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Liver Cirrhosis

Gastroenterology Hepatology

Liver cirrhosis is a chronic progressive fibrotic disease caused by prolonged liver damage or inflammation. Fibrous tissue and regenerative nodules replace the normal liver structure, gradually losing liver function. Cirrhosis represents the final stage of many chronic liver diseases and may progress to liver failure or liver cancer in severe cases.

Symptoms

Liver cirrhosis in the early stages may present no symptoms, while advanced stages can lead to severe complications such as ascites, hepatic encephalopathy, and liver cancer.

Early Symptoms

Fatigue and weakness.
Loss of appetite, nausea, and weight loss.
Mild discomfort or dull pain in the upper abdomen or right upper quadrant.

Late Symptoms

Jaundice: Yellowing of the skin and whites of the eyes.
Ascites: Abdominal swelling caused by fluid accumulation in the abdominal cavity.
Lower Limb Edema: Swelling in the legs.
Hepatic Encephalopathy: Symptoms include confusion, personality changes, or coma.
Bleeding Tendencies: Due to reduced clotting factors, presenting as gum bleeding or subcutaneous bruises.
Gynecomastia in Males: Enlarged breasts due to hormone imbalances caused by liver dysfunction.
Spider Angiomas: Abnormal dilation of blood vessels visible on the skin.

Causes and Factors

Causes

Viral Hepatitis: Hepatitis B and C are the leading causes of liver cirrhosis in Hong Kong.
Fatty Liver Disease: Closely associated with obesity, diabetes, and hyperlipidaemia.
Alcoholic Liver Disease: Chronic excessive alcohol consumption leading to liver damage.
Cholestatic Diseases: Primary Biliary Cholangitis (PBC). Primary Sclerosing Cholangitis (PSC).
Autoimmune Liver Diseases: Autoimmune Hepatitis (AIH).
Other Causes: Iron overload (Hemochromatosis), Copper metabolism disorder (Wilson's Disease), Drug-induced liver injury or exposure to toxic substances.

Risk Factors

Chronic Viral Hepatitis Infections: Hepatitis B and C infections.
Chronic Alcohol Consumption: Prolonged heavy drinking.
Obesity and Metabolic Syndrome: Increases the risk of fatty liver and its progression to cirrhosis.
Exposure to Hepatotoxic Substances: Certain medications or chemicals that damage the liver.
Family History: Hereditary conditions such as Hemochromatosis or Wilson's Disease.

Diagnosis

Clinical Examination	The doctor will inquire about a history of chronic liver disease, alcohol use, or viral hepatitis infection. Typical signs include jaundice, spider angiomas, ascites, and a shrunken liver.
Blood Tests	Liver Function Tests: ALT (Alanine Aminotransferase), AST (Aspartate Aminotransferase), ALP (Alkaline Phosphatase), Total Bilirubin, and Albumin levels. Coagulation Tests: Prothrombin Time (PT). Viral Markers: HBsAg (Hepatitis B Surface Antigen), Anti-HCV (Hepatitis C Antibody). Other Tests: Ferritin and copper metabolism tests to rule out hereditary conditions.
Imaging Studies	Abdominal Ultrasound: Evaluate liver morphology, degree of fibrosis, and presence of ascites. CT or MRI: Detects liver tumours, portal hypertension, and other complications. FibroScan: A non-invasive test to measure liver stiffness and fibrosis severity.
Liver Biopsy	Used to confirm the degree of fibrosis and cirrhosis, mainly when the cause is unclear.

Treatments

Controlling Underlying Causes

Viral Hepatitis: Use antiviral medications.
Fatty Liver Disease: Adopt lifestyle changes, including healthy eating, weight loss, and regular exercise.
Alcoholic Liver Disease: Complete abstinence from alcohol.
Cholestatic Diseases: Use Ursodeoxycholic acid (UDCA), a naturally-occurring bile acid that constitutes a minor fraction of the human bile acid pool.

Managing Complications

Ascites: Diuretics to reduce fluid retention. Severe cases may require paracentesis (draining fluid from the abdomen).
Hepatic Encephalopathy: Lactulose and antibiotics to reduce toxin absorption.
Esophageal Varices: Beta-blockers to prevent bleeding. Emergency endoscopic interventions (e.g., band ligation or sclerotherapy) in case of active bleeding.
Infections: Prompt antibiotic treatment.

Liver Transplantation

Recommended for end-stage liver disease (complete liver failure) or uncontrollable complications.

In Hong Kong, patients must undergo evaluation and be listed on the transplant waiting list.

FAQ

Early-Stage Cirrhosis (Compensated Stage): If the underlying cause is treated (e.g., antiviral therapy, alcohol abstinence, or lifestyle changes), liver fibrosis may partially reverse. Late-Stage Cirrhosis (Decompensated Stage): Fibrosis is irreversible, but treatment can slow progression and alleviate symptoms. For end-stage liver failure, a liver transplant may be the only viable option.

Low-Salt Diet: Helps reduce fluid retention for those with ascites or oedema. Protein Intake: Adequate protein is necessary to maintain nutrition and prevent malnutrition caused by cirrhosis. Avoid Alcohol: Alcohol exacerbates liver damage and must be completely avoided.

Patients with cirrhosis are at elevated risk and should undergo regular screening every 6 months. Screening Methods: Abdominal Ultrasound: To assess liver morphology and detect tumours. Alpha-Fetoprotein (AFP) Test: Supports liver cancer screening, though a negative AFP result does not entirely rule out liver cancer. Importance of Early Detection: Early detection significantly improves treatment outcomes, while late-stage liver cancer has limited treatment options and poorer prognosis.