Liver cirrhosis

Liver cirrhosis means that the healthy cells in the liver are destroyed and gradually replaced by scar tissue. The liver changes from a large, smooth organ to a bumpy and hard mass.

As a result, the liver no longer works properly and loses its functions (production of blood cells, proteins and substances that clot the blood in the body; breaking down medications; removing harmful substances). Because the liver becomes' harder ', there is a higher pressure at the level of the blood vessel system between the intestines and the liver (portal hypertension), which can cause complications and a hospital stay is often necessary.

In an early phase of liver cirrhosis, most patients have no symptoms.

Common symptoms of liver cirrhosis include:

• Red discoloration of the palms (palmar erythema)
• Blood vessels in the skin form a spider-shaped pattern (spider nevi)
• Expanded blue veins on the abdominal wall (collaterals)
• Shaking of the hands (flapping tremor)
• Decreased appetite
• Lack of energy, tiredness
• Yellowing of the skin or whites of the eyes (jaundice)
• Loss of muscle

Complications

• Accumulation of fluid in the abdomen (ascites)
• Varicose veins in the esophagus (esophageal varices) that may bleed.
• Drowsiness and confusion that can sometimes occur suddenly (hepatic encephalopathy). Sometimes this can cause a person to fall into a coma. This is because the toxic substances are not broken down enough.
• Enlarged spleen because there is more blood flow to the spleen (splenomegaly)
• A blood clot in one of the veins that supplies blood to the liver (porta thrombosis)
• Liver cancer (hepatocellular carcinoma or HCC)
• Infections
• Kidney function may be impaired (hepatorenal syndrome)

When something damages the liver, the liver tries to repair itself again. This process causes scar tissue on the liver.

Possible causes of liver damage include:

• Excessive alcohol consumption.
  People who drink a lot of alcohol or who are addicted to it are at risk of developing liver cirrhosis.
• Hepatitis B and Hepatitis C. (link to AZ Delta web pages about HCV and HBV)
  These are viruses that affect the liver. You can get these viruses at birth if the mother was infected, when sharing needles (intravenous drug use), having unsafe sex with people who already have this virus in their blood, etc.
• Fatty liver disease (NAFLD/NASH). (link to the AZ Delta webpage about fatty liver disease)
  This is a condition that mainly occurs in overweight (obese) and diabetes (diabetes) patients.
• There are other causes of liver cirrhosis that are less common, such as certain hereditary diseases (iron storage disease or hemochromatosis), biliary tract disorders (PBC, PSC), taking certain medicines, prolonged exposure to harmful substances, etc.

Blood tests

If you have cirrhosis, blood tests will be needed to identify the cause of the liver cirrhosis and to assess the severity of the liver cirrhosis.

The severity of liver cirrhosis can be calculated in the blood using the following scores:

• Child Pugh classification

This is a type of scoring system for patients with liver cirrhosis. The patients with cirrhosis of the liver are divided into three classes: class A (score 5-6), class B (score 7-9), class C (score 10-15). Patients are assigned to these classes based on how well they function and what complications they have. Class C includes patients with the most severe cirrhosis of the liver.
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This is a calculation for the end stage of liver disease based on the blood results. An estimate of the mortality rate for these patients in the next 3 months is shown. The higher the score, the higher the risk of death. The score can range from 7 to 40. When a patient has a MELD score between 15 and 20, it is checked whether the patient is eligible for a liver transplant.

A blood test involves taking a tube of blood from a vein on the inside of the arm, usually in the crease of the elbow. In order to see and feel this vein properly, a thrust band is pulled tightly around the upper arm. The vein is pricked with a needle so that the blood is drawn into the tube. The needle is used only once and then destroyed.

Radiological examination

Every 6 months, patients with cirrhosis of the liver should either have an abdominal ultrasound (ultrasound) or an MRI scan of the liver. This is necessary because this patient group has a higher risk of developing liver cancer (HCC). On both an ultrasound and an MRI scan, these 'spots' are easy to see when they are there.

Fibroscan

The fibroscan is an examination that measures the stiffness of the liver. The more scar tissue, the stiffer the liver.
A fibroscan is an examination in which a type of ultrasound head is placed between the ribs on the right side of the body (where the liver is located). Tiny shock waves are sent to the liver. The examination takes about 10 minutes and does not hurt.

Stomach exam

Every patient diagnosed with liver cirrhosis needs to have a stomach examination (gastroscopy). This is to detect varicose veins in the esophagus. If left untreated, they can cause major bleeding.

During a stomach exam, a tube is inserted through the mouth. This tube contains a camera and light. This makes it easy to look into the esophagus and stomach and the varicose veins can possibly be treated.

Liver biopsy

A biopsy is taking a piece of tissue from the liver and then examining it further. When the cause of the liver cirrhosis is difficult to find, or when proof is needed to reimburse certain medications, a liver biopsy is necessary. There are two types of liver biopsy:

• Percutaneous liver biopsy: In this biopsy, the doctor pierces the skin, between the ribs, to remove a piece of liver. (link to folder: 0520 1180-NL)
• Transjugular liver biopsy: When there is too much risk of bleeding (e.g. If you take blood thinners (which cannot be stopped, in patients with clotting problems, etc.), a transjugular liver biopsy is chosen. This means that a small piece of liver tissue is removed via your blood vessels.

After both biopsies, the pieces of tissue go to the lab to be further examined. You will receive the results at the next consultation, which will be scheduled shortly afterwards.

Treatment for liver cirrhosis depends on its cause, the severity of the cirrhosis and what symptoms the patient has. If liver cirrhosis is diagnosed at an early stage, recovery of the liver's functions may still occur. Since cirrhosis of the liver should be seen as a chronic disease, a good follow-up of at least every 6 months is necessary.

Treatment of the cause of liver cirrhosis

Some causes of liver cirrhosis can be treated:

• Patients with cirrhosis of the liver caused by excessive alcohol consumption are encouraged to stop drinking it.
• Patients with Hepatitis C and B may take medication to remove the virus from the body (hepatitis C) or suppress the virus in the body (hepatitis B).

Treating symptoms and complications

Reducing the risk of bleeding

Liver cirrhosis can cause the blood vessels around the esophagus to swell and even 'jump', causing bleeding. To prevent this, there are the following options:

• The doctors can prescribe “beta blockers”. This is a type of medication in the form of pills that reduce blood pressure around the liver and thereby reduce the risk of bleeding. One such beta blocker is Inderal®.
• The doctors can do small stretches around the swollen blood vessels via the stomach exam (gastroscopy) so that they can no longer 'jump' and therefore no longer cause bleeding.

Reducing the accumulation of fluid in the abdomen

• Starting pee medication (Lasix®, Aldactone®, Burinex®, etc.) in combination with a low-salt diet that removes excess fluid and is less retained in the body and therefore also in the abdomen.
• Puncturing the belly. Here, the fluid is removed from the abdomen by pricking the abdomen with a needle and letting the fluid drain off.
• TIPS (Transjugular Portosystemic Shunt). This is the placement of a tube that connects the blood vessels to the liver with the blood vessels that drain from the liver. As a result, the liver is' bridged ', as it were.

Treating or preventing infection

People with cirrhosis of the liver are more likely to get an infection, and if they have an infection, they also become sicker than patients without cirrhosis. As a result, these patients often need antibiotics. We recommend that these patients get the following vaccinations to prevent serious infections:

• Annual flu vaccination
• Get vaccinated against pneumonia (pneumococci) every 5 years
• Hepatitis B vaccination

Treating confusion

Lactulose (Bifiteral®) or rifaximin (Targaxan®) can be started so that the patient is less confused. This medication is reimbursed through the health insurance fund.

Diet

Patients with cirrhosis of the liver have different physical dietary needs: malnutrition must be prevented, muscle mass maintained, etc. A brochure with information about this can be found here.

Liver transplant

If there are no other options, a liver transplant can be chosen. To do this, we forward patients to UZ Leuven or UZ Gent.

Prevent

You can reduce your chances of liver cirrhosis by taking the following measures:

• Seeking help with alcohol addiction
• Get yourself vaccinated against hepatitis A and B (there is no vaccine for hepatitis C yet)
• Use clean needles when using drugs through the veins. You can do this, for example, at the MSOC in Roeselare.

Learn more about Liver Cirrhosis here [uptodate.com]
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