Liver Fibriosis

LIVER FIBROSIS

Fibrosis is the formation of abnormally large amount of scar tissue in the liver. It occurs when the liver attempts to repair and replace damaged cells. It also occurs when injury persists for long periods or inflammation causes build up or scar tissue in the liver. Most types of chronic liver disease can eventually cause fibrosis.

Scar tissue cells cannot repair themselves or function, unlike healthy liver cells. Due to this, fibrosis can reduce overall liver function and impair the organ's ability to regenerate.

The flow of blood within the liver can also be blocked or limited by scar tissue from fibrosis. This can starve and eventually can even kill healthy liver cells, in the process of which creates more scar tissue.

Treatment tends to involve the making lifestyle changes, clearing of infections, and taking certain medications. The mentioned regimens can often reverse the damage of mild to moderate liver fibrosis.

If a person does not receive appropriate treatment or possibly receives no treatment at all, liver fibrosis could develop into more serious liver conditions.

Liver fibrosis occurs when the healthy tissue of the liver becomes scarred and therefore cannot work as well. Fibrosis is the first stage of liver scarring. Later, if more of the liver becomes scarred, it is known as liver Cirrhosis.

STAGES

A doctor may order a liver biopsy to diagnose liver fibrosis. A small tissue sample, or biopsy, from the liver will be carefully collected using a large needle.

A pathologist, (a doctor who specializes in finding the root cause of disease) will examine the sample under a microscope. This is to assess the extent and type of damage.

Determining the degree of fibrosis is quite difficult because pathologists only have a small sample to work with.

Several scales can be used to define the stages of fibrosis. These include the Ishak, Metavir and Batts:Ludwig scales.

These and indeed other similar scoring systems take into account the effect that the fibrosis has had on the portal vein (which delivers blood from the intestines to the liver).

Some other scales measure the extent of fibrosis and the location or number of septa (fibrous bands of tissue in the biopsy sample).

• The Ishak fibrosis scoring system is more complex, and it typically runs from 0 to 6:
• 0: An absence of fibrosis
• 1: An expansion of some portal areas, possibly with short, fibrous septa
• 2: An expansion of most portal areas, possibly with short, fibrous septa
• 3: An expansion of portal areas with sporadic portal-to-portal bridging
• 4: An expansion of portal areas with significant portal-to-portal and portal-to-central bridging
• 5: Significant portal-to-portal and portal-to-central bridging with sporadic nodules
• 6: Likely or definite cirrhosis

Using the Ishak scale, the most advanced stage of fibrosis a person can have before developing cirrhosis is stage 5.

• The Metavir scoring system on the other hand, rates the progression of fibrosis on a scale from A0 to A3:
• A0: No activity
• A1: Mild activity
• A2: Moderate activity
• A3: Severe activity

The Metavir system also scores the level of fibrosis from F0 to F3:

• F0: An absence of fibrosis
• F1: Portal fibrosis with no septa
• F2: Portal fibrosis with infrequent septa
• F3: Numerous septa but no cirrhosis
• F4: Cirrhosis

Cirrhosis is scar tissue that builds up in the liver. This can occur due to unchecked fibrosis.

The most advanced type of fibrosis someone can have before developing cirrhosis, according to the Metavir system, is stage A3F3.

The Batts:Ludwig scale, is slightly simpler. This scale runs from 0 to 4:

• 0: A lack of fibrosis
• 1: Portal fibrosis
• 2: Rare portal-to-portal septa
• 3: Fibrous septa
• 4: Definite or likely cirrhosis

With the Batts:Ludwig scale, the most advanced stage of fibrosis a person can have before developing cirrhosis is stage 3.

CAUSES

Various disorders and drugs can either repeatedly, or continuously damage the liver and in the process cause fibrosis. The most common causes are;

• Viral hepatitis C - a liver disease caused by the hepatitis C virus (HCV): the virus can cause both acute and chronic hepatitis, ranging in severity from a mild illness lasting a few weeks to a serious, lifelong illness.
• Alcohol abuse - Alcohol abuse encompasses a spectrum of unhealthy alcohol drinking behaviors, ranging from binge drinking to alcohol dependence, in extreme cases resulting in health problems for individuals and large scale social problems
• Cystic fibrosis - The body produces thick and sticky mucus that can clog the lungs and obstruct the pancreas. This can be life-threatening, and people with the condition tend to have a shorter-than-normal life span.
• Chronic alcohol abuse - Heavy drinking is defined as consuming eight drinks or more per week for women, and 15 or more for men.
• Chronic viral hepatitis (hepatitis B, C and D) - Inflammation of the liver that lasts at least 6 months. Common causes include hepatitis B and C viruses as well as certain drugs.
• Fat accumulating in the liver (non-alcoholic fatty liver disease) - When the body produces too much fat or does not metabolize fat efficiently enough. The excess fat is stored in liver cells, the accumulation causes fatty liver disease.
• Iron buildup in the body (hemochromatosis) - Too much iron in the liver can cause an enlarged liver, liver failure, liver cancer, or cirrhosis
• Copper accumulated in the liver (Wilson's disease) - a rare inherited disorder that causes copper to accumulate in the liver, brain and other vital organs. Most people with Wilson's disease are diagnosed between the ages 5 and 35.
• Genetic digestive disorder (Alagille syndrome) : This is a hereditary disorder. The individual can be genetically predisposed to develop cystic fibrosis, ulcer colitis, type 1 diabetes, Crohn's disease, celiac disease, and some liver conditions as well.
• Poorly formed bile ducts (biliary atresia) : Occurs when one of the ducts that carry bile from the liver to the intestine via the gallbladder becomes blocked. If left untreated, this blockage can lead to serious complications, including severe infection.
• Alpha-1 antitrypsin deficiency - An inherited condition that raises risk for lung and liver disease. Alpha-1 antitrypsin (AAT) is a protein that protects the lungs but made by the liver.
• Inherited disorders of sugar metabolism (galactosemia or glycogen storage disease) - Lack of glucose for the metabolism of brain, muscle, liver, or kidney. Inability to break down glucose to pyruvate.
• Liver disease caused by the body's immune system (autoimmune hepatitis) - Inflammation of the liver that occurs when the body's immune system turns against liver cells. The actual cause of autoimmune hepatitis is yet unknown.
• Destruction of the bile ducts (primary biliary cirrhosis) - A chronic disease in which the bile ducts in the liver are slowly destroyed. Bile is a fluid made in the liver. It aids with digestion and helps the body get rid of cholesterol, toxins and worn-out red blood cells.
• Hardening and scarring of the bile ducts (primary sclerosing cholangitis) - Inflammation of the bile ducts. 'Sclerosing' refers to the hardening and scarring of the bile ducts (through which bile flows from the liver to the intestines) this results from chronic inflammation.
• Infection, such as syphilis or brucellosis - Brucellosis is an infectious disease caused by a type of bacteria called Brucella. The bacteria can spread from animals to humans. Syphilis is a bacterial infection usually spread by sexual contact.

• Non-alcoholic fatty liver - the buildup of extra fat in liver cells that is not caused by alcohol. It is normal for the liver to contain some fat. However, if more than 5% : 10% percent of the liver's weight is fat, then it is called a fatty liver Viral hepatitis B is also a common cause.

SYMPTOMS

Often times, cirrhosis has no signs or symptoms until damage to the liver is extensive. When signs and symptoms do occur, they may include:

• Weight loss - Weight loss is a decrease in body weight resulting from either voluntary (diet, exercise) or involuntary (illness) circumstances
• Itchy skin - Itchy skin is an uncomfortable, irritating sensation that makes one want to scratch.
• Fatigue - Fatigue refers to a mental or physical state of extreme tiredness and lack of energy. It is common.
• Easily bleeding or bruising - A decrease in blood clotting factors usually causes bleeding and bruising.
• Loss of appetite : When one does not have the same desire to eat as they used to. Signs of decreased appetite include not wanting to eat, unintentional weight loss, and not feeling hungry.
• Fluid accumulation in the abdomen (ascites) - Ascites is the abnormal buildup of fluid in the abdomen.
• Nausea - The sensation of an urge to vomit. Nausea can be acute and short-lived, or it can be prolonged. When prolonged, it makes one very weak and infirm.
• Swelling in the legs, feet or ankles (edema) - When the muscles are inactive, they cannot pump body fluids back up toward the heart. The retention of water and blood can cause swelling in the legs.
• Yellow discoloration in the skin and eyes (jaundice) - Jaundice is a condition in which the skin, whites of the eyes and mucous membranes turn yellow because of a high level of bilirubin, a yellow-orange bile pigment.
• Spiderlike blood vessels on the skin - A spider nevus is a collection of small, dilated arterioles (blood vessels) clustered very close to the surface of the skin.
• Redness in the palms of the hands.
• For women, absent or loss of periods not related to menopause - Such women cannot become pregnant. If amenorrhea lasts a long time, problems similar to those associated with menopause may develop. They include hot flashes, vaginal dryness, and an increased risk of heart and blood vessel disorders.
• For men, loss of sex drive, breast enlargement (gynecomastia) or testicular atrophy - Low testosterone can cause enlarged male breasts (gynecomastia). ... for male physical features and also affects a man's sex drive and mood
• Confusion, drowsiness and slurred speech (hepatic encephalopathy) - Hepatic encephalopathy is a decline in brain function that occurs as a result of severe liver disease. In this condition, the liver cannot adequately remove toxins from the blood.

RISK FACTORS

One may be at risk of liver fibrosis/cirrhosis if he/she has one of the following conditions:

Chronic hepatitis B - inflammation of the liver that is caused by the hepatitis B virus and that has lasted more than 6 months

Chronic hepatitis C - A long term viral infection that affects the liver. Most people who contract the hepatitis C virus develop chronic infection.

Chronic excessive alcohol intake - Alcohol intake in large amounts include an increased risk of alcoholism, malnutrition, chronic pancreatitis, alcoholic liver disease and cancer. In addition, damage to the central nervous system.

Fatty liver disease (non-alcoholic steatohepatitis) - an aggressive form of fatty liver disease, which is marked by liver inflammation and may progress to advanced scarring (cirrhosis) and liver failure. This damage is similar to the damage caused by heavy alcohol use.

Autoimmune liver disease (autoimmune hepatitis, primary biliary cirrhosis or primary sclerosing cholangitis) - Autoimmune hepatitis is a disease in which the body's own immune system attacks the liver and causes it to become inflamed.

Wilson disease (hemochromatosis and other rare inherited liver diseases) - Wilson disease is an inherited disorder in which excessive amounts of copper accumulate in the body, particularly in the liver, brain, and eyes.

COMPLICATIONS

Complications can include:

• High blood pressure in the veins that supply the liver (portal hypertension) - Cirrhosis normally slows the flow of blood through the liver, this increases pressure in the vein that brings blood to the liver from the intestines and spleen.
• Bleeding - Sometimes portal hypertension cause blood to be redirected to smaller veins. When they are strained by the extra pressure, these smaller veins can burst, causing serious bleeding. The same portal hypertension may cause enlarged veins (varices) in the esophagus (esophageal varices) or the stomach (gastric varices) these could lead to life-threatening bleeding, especially if the liver is not able to make enough clotting factors, such contributes to continued bleeding.
• Enlargement of the spleen (splenomegaly) - Portal hypertension can also cause some changes to the spleen as well as swelling and trapping of white blood cells and platelets. A decreased white blood cells and platelets in a person's blood can be the first sign of cirrhosis.
• Swelling in the legs and abdomen - The increased pressure in the portal vein can cause edema (fluid accumulation in the legs) and ascites (fluid accumulation in the abdomen). Edema and ascites can also result from the inability of the liver to make enough of certain blood proteins, such as albumin.

• Jaundice - When the diseased liver doesn't remove enough bilirubin (a blood waste product) from the blood, Jaundice occurs. This condition causes yellowing of the skin and whites of the eyes and also darkening of urine.
• Bone diseases - Some people with cirrhosis are at greater risk of fractures because they lose bone strength.
• Buildup of toxins in the brain (hepatic encephalopathy). A liver that is damaged by cirrhosis is unable to clear toxins from the blood. These toxins could then build up in the brain and cause mental confusion and difficulty concentrating. Hepatic encephalopathy can progress to unresponsiveness or even coma.
• Infections : Cirrhosis can lead to the body having difficulty in fighting infections. Ascites can lead to bacterial peritonitis (the development of a bacterial infection in the peritoneum), a serious infection.
• Appropriate nutrition - The body may find it difficult to process nutrients, leading to weakness and weight loss due to the presence of Cirrhosis.
• An increased risk of liver cancer - Most people who develop liver cancer have pre-existing cirrhosis.

DIAGNOSIS OF LIVER FIBROSIS

The doctor will begin by asking about medical history and symptoms. The patient will also undergo a physical exam.

In order to diagnose Fatty liver disease (FLD) and liver fibrosis, the doctor may order blood tests to evaluate level of liver function. This may include tests to assess the level of the liver enzymes (ALT and AST) which can be high especially when the liver is fatty.

The doctor may also order imaging tests of the liver such as:

• Computed Tomography (CT) - This scan of the abdomen and pelvis combines special x-ray equipment with sophisticated computers to produce multiple images or pictures of the inside of the body. On CT, steatotic livers look darker than normal livers. Cirrhotic livers look lumpy and shrunken.
• Magnetic resonance imaging (MRI) - Uses a magnetic field and radio waves to produce detailed pictures of the liver. For steatosis, MRI remains the most sensitive and highly accurate imaging, even in mild cases. When a special technique is used, MRI is able to calculate the percentage of fat in the liver, of which more than 5-6% of fat in the liver is considered abnormal.
• Abdominal Ultrasound - This uses sound waves to produce pictures to evaluate the size and shape of the liver, as well as blood flow through the liver. Steatotic livers look brighter than normal livers on ultrasound images. Conversely, cirrhotic livers (advanced fibrosis) look lumpy and shrunken.
• Liver biopsy - Essentially an image-guided procedure, a small sample of liver tissue is removed using a needle. The sample is then examined under a microscope for signs of steatosis, inflammation and damage, and fibrosis.
• Ultrasound elastography - This is a special ultrasound technique that tests for liver fibrosis. The movement of the liver which is caused by ultrasound wave is measured in the middle of the liver, and its stiffness (or elasticity) is calculated. A fibrotic liver is stiffer and moves to a lot more compared to a normal liver.
• MR Elastography (MRE) : Yet another special MRI technique that tests for liver fibrosis. The movement of fine vibration waves in the liver is imaged to create a visual map, or elastogram, that shows how stiff (or elastic) the liver is. Both the ultrasound and MR elastography can detect increased stiffness of the liver caused by fibrosis earlier than the other imaging tests and may help eliminate the need for an invasive liver biopsy.

TREATMENT

Treatment for cirrhosis will depend on both the cause and extent of the liver damage. Usually, the goals of treatment are to slow the progression of scar tissue in the liver and to prevent or treat symptoms and complications of cirrhosis.

Treatment for the underlying cause of cirrhosis

It is possible to minimize damage to the liver in early cirrhosis, by treating the underlying cause.

Options will include:

• Treatment for alcohol dependency - People with cirrhosis caused by excessive alcohol use must stop drinking. If stopping the use of alcohol becomes difficult, the doctor may recommend a treatment program for alcohol addiction. It is critical for an individual with cirrhosis to stop drinking since any amount of alcohol is considered toxic to the liver.
• Weight loss - With cirrhosis caused by nonalcoholic fatty liver disease, people may become healthier if they lose weight and control their blood sugar levels.
• Medications to control hepatitis - Medications may limit further damage to liver cells caused by hepatitis B or C through specific treatment of these viruses.
• Medications to control other causes and symptoms of cirrhosis - Medications may slow down the progression of certain types of liver cirrhosis.
• Some other medications may relieve certain symptoms : Symptoms like itching, fatigue and pain can be treated with medications. To treat malnutrition associated with cirrhosis and to prevent weak bones (osteoporosis), nutritional supplements may be prescribed.

Treatment for complications of cirrhosis

The doctor will work to treat any complications of cirrhosis, including:

• Excess fluid in the body - A low-sodium diet coupled with medication to prevent fluid buildup in the body may help control ascites and swelling. More-severe fluid buildup may require procedures to drain the fluid or surgery to relieve pressure.
• Portal hypertension - Some blood pressure medications may control increased pressure in the veins that supply the liver (portal hypertension) and thus prevent severe bleeding. The doctor will perform an upper endoscopy at regular intervals to check for enlarged veins in the esophagus or stomach (varices) that may bleed.
• Infections - Antibiotics or other treatments may be prescribed for infections. The doctor also is likely to recommend vaccinations for influenza, pneumonia and hepatitis.
• Increased liver cancer risk - Periodic blood tests and ultrasound exams to look for signs of liver cancer may be recommended.
• Hepatic encephalopathy - Medications may be prescribed to help reduce the buildup of toxins in the blood due to poor liver function.

Liver transplant surgery

In advanced cases of cirrhosis, when the liver ceases to function, a liver transplant may be the only treatment option. A liver transplant is a procedure to replace one's liver with a healthy liver from a deceased donor or with part of a liver from a living donor. Cirrhosis is one of the most common reasons for a liver transplant. Candidates for liver transplant have extensive testing to determine whether they are healthy enough to have a good outcome following surgery.

To meet the requirements of the program, which would include lifelong commitment to alcohol abstinence as well as other requirements of the specific transplant center.

Potential future treatments

Even though success has been limited, scientists are working to expand current treatments for cirrhosis. Because cirrhosis has numerous causes as well as complications, there are many potential avenues of approach.

Researchers are working on therapies that will directly target liver cells and help to slow or even reverse the fibrosis that leads to cirrhosis. None of the therapies is ready yet, however, the frameworks for developing such treatments is in place, and progress is accelerating steadily.

HOME REMEDIES & LIFESTYLE CHANGES

For people with cirrhosis, care must be taken, to limit additional liver damage:

• Abstain from alcohol : Whether the cirrhosis was caused by chronic alcohol use or another disease, avoid alcohol. Alcohol may cause further liver damage.
• Eat a low-sodium diet : Too much salt can cause the body to retain fluids, worsening swelling in the abdomen and legs. Use herbs for seasoning food, rather than salt. Choose prepared foods that are low in sodium.
• Eat a healthy diet - People with cirrhosis can experience malnutrition sometimes. This can be combatted with a healthy plant-based diet that includes a variety of fruits and vegetables. Lean protein, such as legumes, poultry or fish must be preferred. Avoid raw seafood.
• Avoid infections - Cirrhosis makes it more difficult for the body to fight off infections. Patients must seek protection by avoiding people who are sick and washing their hands frequently and get vaccinated for hepatitis A and B, influenza, and pneumonia.
• Use over-the-counter medications carefully - Cirrhosis makes it difficult for the liver to process drugs. For this reason, it would be prudent for one to ask their doctor before taking any medications, including nonprescription drugs. Drugs such as aspirin and ibuprofen (Advil, Motrin IB, others) must be avoided or taken in low doses for pain relief.