Alcoholic liver cirrhosis

Definition

Alcoholic liver cirrhosis (Laennec’s cirrhosis) is a pathological process accompanied by the death of hepatocytes and their replacement by connective fibrous tissue due to long-term alcohol consumption. It is manifested by asthenia, exhaustion, dyspeptic symptoms, liver enlargement and jaundice of the skin, signs of liver failure, portal hypertension, and toxic encephalopathy. For diagnosis, a study of the biochemical profile, ultrasound, CT, endoscopic retrograde cholangiopancreatography, or ERCP. The most reliable diagnostic methods are liver biopsy or elastography. Treatment is based on complete withdrawal from alcohol and replacement of lost liver functions; if recovery is impossible, transplantation of part of the organ is performed.

General information

Alcoholic cirrhosis of the liver – the most severe disease affecting patients with chronic alcoholism, characterized by the destruction of hepatocytes, often ending in death within a few years from the appearance of signs of liver failure. It has a more unfavorable course in women because the increased level of estrogen favors more rapid and severe liver damage. When cirrhosis passes to the terminal stage, death occurs within six months in half of patients. If you stop drinking, the condition improves significantly, but a complete cure can only be achieved by liver transplantation. Depressing statistics show that 10 to 50% of patients resume drinking alcohol after liver transplantation.

Causes

The immediate cause of alcoholic cirrhosis of the liver is prolonged alcohol intake. According to studies in modern gastroenterology, cirrhosis affects only 35% of all alcoholic patients. It is known that a combination of several damaging mechanisms is required for the development of severe liver fibrosis. Thus, risk factors for cirrhosis are genetic predisposition, prolonged consumption of even small doses of any alcohol, consumption of fatty and spicy foods, lack of protein and vitamins, and female gender.

Classification

It is accepted to divide alcoholic cirrhosis of the liver into small-nodular, large-nodular, and mixed. The disease is also divided by severity. The compensated stage usually has no clinical manifestations; since the liver can still perform its functions, the diagnosis at this stage can be established only by biopsy.

The subcompensated stage is characterized by the appearance of signs of liver failure both clinically and on examination. At this stage, the damage to the liver tissue is still reversible, and the condition may normalize with the refusal of drinking. The decompensated stage is manifested by liver failure, the most severe condition with alcoholic damage to all organs and systems. At this stage, only organ transplantation can help the patient.

Symptoms of alcoholic cirrhosis

The symptomatology of liver damage depends on the stage of the disease. Usually, at the stage of subcompensation, it does not manifest itself in any way, so the diagnosis at this stage is quite rare. From the onset of fibrosis of liver tissue to the appearance of the first symptoms, it usually takes about five years. Cirrhosis can be suspected only when the liver is enlarged.

At the subcompensation stage, the level of fibrosis becomes critical for the preservation of hepatic functions. The first symptoms begin to appear. The patient notes deterioration of appetite, weight loss, weakness, nausea, and dyspeptic manifestations. The liver increases in size.

At decompensation, the process begins a gradual decline in all hepatic functions. A syndrome complex characteristic of cirrhosis develops. The asthenic syndrome is characterized by rapid fatigue, indifference, loss of appetite, and the development of depression. Gradually develops cachexia – the extreme degree of exhaustion. There is arterial hypotension with tachycardia. Reddening of the nose, cheeks, feet, and palms is characteristic. Parotid glands are enlarged.

Men show signs of estrogen excess: fat is deposited in the abdomen and thighs, legs and arms remain very thin, breasts enlarge, male sex glands atrophy, and infertility develops. The skin and mucous membranes turn yellow; bruises often form on the skin. Fingers appear like drumsticks, and small white strokes appear on the nails. Pathognomonic for this pathology is the development of Dupuytren’s contracture—shortening of the tendons of the palm flexor muscles with loss of their motor function.

Diagnosis

Diagnosis of alcoholic cirrhosis of the liver after the appearance of characteristic symptoms is usually not difficult. Blood is drawn for clinical and biochemical tests. In the blood test, anemia is noted, a decrease in the platelet pool is noted, and leukocytosis may be present. It is necessary to determine markers of viral hepatitis since cirrhotic transformation predisposes to their development. 

In the biochemical analysis of blood, there is an increase in the levels of gamma-globulin, immunoglobulin A, and transferrin. The ratio of AST and ALT is shifted towards AST (normal is equal to one). PGA-index (prothrombin, gamma-glutamyltranspeptidase, apolipoprotein A1) increases – if it exceeds 9, the risk of cirrhosis is almost 90%. Markers of fibrosis (any, not only liver) are determined: laminin, hyaluronic acid, procollagen type 3, collagen type 4, metalloproteinases type 4, etc.; coagulogram parameters worsen.

Instrumental methods of diagnostics are appointed. Ultrasound of abdominal organs assesses the size and structure of the liver, the presence of foci of fibrosis, and the state of the spleen. MRI and CT scans of abdominal cavity organs allow you to make targeted layer-by-layer images and assess the structure of hepatic tissue, hepatic passages, surrounding organs (pancreas, spleen), and vessels. EGD allows you to examine the walls of the esophagus and stomach for varices. ERCP makes it possible to assess the state of hepatic passages and the presence of strictures and stenoses.

Elastography and liver biopsy are the most informative. Elastography is an ultrasound method of investigation that allows us to estimate the amount of connective tissue in the organ and, on this basis, determine the severity of fibrosis. A more invasive technique is percutaneous liver biopsy with subsequent examination of the biopsy specimen.

To accurately assess the severity and severity of cirrhosis, the Child-Pugh scale is used. It evaluates the levels of prothrombin, bilirubin, and albumin and determines the presence of ascites and hepatic toxic encephalopathy. After evaluation of all indicators, a class of cirrhosis is assigned: A (compensated), B (subcompensated), or C (decompensated).

Treatment of alcoholic cirrhosis of the liver

In the treatment of liver fibrosis induced by alcoholism, several specialists are involved: a hepatologist, gastroenterologist, therapist, surgeon, psychiatrist, and narcologist. If necessary, doctors of other profiles are involved. A necessary condition for the successful treatment of cirrhosis is a complete refusal to drink alcohol. The patient is prescribed a therapeutic diet (fifth liver table), rich in protein and vitamins, and a protective regime.

Conservative treatment includes using hepatoprotectors, essential vitamins (A, B, C, E), and corticosteroid hormones. Widespread use has received the administration of ademetionine—this substance can protect liver cells from destruction, stimulate their recovery, improve the outflow of bile, protect the brain from toxins, neutralize toxins, and eliminate depression. Protease inhibitors prevent the formation of connective tissue and have an anti-inflammatory effect.

The treatment of portal hypertension includes drugs that limit blood flow in the area of varicose vessels: pituitary hormones, nitrates, beta-blockers, and diuretics. In addition, lactulose is necessarily prescribed, which improves digestion and the excretion of toxins through the intestine. Treatment of ascites is carried out with the help of antitussive drugs and intravenous administration of albumin. This will contribute to the movement of fluid in the vascular channel and the removal of its excess through the kidneys. 

Surgical treatment of cirrhosis consists of the transplantation of a donor’s liver. To be placed on the transplant waiting list, it is necessary to fulfill a mandatory condition: refusal to drink alcohol for six months. Surgical treatment of complications of liver fibrosis consists of spleen removal, portosystemic or splenorenal bypass, suturing, sclerosing, or ligation of esophageal veins, and balloon tamponade of the esophagus with a Blakemore tube.

All these treatment options are available in more than 150 hospitals worldwide (https://doctor.global/results/diseases/laennecs-cirrhosis). For example, Liver transplantation can be done in following countries:

United States in 9 clinics

Germany in 14 clinics

Israel in 2 clinics

Turkey in 10 clinics.

Prognosis and prevention

Prevention of alcoholic cirrhosis of the liver is a complete refusal of alcoholic beverages, timely treatment of the onset of alcoholic hepatitis, and adherence to a high-protein diet. The prognosis of the disease with a complete refusal of alcohol is more favorable in young people with average body weight, in men, with a timely start of treatment. The higher the class of liver tissue damage on the Child-Pugh scale, the worse the survival rate. In class C, half of the patients die within six months.