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Liver Fibrosis / Cirrhosis

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What is Fibrosis / Cirrhosis?

The liver has a very important role to play in the maintenance of human life. It is responsible for the removal of toxins, maintaining metabolic homeostasis, and producing essential proteins1. In addition to these basic functions, the liver is also responsible for regulating blood volume, supporting the immune system, producing bile for digestion, storing iron, converting nutrients to energy, controlling fats and cholesterol, and breaking down drugs

While it is normal to have a small amount of fat in the liver, too much fat or a buildup of fat can result in fatty liver3. An excess of fat in the liver can result in inflammation which damages the liver and causes scarring, also known as liver fibrosis. Liver fibrosis occurs when there is prolonged or chronic injury to the liver, which then tries to heal itself, resulting in scarring4,5. If treatment for liver fibrosis is delayed, it will progress to permanent scarring known as liver cirrhosis6. 

There are a few steps that lead up to liver fibrosis and liver cirrhosis:

What are the common causes Liver Fibrosis / Cirrhosis in Singapore?

Once inflammation or injury occurs to the liver, it will heal itself using collagen and other proteins such as glycoproteins. This initial, reversible scarring is known as liver fibrosis. However, if the inflammation or injury is prolonged or chronic, the liver will soon lose the ability to heal itself resulting in permanent scarring or liver cirrhosis.
The causes of liver fibrosis and cirrhosis are similar as they are along the same line of progression. Causes of liver fibrosis and cirrhosis are
  • Alcoholic fatty liver: consumption of alcohol increases your risk of getting alcoholic fatty liver, causing inflammation, scarring, liver fibrosis, and if left untreated, liver cirrhosis.
  • Hepatitis: also known as an inflammation of the liver; it is the body’s reaction to infections or injuries. Injury causes liver fibrosis which may lead to liver cirrhosis.
  • Nonalcoholic fatty liver: for individuals with nonalcoholic fatty liver, the excess fat comes from an unhealthy lifestyle. The excess fat in the liver causes inflammation, scarring, liver fibrosis, which may lead to liver cirrhosis.
  • Autoimmune liver diseases: examples include autoimmune hepatitis, primary biliary cholangitis, primary sclerosing cholangitis.
  • Medication: some prescription and over-the-counter medications can damage the liver with prolonged use and result in liver fibrosis or liver cirrhosis.
  • Storage diseases: examples include haemochromatosis and Wilson’s disease which affect the body’s ability to store and handle copper and iron.

What are the symptoms of Liver Fibrosis / Cirrhosis?

The early stages of both liver fibrosis/cirrhosis often do not produce any symptoms. In fact, a 2016 study8 showed that approximately 6-7% of the world’s population have liver fibrosis but are unaware because they do not have any symptoms. 

If symptoms occur, it is usually in the late stages, this may include9,10:

  • Loss of appetite
  • Tiredness or lethargy
  • Pain or discomfort in your upper right abdomen
  • Vomiting
  • Nausea
  • Oedema or fluid buildup in your legs or stomach
  • Jaundice
  • Unexplained weight loss
  • Itchy skin
  • Easy bruising or bleeding
  • Dark urine
  • Light coloured stools

Is Liver Fibrosis / Cirrhosis painful?

It can be in the late stages when symptoms have appeared, especially if you experience pain or discomfort in your upper right abdomen. 

Who is at risk of Liver Fibrosis / Cirrhosis in Singapore?

There are certain factors that may increase your risk of liver fibrosis/cirrhosis, these are:

  • Consuming alcohol: a study has shown that consuming any amount of alcohol increases your risk of developing liver fibrosis/cirrhosis11.
  • Viral hepatitis: the main cause of liver cirrhosis in Singapore is due to hepatitis B12, which is a type of viral hepatitis.
  • Diabetes: diabetes has been associated with some major complications of liver cirrhosis13.

Obesity: obesity can cause many medical conditions (e.g., nonalcoholic fatty liver) that have been known to be the beginning of liver fibrosis and liver cirrhosis.

How is the condition diagnosed?

Since symptoms may not appear in the early stages of liver fibrosis/cirrhosis, abnormalities may first show up on your annual blood test, this is observed when there are higher levels of liver enzymes. Once this occurs, your gastroenterologist may use the following tests for accurate diagnosis

  • Liver function tests: this is to test how well your liver is working. If your liver enzyme levels are high, it may indicate that your liver is injured, stressed, or not functioning properly.
  • Physical examination: this allows your gastroenterologist to identify if there are any physical changes in your appearance such as yellow skin or eyes, or abdominal swelling.
  • Liver biopsy: a tissue sample is taken from your liver to check if any liver damage or scarring has occurred. 
  • Ultrasound: used to check for fluid retention in your abdomen, enlarged or damaged liver, liver tumours, or abnormalities of the gallbladder.
  • Magnetic resonance imaging (MRI): allows for a better, all rounded view of your liver and surrounding organs.
  • Endoscopic retrograde cholangio-pancreatography (ERCP): combination of x-rays and an upper gastrointestinal tract endoscopy to identify or treat problems.

What are the treatment options for liver fibrosis/cirrhosis in Singapore?

The treatment for liver fibrosis/cirrhosis depends on what the main cause of it was. There are a number of medical and non-medical interventions that can take place to either reverse liver fibrosis or prevent liver cirrhosis from progressing even further into liver cancer or liver failure. Depending on the cause of your liver fibrosis/cirrhosis, the treatment options are:

  • Stop drinking alcohol
  • Adopt a healthy lifestyle of balanced diets and exercise
  • Control your blood sugar level
  • Medications to manage hepatitis and other chronic conditions

 

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Frequently asked questions

Is liver fibrosis curable?
Yes, if you eliminate the cause of liver fibrosis, you can reverse it
What is the difference between liver fibrosis and liver cirrhosis?
Liver fibrosis and liver cirrhosis both occur due to scarring in the liver. However, the scarring in liver fibrosis is minimal and can be reversed. While the scarring in liver cirrhosis is more extreme and is permanent.
Can the liver regenerate after cirrhosis?
No. Scarring of the liver in cirrhosis is permanent.

References:

  1. Michael L Cheng, D. N. (2021). The immune niche of the liver. Clinical Science, 2445-2466.
  2. Elijah Trefts, M. G. (2017). The liver. Current Biology.
  3. Cleveland Clinic Medical Professional. (2020, July 31). Fatty Liver Disease. Retrieved from Cleveland Clinic: https://my.clevelandclinic.org/health/diseases/15831-fatty-liver-disease 
  4. M. Merve Aydın, K. C. (2018). Liver fibrosis. Turkish Journal of Gastroenterology, 14-21.
  5. Ramón Bataller, D. A. (2005). Liver fibrosis. The Journal of Clinical Investigation, 209-218.
  6. E. J. Williams, J. P. (1998). Liver cirrhosis. Postgraduate Medical Journal, 193-202.
  7. Andrew Smith, K. B. (2019). Cirrhosis: Diagnosis and Management. American Family Physician, 759-770.
  8. Prof Pere Ginès, I. G. (2016). Screening for liver fibrosis in the general population: a call for action. The Lancer: Gastroenterology and Hepatology, 256-260.
  9. Cleveland Clinic Medical Professional. (2020, November 1). Cirrhosis of the Liver. Retrieved from Cleveland Clinic: https://my.clevelandclinic.org/health/diseases/15572-cirrhosis-of-the-liver 
  10. Nall, R. (2018, November 13). Liver Fibrosis. Retrieved from healthline: https://www.healthline.com/health/liver-fibrosis 
  11. Michael Roerecke, A. V. (2019). Alcohol consumption and risk of liver cirrhosis: a systematic review and meta-analysis. American Journal of Gastroenterology, 1574-1586.
  12. National University Hospital Singapore. (2022, September 7). Health Information: Liver Cirrhosis. Retrieved from National University Hospital Singapore: https://www.nuh.com.sg/Health-Information/Diseases-Conditions/Pages/Liver-Cirrhosis.aspx
  13. Laure Elkrief, P.-E. R. (2016). Diabetes mellitus in patients with cirrhosis: clinical implications and management. Liver International

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