Cirrhosis of Liver

Prof JC Sanasam *

Abdominal computed tomography of a 3 year old child showing liver cirrhosis in transverse section :: Pix - Wikipedia/Christaras A

As cirrhosis advances, more and more scar tissue (damaged tissue) forms in the liver, then the damage becomes irreparable. Normal liver cells, once damaged severely, fibrous scar tissue replaces them; they do not heal up again; the damage becomes irreversible. Clinicians unanimously agree that regular, long term heavy drinking is the commonest cause of cirrhosis in Manipur. Generally speaking, it takes ten years for a heavy drinker to develop cirhhosis; but those who drink local brews, which contain high levels of fatty acids, develop cirhhosis much sooner from six months to three years.

Cirrhosis is a chronic (long term persistent) liver disease of various causes (most commonly, prolonged and excessive alcohol consumption in Manipur) that damage the liver cells characterised by weakness, fatigue, loss of appetite and bodyweight, ascites (tummy filled with fluid to become heavy and protuberant) and terminally hepatic failure (liver failure) and hepatic coma (unconsciousness).

Symtoms and signs

In the early stages of cirrhosis, symtoms may not appear at all whereas damage has already started to take place in the liver tissue. However, as the scar tissue increases and normal healthy tissue decreases, signs and symptoms will start manifesting gradually. Blood capillaries sembling thin wiry or thready red worms may be visible on the skin of the upper abdomen; fatigue, insomnia, itchy skin, loss of appetite, loss of weight, nausea (vomiting sensation), pain or sensation of fullness in the upper abdomen, more so on the right side may appear.

In later stage weakness, ascites (large tummy filled with fluid), accelerated heartbeat, altered personality (as blood toxins build up and affect the brain), bleeding gums, body and upper arms losing mass, confusion, dizziness, fluid build-up on ankles, feet and legs (edema), hair loss, higher susceptibility to bruising, jaundice, loss of libido (sex drive), memory problems, more frequent fevers (susceptibility to infection), muscle cramps, nosebleeds, panting (breathlessness), dark or pale discoloration of stool, darker urine, vomiting of blood: a series of disorders, before terminal hepatic failure and coma, is likely to follow one after another.

Normal tissue of liver, its destruction and disturbed function concisely

The liver is an important organ in the body. It performs many critical functions, two of which are: producing substances required by the body e.g., clotting proteins that are necessary in order for blood to clot; and the other is removing toxic (harmful) substances like drugs. Another important role is regulating the supply of glucose (sugar) and lipids (fat) that the body uses as fuel.

For this, the liver cells must work normally and have an intimate relationship with the blood because the blood has to transport substances, which the liver adds or remove, to and from the organ itself. This relationship is unique. In fact, the liver, the largest organ in the body though, receives only a small amount of arterial blood as compared to other organs.

Most of the liver's supply of blood comes from the intestinal veins on the pathway of the blood's return to the heart. The name of the main vein that returns blood from the intestines is the portal vein. As the portal vein passes through the liver, it breaks up into increasingly smaller and smaller veins. The tiniest veins (called sinusoids because of their unique structure) are in close contact with the liver cells.

In fact, the liver cell line up along the length of the sinusoids. This close relationship between the liver cells and blood from the portal vein allows the liver cells to remove and add substances to the blood. Once the blood has passed through the sinusoids, it collects in increasingly larger and larger veins that ultimately form a single vein onwards, the hepatic vein, which returns the collected blood to the heart.

Cirrhosis is a result of the destruction of this relationship between blood and liver cells. Even though the liver cells that survive or are newly formed may be able to produce and remove substances from the blood, they no longer have the normal, intimate relationship with the blood; and this interferes with the liver cells' ability to add or remove substance from the blood. The scarring of liver tissues also causes obstruction of blood flow through it.

In this way, the blood in the portal vein gets stagnant whereas the amount of returning blood keeps increasing; this results to the increase of pressure in the portal vein, complicating into portal hypertension. This is a serious condition. Because of obstruction in its normal path, blood in the portal vein seeks other veins with lower pressure, veins that bypass liver, to empty out and reach the heart. Then the liver becomes unable to perform its important function of transportation and detoxification that ultimately leads to many of the manifestations of cirrhosis.

One more disorder that creates problem, associated with cirrhosis, is the disturbed relationship between the liver cells and the channels, through which bile flows. Bile, a fluid produced by liver cells, has two important functions: helping digestion, and removal and elimination of toxic substances from the body.

Bile has to reach intestine for digestion, it collects into tiny channels called canaliculi, which empty into small ducts then to larger ducts, which ultimately form the final large duct called hepatic duct, which drain into the intestine for digestion. The toxic products in the bile at the same time get collected into the stool in the intestine, which is defecated. Diseases causing cirrhosis destroy these canaliculi, make the liver unable to detoxicate.

Cirrhosis is a result, a complication, of various diseases caused by chemicals such as alcohol, fat, and certain hepato-toxic (toxic to liver) medications, viruses, toxic metals like iron and copper that may accumulate in the liver due to certain autoimmune disorder that attacks the liver. These diseases injure and kill liver cells.

Repair takes place among the inflammed cells that did not die; they multiply (increase their numbers) to replace the dead cells. These newly formed cells form clusters called regenerative nodules; but the surrounding constricting scar tissue formed by the dead cells smother the function and physiology of the new cells making them unable to do anything.

Ultimately, the liver tissue remains irregular with hard nodules; physicians can feel these nodules during clinical examination, and medico-legal doctors and pathologists can see these swellings over the external surface of liver during a post-mortem examination. Normally liver tissue is soft and its external surface is smooth.