What is Chronic Liver Disease (Longterm Liver Disease)?
Chronic liver disease (CLD) describes the gradual worsening of liver functions over a period of more than six months. These functions include the creation of clotting factors, detoxification of harmful substances, and bile production. This disease continually causes inflammation and damage to the liver, while also causing the liver to repeatedly try to repair itself. This cycle leads to scarring and cirrhosis, or severe liver damage.
There are many causes of chronic liver disease, including toxin exposure, long-term alcohol abuse, infections, autoimmune diseases, and genetic or metabolic disorders. Cirrhosis is the final stage of chronic liver disease and leads to a significant disturbance of the liver’s structure, formation of widespread nodules, changes in blood vessels, and an increase in extracellular matrix – the non-cell part of tissues.
On a cellular level, the process of scarring and cirrhosis involves the activation of special cells, called stellate cells and fibroblasts, which results in fibrosis. Meanwhile, attempts at liver regeneration are reliant on specific stem cells. Chronic liver disease is a very common health issue, and it is crucial to focus on understanding the common causes, signs and symptoms, and treatment strategies.
What Causes Chronic Liver Disease (Longterm Liver Disease)?
Common causes of chronic liver disease include:
Alcohol-related liver disease: This ranges from alcoholic fatty liver disease, which may include inflammation due to excessive alcohol consumption, to irreversible scarring of the liver, known as cirrhosis. Severe alcohol use disorder is the most common reason for chronic liver disease.
Non-alcoholic fatty liver disease: This condition is often linked to obesity, high cholesterol, and diabetes, forming a condition known as metabolic syndrome. Some people with this disease can develop non-alcoholic steatohepatitis, which leads to scarring of the liver. Risk factors of metabolic syndrome can make the condition worse.
Chronic Viral Hepatitis: Chronic hepatitis B, C and D are the most common causes of chronic liver disease in East Asia and Africa. In Europe and America, certain genotypes of Hepatitis C are more common. Untreated hepatitis C can lead to liver cancer.
Hereditary causes: There are specific genetic disorders that cause chronic liver disease such as Alpha-1 antitrypsin deficiency in children and Hereditary hemochromatosis, an inherited disorder that results from excessive iron being absorbed from food leading to damage and scarring of the liver. Wilson disease is another genetic disorder that leads to copper accumulation in the liver.
Autoimmune causes: In some rare cases, the body’s immune system attacks the liver, causing damage and scarring. This condition, known as autoimmune hepatitis, is more common in women. Other conditions include primary biliary cirrhosis, which most often affects middle-aged women and results in the destruction of the liver’s bile ducts, and primary sclerosing cholangitis, often linked with a bowel disorder known as ulcerative colitis, which causes inflammation and scarring of the bile ducts.
Other causes: Certain medications like amiodarone, isoniazid, methotrexate, phenytoin, nitrofurantoin, and conditions like Budd-Chiari syndrome, a rare liver condition, can cause chronic liver disease. Some instances of chronic liver disease do not have a clear cause.
Risk Factors and Frequency for Chronic Liver Disease (Longterm Liver Disease)
Chronic liver disease is a leading cause of death, particularly in developing countries. The number of people suffering from this condition has been rising. Most cases in developed countries like the United States are a result of conditions such as alcoholic liver disease, chronic viral hepatitis (including hepatitis B and C), non-alcoholic fatty liver disease (NAFLD), and Hemochromatosis. According to a 2017 report by the Center for Disease Control and Prevention, about 4.5 million adults in the US had chronic liver disease and cirrhosis, accounting for 1.8% of the adult population. This same report stated there were over 41,000 deaths from this condition that year.
- Chronic liver disease is a main cause of death, particularly in developing countries.
- The number of people affected by this condition has been increasing.
- In developed countries, common causes are alcoholic liver disease, chronic viral hepatitis (including hepatitis B and C), non-alcoholic fatty liver disease (NAFLD), and Hemochromatosis.
- In the United States, about 4.5 million adults, or 1.8% of the adult population, have chronic liver disease and cirrhosis according to a 2017 report.
- In 2017, over 41,000 people in the US died from chronic liver disease and cirrhosis.
Signs and Symptoms of Chronic Liver Disease (Longterm Liver Disease)
Chronic liver disease (CLD) can create various symptoms which may be generic such as tiredness, loss of appetite, and weight loss. These symptoms rely on the complication that the patient has developed. The three main complications arising from CLD are due to increased pressure in the liver’s blood vessels (portal hypertension), insufficient liver cells (hepatocellular insufficiency), and liver cancer (hepatocellular carcinoma). Depending on the severity of CLD, different complications can occur.
Portal Hypertension
Portal Hypertension is a condition where there’s high blood pressure in the liver’s blood vessels due to reasons like liver cirrhosis. When this pressure exceeds 12mmHg, it can lead to complications such as:
- Esophageal varices: This condition, which can cause black stool or bleeding in the upper digestive tract, is a result of high blood pressure in the liver’s vessels leading to esophageal or gastric varices. Such bleeding is a dangerous complication of CLD.
- Ascites: This condition is the collection of fluid in the abdominal cavity due to high blood pressure in the liver’s vessels, decreased protein levels that maintain water in the bloodstream and blood vessels in the abdomen dilating. In later stages of cirrhosis, patients may develop ascites. Symptoms include a swollen abdomen, a shifting feeling when leaning to one side, and a sense of a wave of fluid in the abdomen when tapped. Severe ascites can cause difficulty breathing or early feelings of fullness when eating.
Hepatocellular Insufficiency
In patients with liver cirrhosis, harmful substances like ammonia build up because the liver isn’t clearing them out efficiently, which can lead to a brain disorder called ‘Hepatic Encephalopathy’. Around 50% of patients with severe chronic liver disease can develop this condition. Grades for the severity of hepatic encephalopathy include:
- Grade 0: Minimal changes in memory, coordination, intellectual function, concentration, but normal mental status.
- Grade 1: Short attention span, inability to do basic addition or subtraction tasks, and altered sleep rhythm.
- Grade 2: Contains changes such as lack of energy, disorientation to time, altered behavior, and inability to perform certain tasks.
- Grade 3: Sleepiness to semi-unconscious but responsive to stimuli, drastically disoriented, bizarre behavior.
- Grade 4: Coma.
CLD can also result in jaundice, a yellow color in the skin, eyes and mucous membranes caused by the build-up of a substance called bilirubin due to the liver not being able to clear it out. Another complication is Spontaneous Bacterial Peritonitis (SBP) caused by bacteria infiltrating and infecting the ascitic fluid in the abdominal cavity, resulting in fever, widespread abdominal pain, tenderness and lack of bowel sounds.
CLD can also cause excessive estrogen in the body, resulting in symptoms like redness of the palms, spider angiomas (dilated blood vessels on the skin), enlarged male breasts, and shrinking of the testicles.
A complication called Hepatorenal Syndrome (HRS), a gradual loss of kidney function, can occur. It is caused by the contraction of kidney blood vessels due to some substances which are released during Chronic Liver Disease. The liver is also responsible for producing blood clotting factors, meaning patients with CLD can have issues with blood clotting leading to easy bruising and bleeding.
Testing for Chronic Liver Disease (Longterm Liver Disease)
Deciphering chronic liver disease depends largely on the root cause and any existing complications. Here are some ways to detect various types of chronic liver disease:
– Viral hepatitis B and C: These are identified using a blood test and PCR, which is a test that can identify the genetic makeup of the virus.
– Alcoholic liver disease: A person may be diagnosed if their AST is higher than ALT, in combination with a history of heavy drinking. Usually, the AST to ALT ratio is 2 to 1.
– Hemochromatosis: This is characterized by high iron and ferritin levels, low TIBC, and it can be confirmed with a liver biopsy. Genetic testing also helps to identify an HFE gene mutation, especially C282Y.
– Wilson disease: This is determined by high urine copper, low serum ceruloplasmin, and a liver biopsy. Genetic testing for the ATP7B gene is also performed.
– Non-alcoholic fatty liver disease: This is often a diagnosis of exclusion and diagnosis is aided by an ultrasound of the liver and ALT being higher than AST.
– Autoimmune hepatitis: This is characterized by elevated ANA, ASMA, and LKM-1
In chronic liver disease, liver cells are damaged and release markers AST and ALT into the bloodstream, indicating inflammation. Other markers like ALP and GGT are also elevated in conditions like PBC. AST and ALT are usually two to three times the normal limit, but normal levels do not necessarily mean cirrhosis is ruled out. In severe chronic liver disease, albumin levels drop and ammonia levels rise, leading to conditions like buildup of fluid in the abdomen (ascites) and liver-induced brain disorders.
To manage ascites, doctors may remove a sample of the fluid from the abdomen to determine its cause. If the protein count in this fluid is high, it can indicate issues with blood pressure in the liver. An abdominal ultrasound and blood levels of a protein called AFP can help diagnose liver cancer. In conditions like hepatorenal syndrome, creatinine levels often exceed 1.5 g/dl. A low platelet count may indicate an enlarged spleen due to increased blood pressure in the liver.
Investigations using medical imaging are crucial for confirming diagnosis. These include abdominal ultrasound, CT scans, fibro scans, measuring pressure in the liver, endoscopies, EEG, triphasic CT scan, and Doppler scans. An ultrasound of the abdomen is a common first step, as it provides information about the size and texture of the liver, helping to detect liver cirrhosis. CT scans can provide more detailed views if needed, especially when identifying liver cancer.
A liver biopsy, performed in various ways, can ultimately confirm the diagnosis of chronic liver disease.
Treatment Options for Chronic Liver Disease (Longterm Liver Disease)
The goal in treating chronic liver disease is to halt the disease’s progression and prevent secondary issues. This usually requires a team of healthcare professionals and a three-pronged strategy: correcting the cause of the disease, managing the resulting high blood pressure in the liver, and tailoring treatments to each particular disease.
Patients tend to seek treatment due to complications including, but not limited to, esophageal varices or hepatic encephalopathy.
In the case of esophageal varices, treatment focuses on managing severe bleeding, typically via fluid resuscitation, medication, and endoscopy. Drugs used for reducing blood pressure in the veins (propranolol, for instance) and diuretics, alongside a low-salt diet, are used to help prevent relapsing issues. In severe cases, a process called TIPS may increase survival rates.
When a patient has hepatic encephalopathy, treatment often involves addressing the underlying causes. Medications such as rifaximin and lactulose, alongside general treatment to help alleviate constipation, can help relieve symptoms and decrease absorption of certain toxins in the gut. If these treatments are unsuccessful, a liver transplant may be necessary.
Sometimes, liver conditions can lead to kidney issues. The severity of hepatorenal syndrome depends on the patient, but generally, treatment will focus on addressing the underlying issues that are causing kidney injury. This often involves medication, TIPS procedures, and potentially a liver transplant.
For liver cancer, the treatment required will depend on the stage: whether it is in the initial stages, intermediate stages, or if it is a metastatic disease. These can range from removal of the cancer, to chemoembolization and radio-embolization, or use of targeted drug therapy.
More specific treatments can be applied for viral hepatitis, alcoholic liver disease or non-alcoholic fatty liver disease, autoimmune hepatitis, genetic conditions leading to iron or copper overload, certain deficiencies, exposure to harmful substances, and certain rare liver conditions. These treatments range from specific medications to procedures for removing harmful substances from the body, and in severe cases, may even involve a liver transplant.
What else can Chronic Liver Disease (Longterm Liver Disease) be?
Some conditions that might get confused with each other because their symptoms are alike include:
- Constrictive pericarditis (a type of heart disease)
- Cor-pulmonale (a condition that causes the right side of the heart to fail)
- Dilated cardiomyopathy (a disease of the heart muscle that causes it to become thin and weak)
- Inferior vena cava thrombosis (a blood clot in a major vein that could lead to serious problems)
- Nodular regenerative hyperplasia (a condition where the liver changes shape due to excess growth)
- Sarcoidosis (an inflammatory disease that could affect any organ in the body)
- Schistosomiasis (an infection caused by a type of parasite found in certain tropical countries)
Understanding the exact condition is important for providing the right treatment, so it’s crucial that doctors examine all these possibilities.
What to expect with Chronic Liver Disease (Longterm Liver Disease)
Chronic liver disease with no severe complications generally has a better outlook than decompensated liver cirrhosis, where severe complications like variceal bleeding or hepatorenal syndrome have developed. Unfortunately, for those with decompensated liver cirrhosis, the average survival rate is about six months, especially if they score 12 or more on the Child-Pugh test or 21 or more on the MELD test.
To estimate the seriousness of chronic liver disease, doctors usually use scoring systems. One of them is the Child-Pugh score that assesses factors like bilirubin (a substance found in bile), albumin (a type of protein), Prothrombin Time, and encephalopathy (brain disease, damage, or malfunction). Based on the total score:
* Class A refers to well-managed disease with a score from 5 to 6
* Class B points to functional compromise with a score from 7 to 9
* Class C indicates decompensated disease with a score from 10 to 15
Another assessment tool is the MELD (Model of End-Stage Liver Disease) score that analyzes bilirubin, serum creatinine (a waste product from muscle metabolism), and the International Normalized Ratio (INR, a blood clotting test). Originally developed to predict mortality risk after a specific liver procedure, the MELD score is now used to prioritize patients needing a liver transplant.
Possible Complications When Diagnosed with Chronic Liver Disease (Longterm Liver Disease)
Chronic liver disease can lead to several complications. These include:
- Bleeding from the esophagus and stomach, called variceal bleeding
- Buildup of fluid in the abdomen, known as ascites, and bacterial infection in the abdomen, called spontaneous bacterial peritonitis (SBP)
- Disorders of brain function caused by liver disease, referred to as hepatic encephalopathy
- Deterioration of kidney function due to liver disease, known as hepatorenal syndrome
- Breathing difficulties caused by liver disease, known as hepatopulmonary syndrome
- Liver cancer, also referred to as hepatocellular carcinoma (HCC)
Preventing Chronic Liver Disease (Longterm Liver Disease)
Teaching patients about their health is key in preventing chronic liver disease. Chronic liver disease usually harms the liver over time, so early prevention methods can help avoid serious conditions like cirrhosis and related complications.
Here are a few preventative measures you can take to lower the risk of chronic liver disease:
- Avoid all types of alcohol – this includes wine, liquor, mixed drinks, and beer.
- Make sure you get regularly checked for hepatitis B and hepatitis C.
- Try to get vaccinated against hepatitis A and B.
- Don’t take iron supplements unless you have a diagnosed iron deficiency.
- Refrain from taking over-the-counter painkillers like aspirin and acetaminophen, along with other medicines that can harm the liver.
- Keep your cholesterol and other blood fats at a healthy level to avoid developing conditions like metabolic syndrome and non-alcoholic fatty liver disease (NAFLD).