Alcoholic cirrhosis is a pathological process accompanied by the death of hepatocytes and their replacement by connective fibrous tissue due to prolonged use of alcoholic beverages. It is manifested by asthenia, exhaustion and dyspeptic symptoms, enlarged liver and jaundice of the skin, signs of liver failure, portal hypertension, toxic encephalopathy. For diagnosis, a study of the biochemical profile, ultrasound, CT, ERCP is carried out. The most reliable diagnostic methods are liver biopsy or elastography. Treatment is based on the complete rejection of alcohol and the replacement of lost liver functions, if it is impossible to restore, a part of the organ is transplanted.
ICD 10
K70.3 Alcoholic cirrhosis
Meaning
Alcoholic cirrhosis is a 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, since an increased level of estrogens favors faster and more severe liver damage. With the transition of cirrhosis to the terminal stage, death occurs within six months in half of the patients. If you refuse to drink, the condition improves significantly, but a complete cure can only be achieved by liver transplantation. Depressing statistics show that from 10 to 50% of patients resume drinking alcohol after liver transplantation.
Causes of alcoholic cirrhosis
The immediate cause of alcoholic cirrhosis is prolonged alcohol intake. According to research in the field of modern gastroenterology, cirrhosis affects only 35% of all patients with alcoholism. It is known that the development of severe liver fibrosis requires a combination of several damaging mechanisms. Thus, the risk factors for cirrhosis are genetic predisposition, prolonged use of even small doses of any alcohol, the use of fatty and spicy foods, lack of protein and vitamins, female sex.
Pathogenesis
Since the ethanol entering the body is processed precisely in the liver, the free radicals formed at the same time most affect this organ. In this case, cell membranes are damaged and their subsequent destruction occurs. The structure of the vascular endothelium is disrupted, which causes their spasm, followed by hypoxia of the hepatic tissue and aggravation of damage to hepatocytes. All these processes stimulate the production of fibrous tissue, which gradually replaces the dead areas. The liver gradually loses its functions, the main of which are protein-forming, hematopoietic, detoxification. These processes are irreversible, lead to disability and death, a cure is possible only with organ transplantation.
Classification
The division of alcoholic cirrhosis into small-nodular, large-nodular and mixed is accepted. Also, the disease is divided by severity. The compensated stage usually has no clinical manifestations, since the liver is still able to perform its functions, the diagnosis at this stage can only be established by biopsy.
The subcompensated stage is characterized by the appearance of signs of liver failure both clinically and in studies. At this stage, the damage to the liver tissue is still reversible, and if you refuse to drink, the condition can normalize. The decompensated stage is manifested by liver failure, a severe condition with alcoholic damage to all organs and systems. At this stage, only organ transplantation can help the patient.
Alcoholic cirrhosis symptoms
The symptoms of liver damage depend 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. It usually takes about five years from the beginning of fibrosis of liver tissues to the appearance of the first symptoms. Cirrhosis can be suspected only when the liver is enlarged.
At the stage of subcompensation, the level of fibrosis becomes critical for the preservation of liver functions, the first symptoms begin to appear. The patient notes a deterioration in appetite, weight loss, weakness, nausea and dyspeptic manifestations. The liver increases in size.
With decompensation of the process, a gradual extinction of all liver functions begins. A syndrome complex characteristic of cirrhosis develops. Asthenic syndrome is characterized by rapid fatigue, indifference, loss of appetite, and the development of depression. Cachexia is gradually developing – an extreme degree of exhaustion. Arterial hypotension with tachycardia is noted. Redness of the nose, cheeks, feet and palms is characteristic. The parotid glands are enlarged.
Men show signs of an excess of estrogen: fat is deposited in the abdomen and thighs, legs and arms remain very thin, breasts increase, male sex glands atrophy, infertility develops. The skin and mucous membranes turn yellow, bruises often form on the skin. Fingers take the form of drumsticks, small white strokes appear on the nails. Pathognomonic for this pathology is the development of Dupuytren’s contracture – shortening of the tendons of the flexor muscles of the palms with the loss of their motor function.
Complications
If you do not start treating alcoholic cirrhosis in time, the loss of liver function leads to severe complications and irreversible changes in the body. Varicose veins of the esophagus and rectum are formed, bleeding from altered veins often occurs, leading to a significant deterioration of the condition. There are signs of portal hypertension (increased pressure in the portal vein). An effusion (ascites) forms in the abdominal cavity. The abdomen increases in size, a venous network in the form of a jellyfish head is clearly traced on it. In the future, this effusion may become inflamed (due to a decrease in immunity), peritonitis develops. The liver increases significantly.
In the later stages, hepatic encephalopathy develops – since the liver does not perform the function of detoxification, toxins freely circulate in the blood and cause damage to brain cells. There are various disorders of consciousness, personality changes. Also, liver damage can lead to disruption of the lungs, stomach and intestines, kidneys, provoke the development of pancreatitis. Nerve damage is manifested by peripheral polyneuropathy. Sometimes, due to cirrhotic changes in the liver, a malignant neoplasm is formed – hepatocellular carcinoma.
Diagnostics
Diagnosis of alcoholic cirrhosis after the appearance of characteristic symptoms is usually not difficult. Blood sampling is carried out for clinical and biochemical tests. In the blood test, anemia is noted, a decrease in the platelet pool, there may be leukocytosis. It is necessary to determine the markers of viral hepatitis, as cirrhotic transformation predisposes to their development. There are also changes in urine and stool tests.
In the biochemical analysis of blood, an increase in the levels of gamma globulins, immunoglobulin A, transferrin is noted. The ratio of AST and ALT is shifted towards AST (normally equal to one). The PGA index increases (prothrombin, gammaglutamyltranspeptidase, apolipoprotein A1) – if it exceeds 9, the risk of cirrhosis is almost 90%. Markers of fibrosis (of any, not only liver) are determined: laminin, hyaluronic acid, procollagen type 3, collagen type 4, metalloproteinases type 4, etc.; the coagulogram worsens.
Instrumental research methods are assigned. Ultrasound of the abdominal cavity organs assesses the size and structure of the liver, the presence of foci of fibrosis, the condition of the spleen. MRI and CT of the abdominal cavity organs allow you to take targeted layer-by-layer images, assess the structure of liver tissue, liver passages, surrounding organs (pancreas, spleen) and blood vessels. EGDS allows you to examine the walls of the esophagus and stomach for varicose veins. ERCP makes it possible to assess the condition of the hepatic passages, the presence of their strictures and constrictions.
The most informative are elastography and liver puncture. Elastography is an ultrasound examination method that allows you to estimate the amount of connective tissue in an organ and, based on this, determine the severity of fibrosis. A more invasive technique is percutaneous liver biopsy followed by biopsy examination.
The Child-Pugh scale is used to accurately assess the severity and severity of cirrhosis. It evaluates the levels of prothrombin, bilirubin, albumin; after that, the presence of ascites and hepatic toxic encephalopathy is determined. After evaluating all the indicators, the cirrhosis class is set: A (compensated), B (subcompensated) or C (decompensated).
Alcoholic cirrhosis treatment
A number of specialists take part in the treatment of liver fibrosis induced by alcoholism: a hepatologist, a gastroenterologist, a therapist, a surgeon, a psychiatrist and a narcologist. If necessary, doctors of other profiles are involved. An absolutely necessary condition for the successful treatment of cirrhosis is a complete refusal to drink alcohol. The patient is prescribed a therapeutic diet (the fifth liver table), rich in protein and vitamins, a protective regime.
Conservative treatment includes the use of hepatoprotectors, ursodeoxycholic acid preparations, essential vitamins (A, B, C, E), glucocorticoid hormones. The appointment of ademetionine has been widely used – this substance is able to protect liver cells from destruction, stimulate their recovery, improve the outflow of bile, protect the brain from toxins, neutralize toxins, eliminate depression. Protease inhibitors prevent the formation of connective tissue, have an anti-inflammatory effect.
Treatment of portal hypertension includes drugs that restrict blood flow in the area of varicose veins: pituitary hormones, nitrates, beta blockers, diuretics. In addition, lactulose is prescribed, which improves digestion and improves the excretion of toxins through the intestines. Treatment of ascites is carried out with the help of decongestants, intravenous administration of albumin. This will facilitate the movement of fluid into the vascular bed and the removal of its excess through the kidneys. In order to treat hepatic encephalopathy, the patient should receive detoxification infusion therapy, a protein-restricted diet, lactulose, and antibacterial drugs.
Surgical treatment of cirrhosis consists in transplantation of a donor liver. To be put on the waiting list for transplantation, it is necessary to fulfill a mandatory condition: refusal to drink alcoholic beverages for six months. Surgical treatment of complications of liver fibrosis consists in removal of the spleen, portosystemic or splenorenal shunting; suturing, sclerosing or ligation of esophageal veins, balloon tamponade of the esophagus with a Blackmore probe.
Prognosis and prevention
Prevention of alcoholic cirrhosis consists in the complete rejection of alcoholic beverages, timely treatment of the onset of alcoholic hepatitis, compliance with a high-protein diet. The prognosis of the disease with complete abstinence from alcohol is more favorable in young people with normal body weight, in men, with timely initiation 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.