Dr. Victor Emanuel MD

Today, we’re going to talk about CIRRHOSIS OF THE LIVER.  The fact is, if your liver doesn’t live, and live well, neither can you.  What do you expect, after all? It is the largest organ in the body and has a number of functions to keep your body functioning properly.

WHAT ARE SOME OF THESE FUNCTIONS?

•    It removes or neutralizes poisons from the blood.
•    It produces immune cells to control infection.
•    It removes bacteria and other germs from the blood.
•    It makes the proteins that regulate blood clotting, so that you don’t bleed to death from the slightest cut,
•    It produces bile to help absorb fats and vitamins A, D, and E, the fat – soluble vitamins.  Vitamin K is another fat- soluble vitamin, by the way.

I’m giving some importance to cirrhosis of the liver because it is affecting many a person and has killed many more in our little country.  And guess what the main reason is.  You guessed it: ALCOHOL; that which I do not consume, not a drop on my tongue, and implore at every opportunity, others to follow me.  You may want to think about it in  Drug Awareness Month next month, one more time.

SO WHAT IS CIRRHOSIS OF THE LIVER?

Simply put, in this condition, scar tissue replaces normal healthy tissue. When this happens, essentially the architecture of this powerhouse is disturbed.  The consequence of this is that the flow of blood through the organ is blocked, preventing it from working as it should.  Alcohol is not the only cause, though.  Here are some others, below.

CAUSES OF CIRRHOSIS

Just because you know how I feel about alcohol, let me mention one or two facts in its role in cirrhosis.  It causes it to develop after more that ten years of heavy drinking.  It takes different amounts for different people. In women, as few as two or three drinks per day might do it, and in men, as few as three to four drinks per day.  How it does it is by blocking the normal metabolism of your proteins, fats and carbohydrates; you know, your main food groups.

Other causes are:

•    Chronic Hepatitis C.  Hepatitis C is a virus which causes inflammation of and low- grade damage to the liver.  But over several decades, it can lead to cirrhosis.  So really, this would have to infect you from a fairly young age and over the years, do its damage.

•    Chronic Hepatitis B and D.  As far as viruses are concerned, the Hepatitis B virus is thought to be the most common cause of cirrhosis worldwide.  It can be carried in the feces, in blood, and is even transmitted sexually, usually by the homosexual method.  It works like Hepatitis C in the amount of time it takes to cause damage to the liver.  By the way, it can cause cancer of the liver, too, do not forget.  Hepatitis D virus infects only the liver of people who already have hepatitis B; they are partners, they are tight.

•    Drugs, toxins, and infections. Some people react severely to prescription drugs.  Others are exposed for a long time to environmental toxins.  A parasite called Shistosoma which is found in Guadeloupe, where many of us frequent, causes an infection which may affect the liver.  Repeated bouts of heart failure with the liver congestion it causes also occurs in many people in Dominica.  All of these factors can eventually lead to cirrhosis.

•    Autoimmune hepatitis.  The immune system sometimes gets out of control and attacks its own body, including the liver.  Inflammation, damage, scarring, and cirrhosis follow.

•    Inherited Diseases.  There are many of these that interfere with the way the liver produces, processes, and stores enzymes, proteins, metals and other essential substances the body needs for proper functioning.  Wilson’s disease, a disorder of copper metabolism; hemochromatosis, abnormal deposition of iron in many organs, are two I can mention for interest.  Bet you’re saying, “Copper, iron, what are these metals we use in pipes and construction doing in my body?  It’s the Creator’s work, is all I can say.

•    Blocked Bile Ducts. The right and left hepatic (liver) ducts leave the liver as a common duct, after they have joined.  The cystic duct from the gallbladder joins this duct to form the common bile duct, which drains bile into the small intestine, right next to the main duct from the pancreas. If the ducts from the liver carrying bile are blocked, bile backs up and damages liver tissue.  There are one or two relatively rare causes of this, but it has been known to happen after surgery on the gall bladder if the ducts are accidentally tied off or injured.

•    Nonalcoholic steatohepatitis (NASH).  In this, fat builds up in the liver and later causes scar formation.  It seems to be associated with diabetes, obesity, heart disease, protein malnutrition, and treatment with medications like prednisolone.  In each of these categories we have enough in Dominica, so be careful, folks.  Protect your liver.

WHAT ARE THE SYMPTOMS?

In the early stages many people have none at all.  But as more and more scar tissue replaces healthy ones, liver function begins to fail and one may experience EXHAUSTION, FATIGUE, LOSS OF APPETITE, NAUSEA, WEIGHT LOSS, WEAKNESS, ABDOMINAL (STOMACH) PAINS, SPIDER-LIKE BLOOD VESSELS (SPIGER ANGIOMAS) on the skin.

COMPLICATIONS OF CIRRHOSIS

•    Edema and Ascites.  Edema means swelling, and ascites means free fluid in the abdomen.  A lot of men with big tight stomachs have ascites from cirrhosis, no joke.  This happens when the liver loses its ability to make protein.  Osmotic pressure in the blood vessels is low, and water is drawn out of them and accumulates in the legs and abdomen.

•    Bruising and bleeding.  Remember that the liver makes clotting proteins so a person with cirrhosis may bruise or bleed easily.  The palms of the hands may be blotchy and reddish.

•    Jaundice is a yellowing of the skin and eyes when the diseased liver does not absorb enough bilirubin.

•    Itching.  Intense itching may result from bile products being deposited in the skin.

•    Gallstones.  If cirrhosis stops bile from reaching the gallbladder, stones may develop.  Bad news.

•    Toxins in the blood or  brain.  The damaged liver cannot remove toxins from the blood, so they accumulate in the blood and the brain.  The results can be mental dullness, personality changes, and coma, even death.

•    Sensitivity to medication.  Cirrhosis slows the liver’s ability to filter medications from the blood.  These then last longer than expected and build up in the body.  A person will be more sensitive to medications and their side effects.

•    Portal hypertension.  Now, blood from the intestines, the spleen, the pancreas, the gallbladder and its ducts go through the liver via an important vein called the portal vein.  But cirrhosis slows the normal flow of blood through this vein- remember its architecture is all messed up- and pressure is increased within it;  this is portal hypertension.

•    Varices.  Slow blood in the portal vein backs up into blood vessels in the stomach and esophagus, and even the anus / rectal area.  These vessels become enlarged because they are not designed to carry this much blood.  These vessels, now called varices, have thin walls and carry high pressure, and naturally can burst easily.  Serious bleeding and death can occur.  Having mentioned the anus / rectal area, hemorrhoids which bleed can result too.

•    Liver cancer.  Yes, whatever the cause, cancer can develop.  Of course, this kills many.

•    Type 2 Diabetes and insulin resistance.  Cirrhosis causes resistance to insulin.  If you have insulin resistance, your muscle, fat, and liver cells do not use insulin properly.  The pancreas tries to keep up with the demand for insulin by producing more.  But eventually it can’t, and diabetes develops as excess glucose builds up in the blood.

•    Other problems.  Immune system dysfunction, leading to infection. Impotence, enlarged breasts in men, and shrinking of the testicles, because the liver cannot produce enough male hormones; the female one predominate. Kidney failure and osteoporosis (brittle bones) also occur.

HOW IS CIRRHOSIS DIAGNOSED?

On the basis of the information given, the physical examination in which the liver may feel harder and larger than normal, the doctor can safely make the diagnosis.  In some advanced cases, the liver may shrink though.  Ascites is pretty much always there.

Blood tests can be done, and if the liver needs to be looked at, ultrasound, CAT Scan and MRI’s may be done.  Or the liver can be looked at directly with a laparoscope (women know a lot about this).  Or a piece can be taken with a special needle and looked at under the microscope.

HOW IS IT TREATED?

Cirrhosis cannot be reversed, but treatment can stop or delay progression and reduce complications.  If there is a known cause, we can try to treat it, and this is possible in most of the situations mentioned under “causes.” In all cases, a healthy diet and abstinence from alcohol are necessary.  Light physical activity will help stop or delay cirrhosis also.

For complications, measures can also be taken for edema and ascites; a low-sodium (low salt) diet or the use of water-pills may be recommended.  Other measures include:

–    Use of antibiotics for infection.
–    Medications for itching.
–    Eating less protein (they cause toxins to form in the digestive system).
–    Laxatives may help absorb and remove toxins from the intestine.
–    Portal hypertension may be treated with what we call a beta blocker as we use for regular hypertension.
–    Varices require special devices to control bleeding.

When complications cannot be controlled, or the liver is so badly scarred that it stops functioning, a new liver, a liver transplant, is the last resort.  Now you know I’m not talking about Dominica.  But you do know I’m talking about a long waiting list, and plenty of  cash. So people, don’t allow anything to affect your liver, especially alcohol.  It is too precious.

See you next week.

People of the north, Dr. Victor Emanuel will be in Portsmouth on Fridays from 8 am to  3 pm at Bayside Medical Center across from the police station.