Fibrosis and cirrhosis

Fibrosis refers to the development of hard, fibrous tissue in the liver. Fibrosis may progress to cirrhosis, in which normal liver tissue is replaced by non-functional scar tissue. Fibrosis may be reversible, but once cirrhosis has occurred it appears to be largely irreversible, even if HCV replication and liver inflammation are controlled.

Factors associated with a greater risk of HCV-related fibrosis and cirrhosis include age over 40, male gender, long-term HCV infection, and more than four standard alcoholic drinks per day. Co-infection with HIV also can lead to more severe fibrosis (see How does HIV affect hepatitis C?). People who are obese or diabetic are also more prone to fibrosis and cirrhosis, as well as steatosis (fatty liver).

People with cirrhotic livers may start to experience symptoms caused by the inability of blood to flow freely through the scarred organ. As a result, blood is diverted around the liver, which can cause a number of secondary symptoms.

Symptoms related to the deterioration in effective liver function may also occur. Since the liver performs many vital functions, such as metabolism of food, protein synthesis, energy production, vitamin storage and blood filtering, symptoms may be highly varied and may become quite severe. In compensated cirrhosis, the liver is heavily damaged but is still able to function. Decompensated cirrhosis occurs when the damaged organ can no longer perform its vital functions.

Symptoms of cirrhosis include:

  • Muscle wasting.
  • Swollen spleen.
  • Ascites: swelling of the abdomen, caused by the accumulation of fluid. It is treated by reduced salt intake and diuretics (drugs which promote urination).
  • Oedema: swelling, usually of the feet, ankles, and lower legs, due to the accumulation of fluid.
  • Varices (abnormally distended blood vessels). Blood vessels around the gullet and stomach enlarge because the blood is trying to find a way around the scarred liver. Varices can bleed into the stomach, causing vomiting of blood or passing of black stools. Burst varices require immediate medical attention.
  • Circulatory changes. The damaged liver may fail to produce blood-clotting proteins, leading to easy bruising and prolonged bleeding. Patients may also develop high blood pressure (portal hypertension) as blood backs up in the scarred liver. Drugs called beta-blockers may be used to relieve portal hypertension.
  • Pruritis (itching). People with cirrhosis may experience an itching sensation of the skin or internal organs due to the build-up of bile and other toxic chemicals.
  • Encephalopathy. Patients may experience impaired mental function and personality changes because the liver is not breaking down waste products such as ammonia in the blood as efficiently as it should or because blood is bypassing the liver. At its most severe, this can lead to coma or death. Laxatives are sometimes used to treat this.

These symptoms may indicate that cirrhosis is progressing to ESLD or liver failure.

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