Cirrhosis of the Liver and Portal Hypertension

1. Cirrhosis 

What is Cirrhosis of the liver?
Cirrhosis of the liver is hardening of your liver. It happens slowly over time as healthy liver tissue is replaced with scar tissue. When your liver is damaged, either by disease, excessive alcohol consumption, or another cause, your liver cells work to repair themselves. Scar tissue forms and fibrosis, or the formation of abnormally large amounts of scar tissue, occurs. This is the liver’s attempt to repair and replace damaged cells. 

This scar tissue, though, blocks blood flow through the liver, and slows the liver’s ability to process nutrients and hormones and break down drugs and other toxins. As more and more scar tissue forms it prevents the liver from functioning properly. Once liver damage is done, it’s typically permanent. If caught early, and the cause of the disease is avoided, the progression of cirrhosis may be slowed. However, late-stage cirrhosis is life threatening. Cirrhosis of the Liver increases your risk for developing Liver Cancer substantially. 

What are the causes of Cirrhosis of the liver?
The most common causes of cirrhosis of the liver are:

  • Chronic Hepatitis C and B viral infections, 
  • Alcohol related liver disease, and 
  • Non-Alcoholic Fatty Liver Disease associated with obesity and diabetes. 

Other causes include:

  • Autoimmune diseases (where your immune systems mistakenly attacks healthy liver cells)
  • Hemochromatosis (a genetic disorder where excessive iron is absorbed and deposited into the liver and other organs), 
  • Primary biliary cholangitis and Primary sclerosing cholangitis
  • Glycogen storage diseases (where the body is unable to process glycogen)
  • Alpha-1 antitrypsin deficiency 
  • Wilson's disease (a disorder of abnormal copper storage in the liver)
  • Bile duct blockage
  • Repeated heart failure, with fluid backing up into the liver and causing congestion 
  • Parasitic infections and liver flukes
  • Prescription drugs
  • Environmental toxins

What are the symptoms of Cirrhosis of the Liver?
Symptoms depend on disease stage but may include:

  • Loss of appetite
  • Lack of energy 
  • A generalized feeling of malaise
  • Weight loss or sudden weight gain (especially in the abdomen as fluid or ascites collects)
  • Easy bruising or excessive bleeding
  • Jaundice or yellowing of the skin and the whites of the eyes
  • Itchy skin and other skin changes 
  • Swelling in the ankles, legs, and abdomen
  • Dark urine
  • Light-colored stools
  • Confusion, disorientation, and personality changes
  • Blood in the stool
  • GI bleeding

How is Cirrhosis of the Liver Diagnosed?
Cirrhosis is diagnosed by imaging studies such as CT, ultrasound, MRI, Fibroscan or elastography or by needle biopsy of the liver. Physical exam and laboratory findings will help to confirm the diagnosis. 

How is Cirrhosis of the Liver Treated?

  • There is no cure for Cirrhosis of the Liver. 
  • Treatments are intended to delay disease progression, decrease damage to liver cells, and reduce complications:
    • For cirrhosis caused by alcohol, discontinuing alcohol consumption is essential.  
    • Antivirals and other Hepatitis C medications may slow disease progression in patients with early disease
    • For other causes such as autoimmune diseases, Wilson’s disease, or hemochromatosis, treatment of the underlying disease is essential to delaying disease progression. 
    • Decreasing the amount of salt in the diet may help with fluid retention 
    • Lactulose is a colonic acidifier that works by decreasing the amount of ammonia in the blood. It may help with mental confusion in some patients with advanced disease. 
    • Some people with severe cirrhosis may need a liver transplant. 

What at the complications associated with Cirrhosis of the Liver?

  • Variceal bleeding: Varices are enlarged veins, usually in the esophagus and stomach. 
  • Portal Hypertension: This is an increase in the pressure in the portal vein (the blood vessel that carries blood from your digestive tract to the liver) caused by a blockage of blood flow through the liver as a result of hardening of the liver’s tissues. This increased pressure causes varices to form. These varices become quite fragile and can bleed easily. The liver plays a major role in blood clotting, so as it loses it’s ability to function properly as cirrhosis progresses, clotting blood and stopping this bleeding becomes more difficult. 
  • Hepatic encephalopathy: Toxins (such as ammonia and urea) are normally removed by the liver, but as cirrhosis progresses and the liver loses its ability to function properly, it loses its ability to remove these toxins. Toxins get into the bloodstream and cause confusion, changes in behavior, and even coma. 
  • Liver Cancer: Cirrhosis increases your risk of developing liver cancer significantly compared with the general population 

How can I prevent cirrhosis of the liver?

  • Don't abuse alcohol. 
  • Get vaccinated against Hepatitis B.
  • Discuss treatment options for Hepatitis C early on in your disease course
  • Eat a well-balanced, low-fat diet. 
  • Receive routine preventative medical care. Follow medical recommendations to control obesity, diabetes, high blood pressure, high triglycerides, and high cholesterol. 

2. Portal Hypertension 

What is Portal Hypertension?
Portal hypertension is an increase in the pressure in the portal vein (a large vein that carries blood from your digestive tract to your liver). This increased pressure is caused by a blockage of blood flow through the liver due to hardening of the liver. 

Veins coming from the stomach, intestine, spleen, and pancreas all merge together into the portal vein. This vein branches into smaller vessels then travels throughout the liver. If the vessels in the liver are blocked due to scar tissue, fibrosis, and cirrhotic changes, blood cannot easily flow through the liver. High pressure results. This increased pressure in the portal vein causes large, swollen veins (or varices) to form in the esophagus, stomach, rectum, and umbilical area. These varices become quite fragile and can rupture and bleed and cause life-threatening complications. 

What Causes Portal Hypertension?

The most common cause of Portal Hypertension is Cirrhosis of the Liver, or hardening of the liver caused by Chronic Hepatitis B and C, alcohol abuse, autoimmune disease, fatty liver disease and other causes. In cirrhosis, scar tissue blocks blood flow through the liver.

Other causes of portal hypertension include blood clots in the portal vein, blockages in veins that carry the blood from the liver to the heart, and parasitic infections. 

Who is at risk for Portal Hypertension?
Individuals with liver disease that leads to Cirrhosis of the Liver are at increased risk for developing Portal Hypertension. These conditions include:

  • Alcoholic Liver Disease,
  • Chronic Hepatitis B and C infections, 
  • Non-Alcoholic Fatty Liver Disease associated with Diabetes and High Cholesterol, and 
  • Certain Autoimmune and Genetic Disorders 

What Are the Symptoms of Portal Hypertension?
Symptoms and Complications may include:

  • Gastrointestinal bleeding 
  • Black, tarry looking stools
  • Vomiting blood or coffee ground like material
  • Variceal rupture and bleeding
  • Varices
  • Skin Changes
  • Ascites or fluid accumulation in the abdomen 
  • Swelling in the lower extremities
  • Easy bleeding and difficulty clotting blood due to reduced platelets 
  • Encephalopathy, confusion, and forgetfulness 

How Is Portal Hypertension Diagnosed?
Diagnosis is based on a combination of physical exam findings, imaging studies, endoscopic exam findings, and lab tests. Endoscopy may be used to confirm variceal bleeding. 

How Is Portal Hypertension Treated?
Unfortunately, most causes of Portal Hypertension cannot be treated. Instead, the goal of treatment is to prevent and minimize complications associated with the disease, particularly variceal bleeding. 

Endoscopic treatments for variceal bleeding include banding and sclerotherapy. 

  • Banding is a procedure where a rubber band is used to block off varices and stop bleeding. 
  • Sclerotherapy is a procedure where a blood-clotting solution is injected into bleeding varices to stop bleeding.

Medications like beta-blockers reduce the pressure in varices and reduce the risk of bleeding.

How can Portal Hypertension be prevented?
Prevention is key. 

  • Don't abuse alcohol. 
  • Get vaccinated against Hepatitis B.
  • Discuss treatment options for Hepatitis C early on in the disease course. 
  • Eat a well-balanced, low-fat diet. 
  • Receive routine preventative medical care. Follow medical recommendations to control obesity, diabetes, high blood pressure, high triglycerides, and high cholesterol. 

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