. If the liver damage is more advanced, specific liver cirrhosis symptoms also occur.

General symptoms of liver cirrhosis

Liver cirrhosis initially shows no symptoms at all or manifests itself with general symptoms such as

  • Tiredness and poor performance
  • Pressure and a feeling of fullness in the upper abdomen
  • Nausea
  • Weight loss

Specific symptoms of liver cirrhosis

Liver cirrhosis in the later stages is accompanied by specific signs of liver damage. These include, for example, the so-called liver skin signs:

  • “Vascular spiders” (spider naevi): Small, visible vascular branches that spread out in a star or spider shape (especially on the face and décolleté)
  • Reddening of the palms of the hands (palmar erythema) and soles of the feet (plantar erythema)
  • White-colored nails (white nails), raised nails (watch glass nails)
  • Thin, parchment-like skin with shimmering vessels
  • Itching

Hormonal disorders also occur, as the liver no longer breaks down the female sex hormones (oestrogens) properly in the event of damage. This causes the following signs of liver cirrhosis:

  • Men: breast development, loss of abdominal hair (abdominal baldness), shrinkage of the testicles, decrease in sexual desire or potency

Liver cirrhosis: signs of complications

Such complications cause additional symptoms in liver cirrhosis:

Jaundice: In the advanced stage of liver cirrhosis, the liver is no longer able to break down the bile pigment bilirubin. It is deposited in the tissue. As a result, the skin and the sclera of the eye (white of the eye) become yellowish in color. The urine is also often darker, while the stools become discolored.

Liver cell cancer: Liver cell cancer (hepatocellular carcinoma) manifests itself as pressure pain in the right upper abdomen. However, symptoms do not always occur in the early stages. For this reason, all people with liver cirrhosis are screened for hepatocellular carcinoma as a precautionary measure.

  • Stage 1: Sufferers are somewhat drowsy, slightly slower in their reactions and slightly confused. Mood swings, poor concentration and slurred speech also occur.
  • Stage 2: The drowsiness increases. In addition, those affected appear listless (apathetic), have shaky hands (tremor) and their handwriting changes.
  • Stage 4: Due to the failure of the liver, those affected fall into a coma (coma hepaticum). They no longer react to pain stimuli, no longer show any reflexes and the air they breathe has a typical sweet smell (foetor hepaticus).

Esophageal varices

Variceal bleeding in the oesophagus is life-threatening and must be treated by a doctor immediately!

You can read more about this topic in the article Oesophageal varices.

How does liver cirrhosis progress?

Effective therapy primarily involves eliminating or adequately treating the cause of the disease. For example, alcoholics who permanently stop drinking have a comparatively good prognosis for liver cirrhosis. However, liver cirrhosis cannot be cured, as the damage that has already occurred cannot be reversed. Only the progression of cirrhosis can be halted.

Complications of liver cirrhosis further worsen the life expectancy of those affected. Within five years, three out of four people with complications die. Abdominal dropsy in combination with portal hypertension leads to death in half of those affected within two years. Inflammation in the abdomen worsens the prognosis even further.

Causes and risk factors

In industrialized countries, alcohol abuse is the cause of more than half of all cases of liver cirrhosis. In the rest of those affected, cirrhosis can be traced back to liver inflammation (hepatitis B or hepatitis C) or (more rarely) another disease. Sometimes medication also causes the disease.

Liver cirrhosis due to alcohol

As a central metabolic organ, the liver is responsible for breaking down alcohol. This leads to an increase in toxins. They initially cause the liver to store an abnormal amount of fat – a so-called fatty liver develops. At this stage, the changes in the liver tissue are still partially reversible.

Read all about fatty liver here.

The amount of alcohol that leads to liver cirrhosis varies greatly from person to person. In general, even a daily consumption of around 40 grams of alcohol can cause irreversible damage to the liver in men. Women react more sensitively to the stimulant. For them, just 20 grams of alcohol per day may be enough to cause permanent liver damage.

Liver cirrhosis due to viral hepatitis

Other causes of liver cirrhosis

Other causes of liver cirrhosis are much rarer, accounting for around five percent of cases. These include

  • Liver and biliary diseases: For example, immune-related liver inflammation (autoimmune hepatitis), chronic inflammation of the small bile ducts in the liver (primary biliary cirrhosis/cholangitis, PBC), chronic inflammation and scarring of the medium and larger bile ducts (primary sclerosing cholangitis, PSC)
  • Tropical diseases such as schistosomiasis or liver fluke infestation
  • Heart diseases such as chronic right heart failure (cirrhosis cardiaque)
  • Toxic substances such as carbon tetrachloride or arsenic
  • Drugs such as methotrexate (for cancer and autoimmune diseases)

In some cases, no cause for the disease can be found. Doctors then speak of so-called cryptogenic cirrhosis of the liver.

Examinations and diagnosis

Physical examination

Another important indication of liver cirrhosis are the so-called liver skin signs. The doctor checks, for example, whether the palms of the hands are red (palmar erythema), whether “spider naevi” are visible or whether the patient has jaundice (icterus).

Blood test

A blood test can determine the extent of the liver damage. If the following values are reduced, this indicates that the liver is no longer working as well:

  • albumin
  • Coagulation factors II, VII, IX, X (this lowers the Quick value, i.e. it takes longer for the blood to clot)

The following values may be elevated in liver cirrhosis:

  • bilirubin
  • Ammonia (in the case of hepatic encephalopathy)
  • The liver values GOT (ASAT), GPT (ALAT), GLDH and gamma-GT

In patients with portal hypertension, the blood contains fewer platelets and white blood cells.

Imaging methods

Further examinations

In order to detect the structural remodeling into scarred connective tissue, the doctor takes a tissue sample (biopsy) from the liver and sends it to the laboratory for analysis. Sometimes further examinations are indicated. For example, doctors often recommend a gastroscopy for newly discovered liver cirrhosis. This allows varicose veins in the oesophagus or stomach to be detected.

Stages of liver cirrhosis: the Child-Pugh criteria

Liver cirrhosis can be divided into different stages. Doctors use the so-called Child-Pugh score: it takes into account five criteria that give an indication of how advanced the cirrhosis is. The Child-Pugh criteria are

  • Abdominal ascites, assessed by ultrasound
  • Brain damage due to the liver disease (hepatic encephalopathy)
  • Bilirubin concentration in the blood: Bilirubin is a breakdown product of the blood pigment haemoglobin. It is normally broken down further in the liver. In the case of liver cirrhosis, it accumulates in the blood.

The doctor checks each criterion on the patient and awards points for each criterion:

criterion

1 point

2 points

3 points

Albumin (g/dl)

> 3,5

2,8 – 3,5

< 2,8

dropsy

none

little

pronounced

Bilirubin (mg/dl)

< 2,0

2,0 – 3,0

> 3,0

hepatic encephalopathy

none

moderate

pronounced

Quick value (%) or INR

> 70 % or < 1.7

40 – 70 % or 1.7 – 2.3

< 40 % or > 2.3

Liver cirrhosis stages

Based on the stage, the doctor is able to estimate how high the risk of death is for the patient over the next twelve months:

Child-Pugh score

stage

1-year mortality

5 – 6

Child A

3 to 10 %

7 – 9

Child B

10 to 30 %

10 – 15

Child C

50 to 80 %

As the table shows, mortality in the first year of stage Child A is still quite low. However, it increases significantly as the liver cirrhosis progresses.

Therapy

Treating the causes

Every liver cirrhosis therapy involves treating the underlying disease that caused it as well as possible. For example, the doctor prescribes antiviral medication for liver inflammation (hepatitis).

Drugs that suppress the immune system help with autoimmune hepatitis and iron-binding agents with haemochromatosis. In this disease, the liver is affected by the accumulation of excess iron.

Avoiding substances that damage the liver

It is also important for those affected to avoid substances that are harmful to the liver. This primarily includes alcohol. Those affected who regularly consume a lot of alcohol should definitely seek support from relatives, friends and/or self-help groups (such as Alcoholics Anonymous).

Abstaining from alcohol does not only apply to people with alcohol-induced liver cirrhosis, but also to all other people affected.

Treatment of complications

Targeted treatment of complications is also very important. For example, diuretics help to flush out the accumulated fluid. In severe cases of ascites, a so-called puncture may be necessary: This involves the doctor inserting a thin needle into the abdominal cavity to drain the fluid through a tube.

Liver cirrhosis & nutrition

If a special diet is necessary, the doctor treating the patient will discuss this with them. For example, overweight people with a fatty liver should eat a low-fat, low-calorie diet. Together with regular exercise, this helps to lose weight.

It is also advisable for all other people with liver cirrhosis to ensure regular bowel movements in order to support the elimination of toxins via the intestines. A high-fiber diet and an adequate intake of fluids help with this. Patients should discuss with their doctor how much they should drink per day. In certain cases, they should not drink too much fluid, for example in the case of ascites.

Prevention

A hepatitis vaccination can prevent the second most common cause of liver cirrhosis. Such a vaccination is particularly advisable before planned trips abroad.

It is also advisable to be aware of toxic chemicals in the workplace (carbon tetrachloride, benzene, etc.): Company doctors or occupational physicians can provide information about possible dangers and occupational safety measures.