cirrhosis

Last edited 09/2023 and last reviewed 11/2023

Cirrhosis is a condition that occurs as a response to liver damage

• characterised at a cellular level by distortion of the normal liver structure into nodules of liver tissue surrounded by fibrosis
  • liver cirrhosis is a liver disease in which the normal microcirculation, the gross vascular anatomy, and the hepatic architecture have been variably destroyed and altered with fibrous septa surrounding regenerated or regenerating parenchymal nodules (2)
• usually takes several years for liver damage to develop into cirrhosis and approximately 10-20% of people with 1 of the 3 most common chronic liver diseases (non-alcoholic fatty liver disease, alcohol-related liver disease and chronic viral hepatitis) develop cirrhosis over a period of 10-20 years
• although people may have physical signs of cirrhosis or its complications, such as jaundice, abdominal swelling due to ascites, muscle wasting, and (in male patients) breast enlargement and testicular atrophy, the clinical identification of cirrhosis is imperfect, especially in people with compensated disease
  • 40% of people with cirrhosis have no symptoms of liver disease
• people admitted to hospital with liver disease in England in 2012 were more likely to die compared to all cause admissions (8.8% compared with 1.4%)
  • nearly half of liver disease admissions were for alcohol-related liver disease and 12.3% of these admissions resulted in death

NICE note that there is an increased risk of cirrhosis in people who:

• have hepatitis B virus infection
• have hepatitis C virus infection
• misuse alcohol
• are obese (BMI of 30 kg/m2 or higher)
• have type 2 diabetes

NICE state to:

• offer transient elastography to diagnose cirrhosis for:
  • people with hepatitis C virus infection
  • men and people registered male at birth who drink over 50 units of alcohol per week and have done so for several months
  • women and people registered female at birth who drink over 35 units of alcohol per week and have done so for several months
  • people diagnosed with alcohol-related liver disease

Cirrhosis affects about 2.2 million people in the US (3)

• most common causes of cirrhosis in the US are alcohol use disorder, nonalcoholic fatty liver disease, and hepatitis C
  • leading causes of newly diagnosed cirrhosis in the US are nonalcoholic fatty liver disease and alcohol use disorder
  • reduced incidence of hepatitis C related cirrhosis is due to curative therapies available for this condition
• less common causes of cirrhosis include hepatitis B infection, haemochromatosis, Wilson's disease, primary biliary cirrhosis, alpha 1 antitrypsin deficiency, and autoimmune hepatitis.

Cirrhosis represents the end stage of various chronic diseases that cause diffuse parenchymal damage. It is characterised by fibrosis and conversion of the normal hepatic architecture into structurally abnormal nodules resulting in abnormal vascular relationships - arteriovenous shunts - and portal hypertension

• major cause of complications and deaths in people with liver cirrhosis is due to the development of clinically significant portal hypertension (hepatic venous pressure gradient at least 10 mmHg) (4)

Certain points must be stressed:

• the entire liver is affected - focal injury with scarring does not constitute cirrhosis
• parenchymal injury and consequent fibrosis precede nodule formation - nodule formation without fibrosis does not define cirrhosis
• fibrosis is irreversible

Reference:

• NICE (September 2023).Cirrhosis in over 16s: assessment and management
• Tsochatzis EA, Bosch J, Burroughs AK. Liver cirrhosis. Lancet 2014;383(9930):1749-61
• Walter KL. What Is Cirrhosis? JAMA. Published online July 07, 2023. doi:10.1001/jama.2023.8935
• de Franchis R, Baveno VIF. Expanding consensus in portal hypertension: report of the Baveno VI consensus workshop: stratifying risk and individualizing care for portal hypertension. Journal of Hepatology 2015;63(3):743-52.