Alcoholic Cirrhosis- Gastroenterology

The liver produces bile, breaks down proteins, and eliminates toxins from the blood. However, heavy drinking over a prolonged period can cause cirrhosis, a condition in which healthy liver tissue is replaced by scar tissue. The liver cannot function properly because of the scar tissue.

Cirrhosis is sometimes referred to as end-stage liver disease because it develops after other phases of liver damage from illnesses like hepatitis..

Even if you have cirrhosis, your liver may still function. Nonetheless, cirrhosis has the potential to progress to liver failure and cause severe, potentially fatal consequences.

Understanding Alcoholic Cirrhosis

In cirrhosis, there is severe scarring (fibrosis) of the liver. Many different types of liver disorders and conditions, including hepatitis and prolonged alcoholism, can contribute to this serious condition.

Your liver attempts to repair itself each time it is damaged, whether the damage results from drinking too much alcohol or another factor, like an infection. However, scar tissue is created during the process. Scar tissue accumulates as cirrhosis worsens, making it difficult for the liver to function correctly. Advanced cirrhosis may be life-threatening.

In most cases, cirrhosis-related liver damage cannot be reversed. However, further damage can be prevented if liver cirrhosis is detected early and the underlying cause is treated. In exceptionally rare cases, cirrhosis may be reversed.

Alcoholic cirrhosis is a severe form of liver disease brought on by excessive alcohol consumption that develops over time. If you have cirrhosis from alcohol, it is likely that your liver has not been working properly for a very long period.

You might have:

1. Steatosis, often known as fatty liver disease, is a condition brought on by excessive fat levels in the liver.
2. Alcoholic hepatitis -a disorder that results in long-term (chronic) liver inflammation brought on by continuing alcohol consumption.
3. Alcoholic cirrhosis-  an advanced form of alcoholic liver disease that makes your liver swollen, stiff, and barely able to function.

A 2019 study found that 20% to 25% of those who abuse alcohol by consuming large amounts of it over a long time may develop cirrhosis. In addition, a quarter of all cirrhosis-related deaths worldwide were predicted to be caused by alcohol in 2019.

Causes Of Alcoholic Cirrhosis

Many factors can contribute to cirrhosis. Yet alcohol misuse, which can develop into alcohol use disorder, is closely tied to alcohol-induced cirrhosis.

Alcohol-related cirrhosis can result from the harmful effects of long-term alcohol abuse. The functionality of the liver declines as the scar tissue develops in the liver. As a result, the body cannot produce enough proteins or adequately filter toxins from the blood.

The National Institute on Alcohol Abuse and Alcoholism defines heavy drinking as having five or more drinks in a single day on at least five days in the previous month.

A standard alcoholic beverage has 14 grams (g) or less of pure alcohol. According to research, patients with cirrhosis caused by alcohol frequently have a history of consuming between 30 and 50 g (about 2 to 3 drinks) and 100 g (7 drinks) per day or more.

Other Risk Factors

Even with reduced alcohol consumption, people with preexisting metabolic disorders or individuals with different genetic backgrounds may be more prone to develop the condition sooner than others.

For instance, if you were born with a deficiency in the enzymes that help remove alcohol, the condition might develop sooner in you. A 2015 study of patients hospitalized with  alcohol-related liver disease found that Hispanics are more likely to develop the condition earlier than African Americans or white people. The symptoms first appear at least four years earlier.

Obesity, a high-fat diet, and hepatitis C can also increase the risk of developing liver disease linked to alcohol use.

In addition, liver illness brought on by alcohol is more common in women than in males. This is because the amount of stomach enzymes needed to break down alcohol particles is lower in females. As a result, the liver can absorb more alcohol and produce more scar tissue.

Symptoms Of Cirrhosis

Alcohol-related fatty liver disease and alcoholic hepatitis frequently appear approximately 4 to 8 years before symptoms of alcohol-related cirrhosis, which commonly occur around the average age of 52.

While the disease is in its early stages, the body can make up for the liver's diminished function. However, the symptoms will then worsen as it progresses.

The symptoms of alcoholic cirrhosis and alcohol-related liver conditions are similar. They consist of the following:

• Portal hypertension (elevated pressure in the veins that supply the liver) can cause abdominal swelling, vomiting blood, and other symptoms
• Itchy skin (pruritus)
• Jaundice
• Spider-like blood vessels on the ski
• Tarry-looking feces and dark urine
• Pale fingernails, especially the index finger and thumbs
• Redness in the palms of the hands
• Decreased strength
• Clubbing of the fingers where the fingertips extend out and take on a rounder shape than usual
• Muscle wasting
• Confusion or brain fog
• Unintentional weight gain or weight loss
• Fainting
• Problems with sleep
• Shifts in the mood
• Bruising or bleeding easily
• Swollen legs (edema) or abdomen(ascites) from fluid buildup
• Loss or absence of periods not related to menopause in women
• Testicular shrinkage, loss of sex drive, or breast enlargement (gynecomastia) in men

When To See A Doctor?

Book an appointment with your doctor if you suffer any of the symptoms listed above.

Diagnosing Cirrhosis

If you have alcoholic cirrhosis, your doctor will evaluate your medical history and do a physical examination to check for signs of chronic liver disease.

Your doctor will also order some tests to support a cirrhosis diagnosis caused by alcohol.

Laboratory Tests

Your doctor may request blood testing to look for signs of liver dysfunction, such as elevated bilirubin levels or certain enzymes. In addition, your blood is examined for creatinine, which assesses the health of your kidneys.

Your provider may also measure your blood count. In addition, you will undergo testing for hepatitis viruses. The international normalized ratio (INR) is another tool used to evaluate your blood's clotting capacity.

Doctors may be able to determine the underlying cause of cirrhosis based on your medical history and the results of blood tests. Blood tests can also be used to determine how severe your cirrhosis is.

The results of these tests could show the following:

• Anemia, or reduced amounts of red blood cells
• Leukocytosis, or increased number of white blood cell
• Increased blood sugar levels.
• Elevated blood ammonia levels
• Decreased sodium levels
• Decreased potassium levels
• Decreased magnesium levels
• Aspartate aminotransferase (AST) values that are two times greater than those of alanine aminotransferase (ALT) indicate a liver injury

A doctor will attempt to rule out other illnesses that may affect the liver to determine whether alcohol-related cirrhosis has developed.

Imaging Tests

You may be advised to undergo certain imaging studies, such as transient or magnetic resonance elastography (MRE). These non-invasive imaging tests check for liver stiffening or hardening. The use of other imaging tests, including MRI, CT, and ultrasound, may also be done.[1] 

Biopsy

A biopsy, or sample of tissue, is not always required for a diagnosis. Nonetheless, your doctor might utilize it to ascertain the severity of the liver damage and what is causing it.

A general practitioner should refer you to a physician who specializes in liver problems (hepatologist) if tests reveal that you have cirrhosis. You might be referred to a specialized liver center if you have cirrhosis complications or are at high risk of developing complications.

If you have cirrhosis, your doctor may advise routine testing to see whether the liver disease has advanced or to look for complications, particularly liver cancer and esophageal varices. In addition, non-invasive tests are becoming increasingly available to monitor liver disease.

Complications

Complications of cirrhosis can include:

Swelling in the abdomen and legs: Edema and ascites are conditions where fluid builds up in the legs and belly due to elevated portal vein pressure. Edema and ascites may also develop if the liver cannot produce sufficient amounts of specific blood proteins like albumin.

Elevated blood pressure in the veins supplying the liver: The normal blood flow through the liver is slowed by cirrhosis. As a result, the vein that delivers blood to the liver is put under more pressure.

Enlargement of the spleen: White blood cells and platelets may become trapped in the spleen because of portal hypertension. This results in the swelling of the spleen, medically known as splenomegaly. The first sign of cirrhosis can be decreased platelets and white blood cells in your blood.

Infections: Your body may have trouble fighting infections if you have cirrhosis. Bacterial peritonitis, a severe infection, can result from ascites.

Bleeding: Portal hypertension causes redirection of the blood flow to the smaller veins. These tiny veins may get strained by the added pressure and rupture, resulting in severe bleeding. Moreover, due to portal hypertension, varices, or enlarged veins, may develop in the esophagus or stomach. There is a chance that the bleeding from these varices could be fatal. Bleeding may continue if the liver is unable to produce enough clotting factors.

Malnutrition: Your body may have a more difficult time processing nutrients as a result of cirrhosis, which can result in fatigue and weight loss.

Jaundice: Jaundice develops as a result of your damaged liver's inability to adequately filter out bilirubin, a blood waste product. Yellowing of the skin, the white part of your eye, and urine are all symptoms of jaundice.

Bone disease: Some cirrhotic patients experience bone thinning and an increased risk of fractures.

Toxins buildup in the brain: Cirrhosis damages the liver, making it less effective in removing toxins from the blood than a healthy liver. Then, as these toxins accumulate in the brain, they might lead to difficulty concentrating and mental confusion. This is known as hepatic encephalopathy, which can eventually lead to coma or unresponsiveness.

Acute on chronic cirrhosis: Occasionally, a person will experience multi-organ failure. Researchers now think that some people with cirrhosis experience this complication. However, they do not completely understand what causes it.

Increased risk of liver cancer: Many people who develop liver cancer already have cirrhosis.

Treatment

The extent and the cause of liver damage will determine how you are treated for cirrhosis. Treatment aims to prevent or treat cirrhosis symptoms and complications while also slowing the development of scar tissue in the liver. You might need to be admitted to the hospital if you have severe liver damage.

Treatment For Underlying Cause

By treating the underlying cause of early cirrhosis, the damage to the liver may be minimized. Here are some treatment modalities.

Treatment for alcohol dependency: Getting the support you or a loved one needs to stop drinking is the first stage of treating cirrhosis brought on by alcohol. Individuals who have cirrhosis caused by alcohol frequently have such high degrees of alcohol dependence that quitting without getting medical help could adversely affect their health. It is crucial to avoid drinking if you have cirrhosis since any amount of alcohol destroys the liver. Therefore, the first step on the road to sobriety might be found in a hospital or treatment center that a doctor can prescribe.

Medications to control hepatitis:  Through specific treatment of hepatitis B or C viruses, medications may prevent further damage to liver cells caused by these viruses.

Drugs to control symptoms: Some medications can treat specific symptoms like pain, itching, and fatigue. Malnutrition due to cirrhosis may be treated with nutritional supplements. Likewise, prescription creams may help with itching.

Extra protein: To help lower their risk of developing encephalopathy, people with alcohol-related cirrhosis frequently need extra protein in specific forms.

Treatment For Complications Of Cirrhosis

Fluid accumulation throughout your body: Ascites and edema may be managed with the help of a low-sodium diet and medications that stop the body from retaining fluid. Procedures to relieve pressure or drain more severe fluid buildup may be necessary.

Portal hypertension: This may be controlled by some blood pressure medications, which can prevent severe bleeding. Your doctor will regularly perform an upper endoscopy to check for potential bleeding and enlarged veins in the stomach or esophagus, known as varices.

You will probably require medication to minimize the risk of bleeding if you develop varices. In addition, you could need a band-ligation procedure if you exhibit symptoms that indicate your varices are bleeding or are likely to bleed. A band ligation can stop the bleeding or reduce its likelihood of continuing. In extreme circumstances, a tiny tube called a transjugular intrahepatic portosystemic shunt may need to be implanted in your vein to lower liver blood pressure.

Infections: You may be prescribed antibiotics or other treatments for infections. Also, your doctor could advise getting immunized against hepatitis, pneumonia, and influenza.

Increased risk of liver cancer: Your doctor will probably advise routine blood tests and ultrasounds to check for signs of liver cancer.

Hepatic encephalopathy: You may be prescribed medications to help decrease the accumulation of toxins in your blood brought on by poor liver function.

Liver Transplant

A liver transplant may be required in extreme situations. Before being considered a candidate for a liver transplant, you must abstain from alcohol for at least six months.

The criteria for receiving a transplant can differ by region, and the evaluation process is rigorous and in-depth. Therefore, your transplant candidacy can be determined based on various criteria, not just your medical requirements.

It could be necessary to examine you using several scoring methods, such as the Child-Pugh scale or the Model for End-Stage Liver Disease (MELD). The Pediatric End-Stage Liver Disease (PELD) method uses a similar grading system for children.

A doctor may use the results from one or more of these severity rating systems when determining how quickly you need a liver transplant. In addition, the results may be used to help prioritize an organ transplant for you if they indicate that your condition is severe.

The lower your name is listed on the transplant list, the longer you might have to wait. Even though your medical needs are the same as those of an older adult, you could have to wait longer if you are a young adult.

According to research, just 10% of those with alcohol-related cirrhosis are recommended for transplantation annually, and only 4% of those with decompensated liver cirrhosis are given a spot on the waiting list. Of these, only 1.2%may actually undergo the transplant. A variety of factors may be responsible for this including, a  shortage of available organs, the difficulty of the procedure, or concerns that you might relapse into alcohol misuse following the transplant.

A history of mental health issues, restricted access to treatment choices, or a lack of social support are some factors that could cause someone to relapse into alcohol abuse after receiving a transplant. You can work with a doctor to help alleviate these problems ahead of time, which may improve your chances of receiving the transplant.

Potential Future Treatments

Researchers are expanding current cirrhosis treatments, but to date, their progress has been limited.  There are numerous potential avenues of intervention because cirrhosis has a wide range of causes and effects. If implemented early, a combination of improved screening, lifestyle modifications, and new medications may improve outcomes for persons with liver damage.

Scientists are working on therapies that precisely target liver cells which may help slow or reverse fibrosis developing into cirrhosis. However, no targeted therapy is  quite ready.

Lifestyle And Home Remedies

If you have cirrhosis, prevent additional liver damage with the following lifestyle and home remedies:

Avoid alcohol: Do not consume alcohol, regardless of whether your cirrhosis was brought on by prolonged alcohol consumption or another illness. Alcohol use may exacerbate the existing liver disease.

Consume low-sodium foods: Your body may retain fluid due to too much salt, increasing swelling in your legs and belly. Instead of using salt for seasoning your food, use herbs. Also, choose already prepared foods that have little sodium.

Eat a balanced diet: Malnutrition can affect those who have cirrhosis. A balanced diet with various fruits and vegetables will help you fight this. Also, pick lean proteins like fish, poultry, or lentils. Never consume raw seafood.

Protect yourself against infections: Fighting off infections is more difficult if you have cirrhosis. Avoid being around sick individuals, and wash your hands frequently to stay healthy. Vaccinate against pneumonia, influenza, and hepatitis A and B.

Be careful when using over-the-counter medications: Cirrhosis makes it more difficult for the liver to metabolize medications. For this reason, before taking any drugs, even over-the-counter ones, consult your doctor. Avoid using ibuprofen (Advil, Motrin IB, others) and aspirin. Your doctor could advise against taking acetaminophen (Tylenol, among others) if you have liver damage, or they might advise you to take it in minimal quantities.

Prevention

By taking the following steps to care for your liver, you can reduce your risk of developing cirrhosis:

Stop drinking: If you have cirrhosis, avoid drinking. Likewise, you should not drink alcohol if you have other liver diseases.

Maintaining a healthy weight: Too much body fat can damage your liver. If you are obese or overweight, talk to your doctor about a weight-loss strategy.

Decrease your risk of hepatitis: Your risk of contracting hepatitis B and C can increase if you share needles and engage in unprotected sex. Inquire about hepatitis immunizations with your doctor.

Ask your healthcare practitioner how you might lower your chance of developing liver cirrhosis if you are worried about it.

Preparing For Your Appointment

A gastroenterologist or hepatologist, both of whom focus on the liver and digestive systems, may be recommended to you if you have cirrhosis. The following details can help you prepare for your appointment and let you know what to anticipate from your provider.

What Can You Do?

• If there are any restrictions, such as dietary restrictions, the day before your visit, be aware of them.
• Describe your symptoms in detail, noting their onset and any potential changes or aggravations they may have undergone over time.
• Make a list of all your medications and any vitamins or supplements you may be taking.
• Note all of your essential medical information, including any other conditions that have been identified.
• Bring the results of previous medical tests, including digital copies of CT, MRI, or ultrasound scans, and any biopsy slides used for a liver biopsy.
• List important personal details, such as any recent changes or stressors in your life.
• Bring along a friend or family member to assist you remember things.
• Prepare a list of questions for your physician.

Questions To Ask Your Doctor

Creating a list of questions helps you make the most of the time in your doctor's office. Some basic questions you should ask the doctor include the following:

• What can be the root of my cirrhosis?
• Can I slow down or stop the damage to my liver?
• What alternatives do I have for treatment?
• Are there any vitamins or medications that could damage my liver?
• What complications-related symptoms and signs should I look out for?
• I suffer from various medical issues. How can I best manage them collectively?

What To Anticipate From Your Physician?

Be ready to respond to questions, such as:

• When did you start to notice symptoms?
• What degree of symptoms do you have?
• Have your symptoms been continuous or only occasionally present?
• What, if anything, helps your symptoms get better?
• What, if anything, do your symptoms seem to get worse from?
• Have you consumed or been exposed to toxic drugs?
• How frequently do you drink alcohol?
• Do liver disease, hemochromatosis, or obesity run in your family?
• Have you had viral hepatitis or jaundice?
• Have you ever used injectable medicines or received a blood transfusion?
• Do you have any tattoos?

Outlook

Your prognosis depends on your general health and whether you have experienced cirrhosis-related complications. Also, it depends on where you are listed on the organ transplant waiting list and whether you are recommended for a liver transplant.

Your odds of a poor outcome rise if you have problems getting the assistance you need to stop consuming alcohol or if you experience abdominal swelling (ascites). You are also more likely to suffer a negative outcome if you are a woman because of how your body metabolizes alcohol.

Medication that might be able to reverse cirrhosis is the subject of continuing research. However, it will probably take some time and a lot of clinical trials before any medicine is successful enough to be released on the market.

Resources

• Mellinger, Jessica L. “Epidemiology of Alcohol Use and Alcoholic Liver Disease.” Clinical Liver Disease, vol. 13, no. 5, Ovid Technologies (Wolters Kluwer Health), May 2019, pp. 136–39. Crossref, https://doi.org/10.1002/cld.806.
• Patel R, Mueller M. Alcoholic Liver Disease. [Updated 2022 Oct 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546632/
• Levy, Robert et al. “Ethnic differences in presentation and severity of alcoholic liver disease.” Alcoholism, clinical and experimental research vol. 39,3 (2015): 566-574. doi:10.1111/acer.12660
• Marroni, Claudio Augusto et al. “Liver transplantation and alcoholic liver disease: History, controversies, and considerations.” World journal of gastroenterology vol. 24,26 (2018): 2785-2805. doi:10.3748/wjg.v24.i26.2785 

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