What is Cardiac Cirrhosis?
Cardiac cirrhosis refers to a range of liver disorders that occur as a result of heart problems, particularly those affecting the right side of the heart. Specifically, it can happen when a condition causes the right side of the heart to fail, leading to increased pressure and blood buildup in the liver. Conditions like heart valve disease, severe lung-related high blood pressure, diseases affecting both heart ventricles, diseases of the heart’s outer covering, pressure build-up in the heart, or a specific type of heart cover disease, can all lead to cardiac cirrhosis.
What Causes Cardiac Cirrhosis?
Cardiac cirrhosis is a condition resulting from changes in blood flow caused by heart failure. Issues with the left side of the heart, like heart failure itself or heart valve diseases, can cause problems on the right side of the heart. This can make it more challenging for the right side to relax or fill with blood, such as in cases of a condition called constrictive pericarditis.
These issues can lead to an increase in the amount of blood getting backed up into the liver system, causing liver congestion. Over time, this congestion can progress to a condition called liver cirrhosis.
Congestive hepatopathy, a liver disease resulting from chronic systemic congestion, is common in patients with congenital heart disease or those having a single ventricle who’ve undergone an operation called the Fontan procedure.
Risk Factors and Frequency for Cardiac Cirrhosis
Cardiac cirrhosis is a condition that can be difficult to spot. This is because it may not show any symptoms, or it might be overlooked due to other issues affecting the liver. Typically, if someone with this condition passes away, it’s usually due to the heart disease that caused the cirrhosis, rather than the cirrhosis itself. It’s not clear cut at what age people usually develop cardiac cirrhosis because this relies on when heart failure begins. It’s known that getting older increases the risk of cardiac cirrhosis. Also, men are more likely to develop it, as they’re more at risk for developing heart failure, which can lead to cardiac cirrhosis.
Signs and Symptoms of Cardiac Cirrhosis
Cardiac cirrhosis is a liver condition often associated with heart failure. Many people with cardiac cirrhosis do not have any symptoms, and the condition is typically identified due to abnormal liver tests. Some common symptoms can include shortness of breath, leg swelling, sudden breathlessness during sleep, and difficulty breathing when lying flat. Jaundice, or yellowing of the skin, might also be present but can be mistakenly attributed to blockage of the bile duct.
Symptoms can develop slowly or suddenly due to complications such as weak right heart function, rigid heart sac, or worsening valve disease. Bulging neck veins are also common. When liver dysfunction is involved, people might experience abdominal pain, especially in the upper right area due to liver swelling, as well as nausea, vomiting, jaundice, a significantly enlarged liver, bloating, and fluid accumulation in the abdomen. However, these symptoms can be misconstrued as signs of bile duct illness. Jaundice is not usually a common symptom. Sometimes, serious liver damage can become apparent after a heart failure flare-up, with significant liver enzyme increase 24 to 72 hours after the heart failure worsens. In severe cases, this may lead to liver-related mental confusion and this situation is referred to as “acute cardiogenic liver injury” when it happens in the context of congestive kidney disease.
- An enlarged liver felt during an abdominal check-up
- An enlarged liver detected through an ultrasound exam
- The liver edge is typically smooth, firm, and painful to touch
- Fluid accumulation in the abdomen (ascites) with shifting dullness or noticeably moving fluid
- Hepatojugular reflux, a condition where the neck veins visibly widen when pressure is applied to the abdomen
- A liver that pulsates due to severe backflow of blood from the heart or pericardial disease resulting in congestive kidney disease
- Lack of liver pulsatility may indicate a longstanding liver issue or progression to cardiac cirrhosis
In cases where a stiffened pericardium (the sac enclosing the heart) causes congestive hepatopathy, an enlarged, pulsating liver can be observed. Additionally, Kussmaul’s sign (a rise in neck vein pressure when a person inhales), a distinctive sound heard over the heart area, and hardened pericardium visible on a chest x-ray might be noted. Yellowish discoloration of the eye whites (scleral icterus) may not be seen in these patients.
Testing for Cardiac Cirrhosis
When a patient presents symptoms hinting at liver damage and heart issues, medical professionals will need to figure out the cause. They will do this through a thorough examination of the patient’s medical history and a physical examination to spot any potential signs of liver injury, like hepatitis, medication reactions, or gallbladder disease.
A check of the liver’s function will also be done. One common sign associated with cardiac cirrhosis, found in 70% of cases, is high levels of bilirubin, a waste product in the blood; however, the level rarely goes above 3 mg/dl. The liver’s ability to help blood clot can also be affected, leading to longer coagulation times. Other symptoms include a lowered serum albumin level, found in 40% of patients, though it isn’t often less than 2.5g/dL. It’s important to note that a lower albumin can also predict a higher risk of death for heart failure patients. But this doesn’t necessarily mean the liver has suffered more damage – it may just indicate issues such as protein loss from bowel swelling due to heart failure or malnourishment.
Signs of heart failure worsening should also be investigated. High cardiac enzyme and brain peptide natriuretic peptide (BNP) levels may be detected. An ECG might show abnormalities in heart rhythms and evidence of right ventricular enlargement. An echocardiogram can reveal issues such as valve disease, abnormalities in the movement of the heart wall, changes in the size of heart chambers, and any build up of fluid in the pericardial sac around the heart. In addition, a CT or MRI scan can provide further information about the heart and liver conditions.
Finally, if the patient’s symptoms are similar to a gallbladder disease, an imaging evaluation using an abdominal ultrasound can help rule out problems like acute obstructive disease or blood clots in the hepatic vein. In case of a build-up of fluid in the abdomen, known as ascites, a sample of this fluid should be taken and tested. A protein content of more than 2.5g/dl in this fluid could mean that the liver’s lymphatic system has ruptured, causing protein-rich fluid to leak out. If the difference between the serum and abdominal fluid albumin levels (SAAG) is greater than 1.1, it indicates high blood pressure in the liver blood vessels.
Treatment Options for Cardiac Cirrhosis
The treatment of cardiac cirrhosis, a condition affecting the liver caused by heart problems, revolves around treating the underlying heart condition and managing fluid levels in the body. It’s crucial to monitor the patients’ fluid status and make adjustments as necessary.
Improved heart function can significantly reduce the symptoms of cardiac cirrhosis, especially when combined with fluid removal treatments. Regularly checking how well the heart is pumping blood is crucial to prevent a liver condition called ischemic hepatitis.
Regular liver cirrhosis treatments also apply, regardless of the cause. This might include the use of drugs like beta-blockers to relieve high blood pressure in the blood vessels of the liver, diuretics to get rid of excess fluid in the body, or preventative treatments after stomach bleeding to avoid spontaneous bacterial peritonitis, a potentially serious infection.
For patients already on a blood thinning drug called warfarin, it’s essential to consider adjusting the dosage.
What else can Cardiac Cirrhosis be?
Here are different illnesses related to the liver that a doctor might consider diagnosing:
- Alcoholic liver cirrhosis: A serious condition where the liver is scarred due to excessive drinking over many years
- Primary biliary cirrhosis: A disease where the liver slowly sustains damage due to bile duct problems
- Chronic viral hepatitis: A long-term inflammation of the liver often caused by viral infections
- Wilson’s disease: An inherited disorder where the body retains excess copper
- Veno-occlusive disease: A condition that causes blockage of tiny veins in the liver
- Nonalcoholic steatohepatitis (NASH): An illness characterized by fat buildup and inflammation in the liver not associated with alcohol use
- Autoimmune hepatitis: A disease where the body’s immune system attacks the liver
- Ischemic hepatitis: A condition in which the liver doesn’t get enough blood or oxygen leading to damaged cells
These conditions vary in causes, symptoms, and treatments, making it very important for doctors to correctly pinpoint the specific type of liver disease.
What to expect with Cardiac Cirrhosis
The outcome of cardiac cirrhosis is closely related to the state of the heart condition that caused it. One way to predict this is by observing how a patient’s liver enzymes increase and serum albumin decreases during early hospital admission for sudden worsening of heart failure. This is often linked with worse results six months down the line.
Furthermore, patients with heart failure who show a higher degree of liver stiffness, a sign of liver scarring, on non-invasive tests, are more likely to have an increased risk of passing away from any cause.
Possible Complications When Diagnosed with Cardiac Cirrhosis
Cardiac cirrhosis, a heart-related liver disease, has its complications that rely on the issues with the heart and the liver’s dysfunction. This condition can lead to numerous health problems and even death, particularly in severe cases. Such health problems include:
- Portal hypertension – high blood pressure within the veins of your liver
- Hepatic encephalopathy – a decline in brain function due to severe liver disease
- Variceal bleeding – excessive bleeding from enlarged veins
- Recurrent ascites – repeated buildup of fluid in your abdominal cavity
- Hepatorenal syndrome – kidney failure related to severe liver damage
- Spontaneous bacterial peritonitis – a sudden bacterial infection in your abdomen
- Hepatopulmonary syndrome – a lung complication of liver disease
- Coma and death in severe cases
