Symptoms of (latter stage) liver disease (cirrhosis)

Evidence of cirrhosis may not develop until the patient experiences complications of the disease. These include:

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  Abnormal nerve function (peripheral neuropathy)
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  Enlarged breasts in men (gynecomastia)
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  Shrinking (atrophy) of testicles in men
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  Itching of the hands and feet that spreads to other parts of the body - due to bile products that are deposited in the skin
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  Spider-like veins (spider angiomas) that develop under the skin
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  Abdominal pain – due to enlargement of the liver
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  Jaundice - yellowing of the skin and whites of the eyes

This is caused by inability of the liver to remove the bile pigment bilirubin from the blood. Bilirubin is formed from the breakdown of red blood cells that gives bile its colour.

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  Gallstones - caused by not enough bile reaching the gallbladder

• Bruising easily

This is caused by the decreased production of blood clotting factors by the diseased liver. Liver damage interferes with the liver’s absorption of vitamin K and the production of proteins that help the blood clot. As a result, patients may bruise easier and bleed more frequently.

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  Dark, cola-coloured urine
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  Portal hypertension

Blood from the intestines, spleen and pancreas enter the liver through a large blood vessel called the portal vein. When scar tissue in the liver impedes blood flow it can result in increased pressure in the vein.

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  Ascites - fluid in the abdominal cavity

Cirrhosis can cause large amounts of fluid to build up in the abdominal cavity. This accumulation of fluid causes swelling of the abdomen, abdominal discomfort, and increased weight. The fluid may also interfere with breathing or become infected (spontaneous bacterial peritonitis).

Spontaneous bacterial peritonitis (SBP)

Fluid in the abdominal cavity (ascites) is the perfect place for bacteria to grow. Normally, the abdominal cavity contains a very small amount of fluid that is able to resist infection, and bacteria that enter the abdomen (usually from the intestine) are killed or find their way into the portal vein and to the liver where they are killed.

In cirrhosis, the fluid that collects in the abdomen is unable to resist infection as normal. In addition, more bacteria find their way from the intestine into the ascites.

This complication may be life- threatening, and whereas some patients with this complication have no symptoms, others have fever, chills, abdominal pain and tenderness, diarrhea, and worsening ascites.

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  Edema - swelling of the legs and feet

This is caused by signals that are sent to the kidneys to retain salt and water in the body. The excess salt and water accumulates in the tissue beneath the skin of the ankles and legs because of the effect of gravity when standing or sitting.

This accumulation of fluid is called edema or pitting edema. Pitting edema is the result of any pressure (e.g. fingertip; sock) that causes an indentation in the skin which persists for some time after the release of the pressure. The swelling tends to be worse at the end of a day after standing or sitting and may lessen overnight as a result of the loss of the effects of gravity when lying down.

• Encephalopathy

Some of the protein in food that escapes digestion and absorption is used by bacteria that are normally present in the intestine. While using the protein for their own purposes, the bacteria make substances that they release into the intestine. These substances then can be absorbed into the body. Some of these substances can have toxic effects on the brain. Ordinarily, these toxic substances are carried from the intestine in the portal vein to the liver where they are removed from the blood and detoxified.

In addition, some of the blood in the portal vein bypasses the liver through other veins, increasing the accumulation of toxic substances in the blood.

Symptoms of encephalopathy may include:

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  Mental confusion, such as forgetfulness or difficulty concentrating
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  Irritability
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  Mood changes
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  Abnormal sleep patterns - Sleeping during the day rather than at night. Reversal of the normal pattern is among the earliest symptoms of hepatic encephalopathy.
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  Drug sensitivity - The toxic substances also make the brains of patients with cirrhosis very sensitive to drugs that are normally filtered and detoxified by the liver. Doses of many drugs that normally are detoxified by the liver have to be reduced to avoid a toxic buildup in cirrhosis, particularly sedatives and drugs that are used to promote sleep.
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  Loss of memory
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  Delirium and coma
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  Hepatic encephalopathy Infection

The decreased immune system function from liver damage may lead to increased bacterial infections.

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  Varices - esophageal vein bleeding

When blood flow (returning to the heart from the intestines) in the portal vein is blocked due to scar tissue, it can raise the pressure in the portal vein (portal hypertension). When pressure in the portal vein becomes high enough, it causes blood to flow around the liver through veins with lower pressure to reach the heart. The most common veins through which blood bypasses the liver are the veins lining the lower part of the esophagus and the upper part of the stomach.

The abnormally increased blood flow and the resulting increase in pressure, in nearby blood vessels may cause veins to become stretched and dilated (varices). Because the walls of the blood vessels are thin, this can lead to bleeding. The higher the portal pressure, the larger the varices and the more likely a patient is to bleed from the varices into the esophagus or stomach. Bleeding from varices is usually severe and, without immediate treatment, can be fatal.

Symptoms of bleeding from varices include:

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  Vomiting blood - red blood mixed with clots
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  Black stools - due to changes in the blood as it passes through the intestine (melena)
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  Dizziness or fainting - caused by a drop in blood pressure especially when standing up from a lying position

Bleeding also may occur from varices that form elsewhere in the intestines, for example, the colon, but this is rare. For reasons yet unknown, patients hospitalized because of actively bleeding esophageal varices have a high risk of developing spontaneous bacterial peritonitis.