Liver cirrhosis: causes and symptoms

By Cristiano Antonino On Nov 29, 2022

Cirrhosis of the liver is a disease characterised by diffuse alteration of the liver structure, which manifests itself as the end result of processes of necrosis (death of cells or cell groups, tissue areas and portions of the organ) and inflammation in the liver tissue, which are protracted over time and have a multiple genesis

What is cirrhosis of the liver

Cirrhosis of the liver is a chronic, degenerative disease of the liver, characterised by the presence of regenerative nodules (new cells that replace destroyed tissue in the form of nodules) and fibrosis (scarring) as part of a more or less aggressive inflammatory process.

Depending on the size of the nodules, one can classify cirrhosis into micronodular (nodules less than 3 mm), macronodular (nodules greater than 3 mm), or mixed.

The replacement of normal liver tissue with regenerative nodules and fibrotic scars causes a profound alteration of the liver’s microcirculation, making contact and thus exchanges between the blood, rich in nutrients from the intestine, and the liver cells difficult (the contact wall between the cells and the blood vessels thickens and thus the passage of the nutrient-rich blood from the vessels to the cells becomes progressively more complex until it is exhausted).

This process leads to the creation of a vicious circle that causes self-perpetuation and aggravation of cellular damage, with a reduction in the function and consistency (hardening) of the liver and a progressive increase in pressure in the portal vein (vein that conveys blood from the intestine, pancreas and spleen to the liver and general circulation).

The increase in pressure in the portal vein (called portal hypertension), due to the difficulties in the transit of blood through the cirrhotic liver, favours the opening of alternative venous outlets (shunts) and thus the appearance of venous dilatations (varices), which occur mainly in the oesophagus and stomach.

Portal hypertension also leads to congestion of the splenic vein (the vein that connects the spleen with the liver) and the spleen, which is expressed by an increase in its volume (splenomegaly), which in turn causes a sequestration of circulating blood (reduction of white blood cells, platelets and red blood cells – hypersplenism).

Causes of liver cirrhosis

The main causes of cirrhosis are viral infections, alcohol consumption and obesity (excessive consumption of fatty foods).

The viruses known to cause chronic liver damage are hepatitis B virus, hepatitis C virus and Delta virus. All of these viruses are transmitted parenterally, i.e. by contagion with infected blood or more rarely with bodily fluids from infected persons.

The Delta virus is not capable of causing infection on its own, but requires the presence of the hepatitis B virus.

The incidence of B virus infection, and consequently of Delta virus, has been drastically reduced in recent years following the introduction of the hepatitis B vaccination, which is compulsory in pre-school children.

As a consequence of vaccination against the hepatitis B virus, at present, the virus mainly responsible for chronic liver damage has become the hepatitis C virus.

This infection is more frequent in persons over 40 years of age and its prevalence increases progressively with increasing age.

This is due to the use in the past of ‘non-returnable’ glass syringes, inadequately sterilised surgical instruments, haemotransfusions and plasma derivatives (e.g. tetanus immunoglobulin) not tested for hepatitis C virus infection, and in drug-using individuals, the habit of exchanging syringes often infected by a sick person.

These risks are now considered to be steadily decreasing, due to the use of disposable syringes and the introduction of the hepatitis C virus antibody test since 1989.

Therefore, today, C virus infection in young people (under 30 years of age) is limited to risk groups such as drug addicts (due to the promiscuous use of syringes) and individuals undergoing multiple haemotransfusions.

Transmission through sexual intercourse of the hepatitis C virus is extremely rare and therefore there is no obligation to prescribe ‘protected’ intercourse between infected and non-infected individuals.

Transmission of the infection from mother to child at the time of birth (mother-to-child transmission) is also an exceptional occurrence and almost limited to particular risk groups (e.g. HIV-positive mothers).

It is therefore not justified to impose caesarean section on all mothers with hepatitis C virus infection.

A vaccine to prevent hepatitis C virus infection is not yet available.

Liver cirrhosis and alcohol

Alcohol abuse (beer, wine, spirits) is the second leading cause of cirrhosis development in our country.

Prolonged intake (more than 10 years) of at least 45 g of ethanol per day (corresponding to about half a litre of table wine or a litre of beer or a 150 ml glass of spirits) and 90 g of ethanol per day in female and male subjects, respectively, is considered a risk factor for the development of cirrhosis.

However, it should be noted that only 10% of people who drink this amount of alcoholic beverages go on to develop cirrhosis.

This is due to a genetic predisposition and it is likely that individuals with such a predisposition may also become ill after consuming smaller amounts of alcoholic beverages.

It is important to dispel the old myth that people who get drunk easily by drinking alcohol are the ones at risk of liver disease.

On the contrary, the habitual drinker, who is at risk of liver disease, tolerates larger doses of alcohol better without getting drunk.

It is also important to prohibit even moderate intake of alcoholic beverages by people who are already infected with hepatitis B or C viruses, as this has been shown to be responsible for a more rapid progression of liver damage (the damaging effects add up and accelerate the process).

Other less frequent causes of liver cirrhosis are:

genetic haemochromatosis (iron accumulation within the liver);
primary biliary cirrhosis (a disease of unknown cause that develops due to an alteration of the small intrahepatic bile ducts) and primary sclerosing cholangitis;
autoimmune diseases (alterations in immune function involving the formation of abnormal antibodies – autoantibodies – that react against structures in the body);
Wilson’s disease (accumulation of copper within the liver);
certain drugs harmful to the liver and environmental toxins (e.g. carbon tetrachloride or certain pesticides);
the prolonged stagnation of blood in the liver that occurs for example in right heart failure and occlusion of the veins that drain blood from the liver (Budd-Chiari syndrome and veno-occlusive disease);
prolonged obstruction of the outflow of bile from the liver that occurs, for example, in individuals with malformations of the biliary tract (secondary biliary cirrhosis);
metabolic and nutritional diseases such as non-alcoholic steatohepatitis and malnutrition;
rare genetic forms (e.g. alpha-1-antitrypsin deficiency).

Finally, in a small percentage of cases, despite careful research, the causative factor of cirrhosis cannot be identified (cryptogenic cirrhosis).

It is possible that infections with viruses that have not yet been identified are involved in such cases.

Symptoms and diagnosis of liver cirrhosis

Chronic liver diseases, in particular those caused by viruses, do not usually cause the patient any discomfort and give no obvious signs of their presence.

Therefore, the diagnosis of patients with non-advanced cirrhosis in a presumed healthy subject is mostly occasional and directed by laboratory investigations, performed routinely, or by the medical examination.

The main test changes indicative of cirrhosis are changes in the blood count, in particular a reduction in platelet count (below 100,000/mlmc) associated or not with a reduction in white blood cells and red blood cells (hypersplenism).

Increased transaminases are not a sign of the severity of liver disease, being predominantly normal in patients with very advanced liver damage.

The main signs that on medical examination may point to the diagnosis of cirrhosis are:

the reddening of the palms of the hands (palmar erythema)
the appearance on the skin (especially on the arms, face and chest) of small red ‘spider’ skin spots (spider nevi)
an increase in the size of the liver and irregularity of its margin
an increase in the volume of the spleen.

In advanced forms of cirrhosis other more easily detectable signs are the reduction of muscle masses, fluid accumulation in the subcutaneous tissue (swelling of the ankles) and inside the abdomen or ascites (manifested by expansion of the abdomen), diffuse itching without obvious skin lesions, yellowish colouring of the sclerae and/or skin and the emission of dark urine (due to increased bilirubin).

Therapies to be implemented are essentially based on lifestyle modification, controlled weight loss and treatment of coexisting conditions such as diabetes.

Useful tips for the prevention of hepatitis viruses

Regarding general hygiene rules for the prevention of transmission of hepatitis B, Delta and C viruses, it is recommended for those with the infection to avoid the personal use of toileting implements that may become soiled with blood, such as manicure equipment, toothbrush, razor.

It is important that a person who knows he or she has a hepatitis virus infection reports it when visiting the dentist or undergoing surgery.

On the other hand, it is pointless to completely isolate patients with hepatitis virus infection by personalising the use of dishes and limiting emotional contacts (e.g. kissing).

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