Chronic Liver Disease
Complications of Cirrhosis
Non-Alcoholic Fatty Liver Disease
Viral Hepatitis
 

Complications of Cirrhosis

FluidOverload:
Fluidaccumulateswithintheabdomen(ascites)andonthe legs(pedaledema).
Thisisduetoboth increasedpressureinsidetheliverandbecauseofthedecreased
productionofproteins(especiallyalbumin)bytheliver.Treatmentisusuallywith
medicationstohelplosetheretainedsodoumandwater,orbydrainingthefluid
withaneedle.Thehigherthedietarysaltintake,thehigherthelikelihoodof
developingfluidoverload.Thus,patientswithcirrhosisandfluidoverloadareoften
restrictedto2g/dayofdietarysodium.
Partofthepathophysiologicmechanismbehindfluidaccumulationinthesetting
ofcirrhosisisduetoanalterationintherenin-angiotensin-aldosteroneaxis,and
therefore,medicaltreatmentistargetedtowardscombattingthis.Thus,patients
withascitesorpedaledemaareoftenstartedonspironolactoneincombinationwith
furosemide.Thespironolactone,ananti-mineralocorticoidagent,workswellin
patientswithcirrhosis,butisrequiredtobeusedinhigherdosesthaninpatients
withheartfailure.Aswell,thecombinationofbothaloopdiuretic(furosemide)and
anti-aldosterone(spironolactone)ismoreefficaciousthaneitherdiureticalone.
Thus,these2medicationsareusedtogether,with100mgofSpironolactonebeing
usedwith40mgofLasix.Thetwodrugsarethentitrateduptogethertomaintain
thisratio,barringanycomplicationsorelectrolyteabnormalities.
Hepaticencephalopathy:
Normally,theliverdetoxifiesthevarioustoxinsthatarebothproducedbythe
bodyandingested(usuallyasmedications).Inthesettingofliverfailure,or
cirrhosis,theliverisnolongerabletodothis,andthetoxinsbuildupinthe
bloodstreamandcrossoverintotheliver.Patientswithencephalopathycanhave
problemswithdecreasedconcentration,excessivefatigue(sleepingalot),confusion,
orevencoma.Oneofthesetoxinsisammonia.Hepaticencephalopathycanbe
precipatedbymedications(anysedatingmedications,suchasnarcotics,
benzodiazepines,orneuroleptics),infections(especiallyspontaneousbacterial
peritonitis,UTI,orURTI),constipation,renalfailure,orelectrolyteabnormalities.
Treatmentisaimedattreatingtheprecipitatingcauseandsimultaneousremovalof
theammonia.Lactuloseservestodrawammoniafromthebloodstreamintothe
colon,andthenstimulatescolonicmotilitytoexpeltheammoniafromthebody.
Thus,lactuloseactsasmorethanasimplelaxative.
VaricealBleeding:
Astheamountofscarringintheliverincreases,itbecomesmoredifficultforthe
bloodtoflowthroughtheliver,anditstartslookingforother,lowerresistance
routesthroughwhichtoflow.Thisleadstothedevelopmentofvarices,both inthe
esophagusandstomach,aswellaselsewhere.Astheseveinsgetbigger,theyareat
riskforburstingandbleeding.Ifthisoccurs,itcanbecatastrophic,andmayleadto
death.Inordertopreventthisfromoccurring,thereare2methodsoftreatment.
Thefirstistodecreasethepressureintheportalsystem,whichcanbeachieved
throughtheadministrationofnon-selectivebeta-blockerssuchasNadololorarvedilol.Anothermethodofvaricealtreatmentisthroughendoscopicligationor
gluingofthevarices.Whichofthesemethodsisusedtocontrolthevaricesisbased
ontheseverityofthepatient’sliverdisease,thesizeoftheesophagealvarices,and
whetherthereareanyhighriskfeaturesseenendoscopicallytoindicatewhether
thevaricesareathigherriskforruptureandbleeding.Onceapatienthasbeen
banded,theyarethenplacedintoabandingprogram,wheretheyarebroughtback
totheendoscopysuiteforbandingevery4weeksuntilthevariceshavebeen
completelyeradicated.
Jaundice:
Astheliverbecomeslessandlessabletofunction,patientsmaystarttodevelop
yellowingofeithertheskinortheeyes,whichisduetothebuild-upofbilirubinin
theblood(bilirubinisnormallyexcretedintotheintestinesbytheliverviathebile
ducts,andfromthere,intothestool). Althoughthiscanbeseeninacutehepatitis,in
patientswithpre-existingliverdisease,thedevelopmentofjaundicecanindicatean
acuteflareoftheirunderlyingdisease,orworseningliverfunction.
LiverCancer:
Havingcirrhosisisariskfordevelopinglivercancer(hepatocellular
carcinoma,orHCC).Ifthisdevelops,thereareanumberofdifferentoptionsfor
treatmentofthecancer,basedonhowwellyourliverisfunctioning,anditssize.
Pleaserefertothe“LiverTumour”sectionforfurtherinformation. Allpatientswith
cirrhosisshouldundergoascreeningprogramwithanabdominalultrasoundevery
6monthsaspartofHCCsurveillance.

                     Normal Liver                                                                                           Cirrhotic Liver

Fluid Overload:

Fluid accumulates within the abdomen (ascites) and on the legs (pedal edema). This is due to both increased pressure inside the liver and because of the decreased production of proteins (especially albumin) by the liver. Treatment is usually with medications to help lose the retained sodoum and water, or by draining the fluid with a needle.  The higher the dietary salt intake, the higher the likelihood of developing fluid overload. Thus, patients with cirrhosis and fluid overload are often restricted to 2g/day of dietary sodium.

Part of the pathophysiologic mechanism behind fluid accumulation in the setting of cirrhosis is due to an alteration in the renin-angiotensin-aldosterone axis, and therefore, medical treatment is targeted towards combatting this. Thus, patients with ascites or pedal edema are often started on spironolactone in combination with furosemide. The spironolactone, an anti-mineralocorticoid agent, works well in patients with cirrhosis, but is required to be used in higher doses than in patients with heart failure. As well, the combination of both a loop diuretic (furosemide) and anti-aldosterone (spironolactone) is more efficacious than either diuretic alone. Thus, these 2 medications are used together, with 100mg of Spironolactone being used with 40 mg of Lasix. The two drugs are then titrated up together to maintain this ratio, barring any complications or electrolyte abnormalities. 

Hepatic Encephalopathy:

Normally, the liver detoxifies the various toxins that are both produced by the body and ingested (usually as medications). In the setting of liver failure, or cirrhosis, the liver is no longer able to do this, and the toxins build up in the bloodstream and cross over into the liver. Patients with encephalopathy can have problems with decreased concentration, excessive fatigue (sleeping a lot), confusion, or even coma.  One of these toxins is ammonia. Hepatic encephalopathy can be precipated by medications (any sedating medications, such as narcotics, benzodiazepines, or neuroleptics), infections (especially spontaneous bacterial peritonitis, UTI, or URTI), constipation, renal failure, or electrolyte abnormalities. Treatment is aimed at treating the precipitating cause and simultaneous removal of the ammonia. Lactulose serves to draw ammonia from the bloodstream into the colon, and then stimulates colonic motility to expel the ammonia from the body. Thus, lactulose acts as more than a simple laxative.

Variceal Bleeding:

As the amount of scarring in the liver increases, it becomes more difficult for the blood to flow through the liver, and it starts looking for other, lower resistance routes through which to flow. This leads to the development of varices, both in the esophagus and stomach, as well as elsewhere. As these veins get bigger, they are at risk for bursting and bleeding. If this occurs, it can be catastrophic, and may lead to death. In order to prevent this from occurring, there are 2 methods of treatment. The first is to decrease the pressure in the portal system, which can be achieved through the administration of non-selective beta-blockers such as Nadolol or Carvedilol. Another method of variceal treatment is through endoscopic ligation or gluing of the varices.  Which of these methods is used to control the varices is based on the severity of the patient’s liver disease, the size of the esophageal varices, and whether there are any high risk features seen endoscopically to indicate whether the varices are at higher risk for rupture and bleeding. Once a patient has been banded, they are then placed into a banding program, where they are brought back to the endoscopy suite for banding every 4 weeks until the varices have been completely eradicated.

Jaundice:

As the liver becomes less and less able to function, patients may start to develop yellowing of either the skin or the eyes, which is due to the build-up of bilirubin in the blood (bilirubin is normally excreted into the intestines by the liver via the bile ducts, and from there, into the stool). Although this can be seen in acute hepatitis, in patients with pre-existing liver disease, the development of jaundice can indicate an acute flare of their underlying disease, or worsening liver function. 

Liver Cancer:

Having cirrhosis is a risk for developing liver cancer (hepatocellular carcinoma, or HCC). If this develops, there are a number of different options for treatment of the cancer, based on how well your liver is functioning, and its size. Please refer to the “Liver Tumour” section for further information. All patients with cirrhosis should undergo a screening program with an abdominal ultrasound every 6 months as part of HCC surveillance.

Giving
Patient Resources

Referring Physicians