What are the different stages of cirrhosis?
Cirrhosis is sometimes called end-stage liver disease. This simply means it comes after the other stages of have damage which can include inflammation (hepatitis), fatty deposits (steatosis) and increased stiffness and mild-scarring of your liver (fibrosis).
Many people with cirrhosis can feel quite well and live for many years without needing a liver transplant. This is because the liver can function relatively well even when it is quite severely damaged.
Cirrhosis is classified as compensated or decompensated.
Compensated cirrhosis is where the liver is coping with the damage and maintaining its important functions.
In decompensated cirrhosis, the liver is not able to perform all its functions adequately. People with decompensated liver disease or cirrhosis often have serious symptoms and complications such as portal hypertension, bleeding varices, ascites and hepatic encephalopathy.
There are also systems for grading cirrhosis according to its severity. One of these is the Child-Pugh score, which uses symptoms including encephalopathy and ascites together with blood test results for bilirubin, albumin and clotting, to grade cirrhosis from A (relatively mild) to C (severe), There are other systems including MELD (model of end-stage liver disease) which are used to help decide which patients most urgently need liver transplants. It uses blood test results for bilirubin, creatinine and clotting (INR).
Cirrhosis: symptoms & diagnosis
You are not likely to feel any symptoms of cirrhosis early on. In fact, many people with cirrhosis only find out during tests for an unrelated illness.
If you have cirrhosis, you have develop one or more of the symptoms below.
- generally feeling unwell and tired all the time
- loss of appetite
- loss of weight and muscle wasting
- feeling sick (nausea) and vomiting
- tenderness/pain in the liver area
- spider-like small blood capillaries on the skin above waist level (spider angiomas)
- blotchy red palms
- disturbed sleep pattern
- intensely itchy skin
- yellowing of the whites of the eyes and the skin (jaundice)
- white nails
- ends of fingers become wider/thicker (clubbed fingers)
- hair loss
- swelling of the legs, ankles, feet (oedema)
- swelling of the abdomen (ascites)
- dark urine
- pale-coloured stools or very dark/black tarry stools
- frequent nosebleeds and bleeding gums
- easy bruising and diffi culty in stopping small bleeds
- vomiting blood
- frequent muscle cramps
- right shoulder pain
- in men: enlarged breasts and shrunken testes
- in women: irregular or lack of menstrual periods
- impotence and loss of sexual desire
- dizziness and extreme fatigue (anaemia)
- shortness of breath
- very rapid heartbeat (tachycardia)
- fevers with high temperature and shivers
- forgetfulness, memory loss, confusion and drowsiness
- subtle change in personality
- trembling hands
- writing becomes difficult, spidery and small
- staggering gait when walking; tendency to fall
- increased sensitivity to drugs, both medical and recreational
- increased sensitivity to alcohol
If you have any of the following symptoms you must see a doctor straight away, especially if you have recently been diagnosed with cirrhosis:
- fever with high temperatures and shivers, often caused by an infection
- shortness of breath
- vomiting blood
- very dark or black tarry stools (faeces)
- periods of mental confusion or drowsiness.
Although these symptoms may seem very different, because your liver is responsible for so many different functions, if it stops working properly, a range of problems can result.
It is not always easy to diagnose cirrhosis. A doctor will take a careful medical history, carry out a physical examination and make plans for further tests.
Some of the tests which may be used for cirrhosis include:
Blood tests which among other things measure the liver function and damage. These are most commonly liver function tests (LFTs). These are used to gain an idea of how the different parts of your liver are functioning.
The liver function test is made up of a number of separate examinations, each looking at different
properties of your blood. It is used to gain an indication of how much your liver is inflamed or unable to work properly. Tl1e test will measure, for example, levels of the liver enzymes ALT and AST as these are increased during inflammation (hepatitis).
It will also look at how well your blood clots (referred to as INR time) and how well your kidneys remove a product called creatinine. These are good indicators for how well your liver is working, and how this is affecting the rest of your body.
Imaging tests in which your liver may be scanned using ultrasound, computerised tomography (CT) or magnetic resonance imaging (MRI).
Ultrasound, the same technology used to confirm all ls well in pregnancy, sends sound waves into your body. The echoes are picked up and used to build a picture of the condition of the liver.
MRI and CT provide a detailed view of your internal organs and are able to generate very detailed cross-sectioned images (or 'slices') of your body area.
Liver biopsy in which a tiny piece of the liver is taken to be looked at under a microscope. A fine hollow needle is passed through the skin into the liver and a small sample is withdrawn. The test is usually done under local anaesthetic and may mean an overnight stay in the hospital, although most people are allowed home later the same day if they live close by.
Endoscopy in which, following sedation, a thin flexible tube wrth a light and a tiny camera on the end (endoscope) is passed down your oesophagus and ,nto your stomach. This is to check for and treat varices in the oesophagus or stomach which may otherwise rupture and suddenly bleed.
Treatment for cirrhosis
Treatment depends on the cause and stage of the cirrhosis. The aim of treatment is to stop the cirrhosis getting worse, to reverse any damage (if this is possible) and to treat any disabling or life-threatening complications.
Making lifestyle changes and cutting alcohol out of your diet may help delay progression.
Many causes of liver disease can now be treated much more successfully than before to stop or at least slow down any decline in the condition of your liver.
This includes treating infections such as hepatitis B or C with new anti-viral medications and autoimmune diseases such as Autoimmune Hepatitis (AIH) with steroid-based drugs. Genetic
Haemochromatosis (GH), an inherited liver disease, can be managed successfully with phlebotomy or venesection, a procedure similar to blood donation in which a quantity of blood is
regularly taken from a vein in your arm.
Until recently, it was thought that a liver with cirrhosis could not be healed. This is usually the case because most diseases that cause scarring of your liver (fibrosis) are long-term and difficult to ‘cure’.However, recent research has shown that it may be possible to heal scarring and even cirrhosis where the liver disease causing this damage is able to be successfully treated.
The treatment of Hepatitis B and C, as already mentioned, gives hope for the development of new drugs to combat scarring of the liver. More research, however, needs to be done before any
new treatments become widely available.
Another aspect of treatment is to deal with the complications of cirrhosis as early as possible. For this reason your doctor may suggest you have regular tests to identify problems even before you notice any symptoms. You may also be given other drugs to reduce blood pressure, to prevent and treat infections and to help support your body’s functions.
Medicines including beta blockers such as propranolol can reduce the risk of bleeding and reduce the severity of any bleed, should it occur. If there is a serious bleed, initial treatment is to replace the fluid and then to identify and correct the cause of bleeding. There are several techniques aimed at stemming the bleeding which involve endoscopy.
One of these is called banding, where a single vein (called an oesophageal varix) is sucked into a ring at the end of the endoscope. A small band is then placed around the base of the varix which will control the bleeding.
Injection sclerotherapy is also used and involves injecting a substance into the veins of the gullet to induce clotting and scar tissue that will help stop the veins from bleeding.
If bleeding can not be stopped by endoscopy, a Sengstaken tube is passed down the throat into the stomach. This device has two balloons which once inflated, put pressure on the varices and help control the bleeding. People are heavily sedated for this procedure.
If bleeding still cannot be controlled a procedure to lower pressure in the portal vein called a transjugular intrahepatic portosystemic stent shunt (TIPSS) may be needed. In this procedure a metal tube (stent) is passed across your liver to join two large veins (the portal vein and hepatic vein). This creates a bypass (shunt) so the blood flows straight into the hepatic vein relieving the pressure which causes the varices.
Ascites (fluid building in your abdominal cavity, appearing like a bulge across your tummy area) and peripheral oedema (swelling in your ankles and legs) are very common in people with advanced cirrhosis. Ascites can be uncomfortable and make it hard for people to breathe and eat normally. In addition, there is a risk of infection in the fluid, called spontaneous bacterial peritonitis (SBP), which can be life threatening and is treated with antibiotics.
The main treatments for ascites and oedema are sodium restriction (low salt diet and diuretics, such as spironolactone and Furosemide). It can be helpful to see a dietitian about how to manage on such a strict diet. Some patients benefit from having the fluid drained off the abdomen with a needle and tube. This usually needs to be repeated every few weeks. Patients considered at higher risk of infection may be offered prophylactic (preventative) antibiotics to take every day.
Many people with cirrhosis experience episodes of hepatic encephalopathy, most at a level where it is not very noticeable. In overt stages (where it is noticeable), it can show up as sleep disturbance, mild confusion, subtle personality changes and slightly poorer performances in tests such as drawing a star and connecting dots. It can also feature problems in movement (called ataxia) and speech, slurring of words, tremor and a particular symptom of fl apping hands when you extend your arms (called asterixis). In some people the sleepiness can progress to a loss of consciousness and even to a coma, where it can be life-threatening.
The main treatment for encephalopathy is lactulose (a sweet syrupy medicine). This not only acts as a laxative but also helps the body remove the toxins that build up in the body when the liver is failing. People are given enough lactulose so that they have one or two loose bowel movements each day. They may also be given other laxatives and/ or an enema. Most periods of encephalopathy are triggered by problems such as an infection, constipation, dehydration, a medicine or a bleed. It is important that patients seek medical advice so the cause of an episode can be identified and treated.
The liver makes products to help blood clot (including clotting factors and platelets) and when the liver stops working effectively, patients can be at risk of severe bleeding. Treatments include administering vitamin K and plasma in medical emergencies. People should seek specialist advice before having medical procedures, including any dental work, and ensure that they treat any cuts that bleed with pressure and bandages and seek medical help.
People with decompensated cirrhosis who are already very ill with problems such as encephalopathy, jaundice and bleeding problems, are at risk of a serious complication called hepatorenal syndrome, which is kidney failure in liver disease. For most patients, a liver transplant is needed, for some urgently.
Some people with cirrhosis develop liver cancer, most commonly hepatocellular carcinoma (HCC). The aim is to detect and treat liver cancer as early as possible.
Treatment can involve cutting out the part of the liver affected by cancer. There are a variety of other treatments aimed at controlling the cancer, including injections of chemotherapy, radio frequency ablation and oral medicines. A liver transplant may be an option for some patients.
If your liver is very badly damaged, a liver transplant may be needed. This is a procedure where a diseased liver is removed during a lengthy operation and replaced with a healthy donor liver.
A liver transplant is usually only recommended if other treatments are no longer helpful and your life is threatened by end stage liver disease. It is a major operation and you will need to plan it carefully with your medical team, family and friends.
Liver transplantation is usually very successful although in some cases it is possible for liver diseases to return and affect your new liver.
Discuss any worries you have about your suitability for treatment with your specialist nurse or doctor and those nearest to you
Anything that leads to the long-term, continuous damage of the liver can cause cirrhosis. These include:
- viral infections such as Hepatitis B and Hepatitis C
- a build up of fat in the liver known as Non-Alcohol Related Fatty Liver disease (NAFLD) that may progress to a more severe condition known as non alcoholic steatohepatitis or NASH
- Autoimmune Hepatitis
- Primary Biliary Cholangitis/Cirrhosis (PBC) and other long-term diseases of the bile ducts such as Primary Sclerosing Cholangitis (PSC) or Biliary Atresia (BA) in children
- certain inherited diseases, such as Haemochromatosis and Wilson’s disease
- long-term contact with some drugs and poisons
- blood vessel (vascular) disease, such as Budd-Chiari Syndrome.
Day-to-day coping strategies
In general, it is best to aim for as near to a normal life as possible. However, there are some points that you should keep in mind to help you feel as healthy as you can.
- Take care of yourself by ensuring enough rest and exercise.
- Follow sensible hygiene measures if your immunity is low.
- Always discuss the use of over-the-counter drugs with your doctor since it is important to avoid some, especially painkillers such as aspirin and ibuprofen, if you have cirrhosis.
- Try to limit your exposure to colds and other infectious diseases.
- Talk to your doctor about having a flu vaccination in the winter months.
- Before travelling abroad, talk to your doctor about whether you should have any vaccinations.
- Join a support group for more information and personal support.
- Take an active interest in your healthcare.
- Gather as much information as you need from charity telephone helplines and their supporting websites.
If you find yourself becoming depressed, talk this over with your doctor who can discuss ways of overcoming this. If appropriate, certain medications can be helpful in helping you cope. Remember that liver function can improve if you take care of yourself and receive early treatment. However, you must ensure that health professionals know you have cirrhosis before giving or prescribing any treatment or medication for you.
It is important to eat well and to include a good balance of foods in your diet including vitamins, minerals and calcium. It is likely you will need extra energy and protein.
Cirrhosis affects your ability to store glycogen, a carbohydrate that gives you short-term energy. This means that your body has to use its own muscle tissue to provide energy between meals and this can lead to muscle wasting and weakness.
If you are affected in this way, snacking between meals is a way you can top up on calories and protein. Another good method is to eat three or four small meals in a day rather than one large protein or carbohydrate-heavy meal.
You may find having nourishing drinks a help. These can include homemade milkshakes or commercially-made products such as Build Up, Complan, Recovery and Nourishment. These are available at most chemists. It is a good idea to check with your doctor or dietician first to make sure they are suitable for you.
Try to avoid salty foods or adding salt to what you eat, to help control fluid retention.
Alcohol and cirrhosis
Almost everyone who drinks too much alcohol will suffer some liver damage, but this does not necessarily turn into cirrhosis. As many as nine out of ten people who drink to excess will develop a fatty liver, with one in ten progressing to cirrhosis.
In general, the more you drink, the greater your chance of developing alcohol related hepatitis or cirrhosis. A poor diet may make the problem worse.
All types of alcoholic drinks can lead to liver disease. If you have cirrhosis – whether it is caused by alcohol or not – you should not drink alcohol at all.
This guideline covers assessing and managing suspected or confirmed cirrhosis in people who are 16 years or older. It aims to improve how cirrhosis is identified and diagnosed. It recommends tools to assess the severity of cirrhosis and gives advice on monitoring people with cirrhosis to detect and manage complications early, and referral criteria for tertiary care.
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