Sr. Consultant, Liver Transplant, HPB & GI Surgery, Metro Heart Institute with Multispeciality, Faridabad
Part 2 of 10 in Diagnosis and Management of Liver Cirrhosis
What Causes Liver Cirrhosis: Hepatitis, Alcohol and NAFLD
June 16, 2024
Cirrhosis is damage to the liver that can arise from many different causes, but they all end in the same place: a shrunken, hardened liver that blood can no longer flow through properly.
The major causes
Prolonged alcohol intake, chronic hepatitis B infection, and chronic hepatitis C infection are the major causes of cirrhosis; hepatitis B and C are the dominant cause in the east, while hepatitis C and alcoholic liver disease dominate in the west. Of the five hepatitis viruses (A through E), only B, C and D can lead to cirrhosis and liver cancer; hepatitis A and E cause acute viral hepatitis and, rarely, acute liver failure, but not cirrhosis.
The rise of NAFLD
Non-alcoholic fatty liver disease (recently renamed metabolic-associated fatty liver disease), seen in people with diabetes, obesity or dyslipidaemia, is rising rapidly due to sedentary lifestyles and increasing obesity and diabetes, and is quickly becoming the leading cause of both cirrhosis and liver transplant, projected to overtake hepatitis C as the leading transplant indication in the US. Around 60-70% of obese patients have some degree of NAFLD, and 15-50% of obese patients have NASH, many of whom progress to cirrhosis. In children, the most common cause is biliary atresia, where the bile ducts are congenitally absent; surgery must be performed within 60 days of birth to have a chance of preventing cirrhosis.
This article is based on a Jivo Masterclass session conducted by Dr. Sandeep Jha, Consultant Liver Transplant, Manipal Hospital, New Delhi. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
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This guide is based on a live Jivo Masterclass: Dr. Sandeep Jha taught doctors across Africa on June 16, 2024.
FROM THE LIVE Q&A
Jivo Doctor Partner (name unclear from transcript)
What is refractory ascites and how is it managed?
Dr. Sandeep Jha
Regular ascites is managed with salt restriction, diuretic tablets and tapping. But if tapping the fluid is followed by it returning within a week (refractory ascites), there is no other long-term treatment; the patient will keep losing protein and grow weaker, with a high infection risk, so they should be referred for a liver transplant as soon as possible. In the interim, the only options are tapping at least twice a week and giving albumin.
Frequently Asked Questions
Can hepatitis B be permanently cured with current drugs?▼
Today's drugs are excellent compared to 10 years ago and can control the virus very effectively. However, they cannot permanently cure hepatitis B, because the virus hides inside cells and can reactivate even after years or decades.
Do all patients with liver cirrhosis go on to develop features of decompensation?▼
No, absolutely not. About 5% of cirrhosis patients decompensate every year. If cirrhosis is diagnosed early and risk factors are controlled (weight loss, diabetes control, hepatitis B/C control), there is a good chance the patient can live out their life with the same liver. However, there is no way to know in advance how long a given cirrhotic liver will last, which is why patients are placed under six-monthly surveillance instead.
How is the progression from fatty liver to cirrhosis diagnosed and managed?▼
The first step is to determine whether cirrhosis has actually developed, using a fibroscan or, less often now, a liver biopsy. If the disease is only at the steatohepatitis stage (fatty liver inflammation with no fibrosis yet), controlling risk factors can make it fully resolve. If cirrhosis has already developed, the patient is kept under regular monitoring, since there is no way to predict when a cirrhotic liver will start to fail.
What are the exam findings of cirrhosis, and when do they appear?▼
On examination, jaundice, ascites, leg oedema, spider angiomas, palmar erythema and gynaecomastia are the telltale signs of cirrhosis. Unfortunately, these are only seen in advanced cirrhosis. Since the goal is to catch cirrhosis before complications develop, an ultrasound or fibroscan done proactively is the better approach for early diagnosis.
What are the effective drugs for hepatitis B and C?▼
For hepatitis B, tenofovir and entecavir are very effective drugs with low resistance levels that can practically control the virus. For hepatitis C, directly-acting agents such as sofosbuvir and velpatasvir are very effective and can practically eliminate the virus from the body.
What are the main causes of liver cirrhosis?▼
Prolonged alcohol intake, and chronic hepatitis B or C infection; NAFLD (metabolic-associated fatty liver disease) is rising rapidly and becoming a leading cause.
What is the most common cause of cirrhosis in children?▼
Biliary atresia, where the bile ducts are congenitally absent; surgery within 60 days of birth is critical to prevent cirrhosis.
In This Series: Diagnosis and Management of Liver Cirrhosis
- 1.Liver Cirrhosis
- 2.What Causes Liver Cirrhosis: Hepatitis, Alcohol and NAFLD
- 3.Diagnosing Cirrhosis Early: Fibroscan Before Symptoms Appear
- 4.MELD and Child-Pugh Scores: Grading Cirrhosis and Timing a Transplant
- 5.Decompensated Cirrhosis: Ascites, Encephalopathy and Liver Failure
- 6.Living Donor vs Deceased Donor Liver Transplant
- 7.Living Liver Donor Safety and Evaluation
- 8.Liver Transplant Recovery: Donor and Recipient Timelines
- 9.Hepatitis B and C: Treatment and Family Precautions
- 10.NAFLD and Metabolic Risk Factors: Diet and Lifestyle Management