Overview

Also known as end-stage liver disease, liver cirrhosis describes the impairment of liver function due to damaged liver tissue being replaced by scar tissue, leading to the liver becoming distorted with nodules. Cirrhosis can be the end-point of many different liver diseases.

The fibrosis can lead to increased intrahepatic resistance, leading to portal hypertension, which causes additional complications such as oesophageal varies, water and salt retention, increased cardiac output, and reduced renal perfusion.

Epidemiology

  • Around 7000 new cases are diagnosed each year
  • Around 30,000 people live with cirrhosis in the UK

Types

Compensated liver cirrhosis

Where cirrhosis is present, but the liver synthetic function is preserved (normal clotting and albumin), and there is no evidence of complications as a result of portal hypertension (ascites, oesophageal varies, variceal bleeding, jaundice etc.).

Decompensated liver cirrhosis

Where cirrhosis is present, but there is evidence of liver dysfunction, such as impaired synthesis (deranged clotting and low albumin), and complications as a result of portal hypertension.

Causes

Many causes of liver disease can ultimately result in liver cirrhosis:

Presentation

Initial features may be non-specific, such as fatigue, malaise and weight loss. Features may be:

  • Ascites:
  • Easy bruising
  • Muscle wasting
  • Oedema – may manifest as lower limb swelling
    • Due to hypoalbuminaemia
  • Examination findings:
    • Leukonychia
    • Palmar erythema
    • Spider naevi
    • Engorged paraumbilical veins (caput medusae)
    • Hepatosplenomegaly
    • Gynaecomastia
  • Other features of decompensated cirrhosis:
    • Jaundice and associated pruritus
    • Haematemesis and/or melaena due to varices
    • Easy bruising
    • Altered mental status

Investigations

  • Liver function tests (LFTs):
    • ALT and AST are increased, however normal ALT and AST do not exclude cirrhosis as a diagnosis
    • Generally speaking, ALT>AST in most liver diseases except for alcohol where AST>ALT
  • Liver ultrasound:
    • Patients with cirrhosis should have a liver ultrasound every 6 months + alpha-fetoprotein measurement to screen for the development of hepatocellular carcinoma
  • Ultrasound-based elastography:
    • A non-invasive method of assessing fibrosis and cirrhosis
  • Liver biopsy:
    • The definitive test, however not always necessary if the features and findings are suggestive of cirrhosis

Scoring

The Child-Pugh score and Model for End-Stage Liver Disease (MELD) scores are used to classify the severity of liver cirrhosis.

Management

Overview

  • 1st-line: treat underlying cause + manage triggers
  • Liver transplantation may need to be considered
  • Patients should have 6-monthly ultrasound scans and alpha-fetoprotein measurements to screen for the development of hepatocellular carcinoma

Patient Advice

  • Patients should avoid alcohol to prevent further progression
  • Patients should have a high-protein diet with no added sodium 

Complications

Prognosis

  • Once cirrhosis has occurred, it is considered irreversible
  • The development of complications is associated with a worse prognosis

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