Liver Cirrhosis: Modern Approach to the Problem

Abstract

Introduction. Liver cirrhosis (LC) is an important medical and socio-economic problem not only in Ukraine, but throughout the world. The urgency of this disease is due to its significant spread, increase of the number of etiological factors, as well as the occurrence of severe complications, which often leads to death. The prognosis depends on several factors, such as etiology, the severity of liver damage, the presence of complications and concomitant diseases. The aim of the study. To review the scientific literature and summarize the published studies devoted to the study of the etiology, classification, clinical picture and diagnosis of liver cirrhosis. Materials and methods. The content analysis, the method of systemic and comparative analysis, the bibliosemantic method of studying the current scientific research on the etiology, classification, clinical picture and diagnosis of LC were used. The search for sources was carried out in scientometric databases: PubMed-NCBI, Medline, Research Gate, Cochrane Database of Systematic Reviews for the keywords: liver cirrhosis, diagnosis, treatment. 37 literary sources were selected and analyzed. Results. LC is currently ranked 11th among the most common causes of death. The common causes of LC are chronic alcohol intoxication and viral hepatitis B, C, and D. LC is represented by an increase in severity, which is characterized by the lesions of the liver parenchyma with necrosis, dystrophy of hepatocytes, their nodular regeneration, as well as its interstitium with diffuse proliferation of connective tissue, leading to liver failure and portal hypertension. Most patients with cirrhosis remain asymptomatic until they develop decompensated LC. Despite the existence of a number of LC classifications – by morphology, etiology, severity, course, hepatocellular insufficiency stage, the severity of the disease is usually assessed by evaluation of the hepatic functional reserve (according to the C. G. Child – R. N. Pugh classification). Patients with LC often have life-threatening conditions such as variceal hemorrhages, ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, hepatorenal syndrome. Variceal bleeding is a major complication of portal hypertension, which is associated with significant mortality. Ascites represents the most common decompensating event in patients with LC. The appearance of ascites is strongly related to portal hypertension, which leads to splanchnic arterial vasodilation, reduction of the effective circulating volume, activation of endogenous vasoconstrictor systems, and avid sodium and water retention in the kidneys. Bacterial translocation further worsens hemodynamic alterations of patients with cirrhosis and ascites. Ascites is also associated with a high risk of developing the further complications of cirrhosis such as dilutional hyponatremia, spontaneous bacterial peritonitis and/or other bacterial infections and acute kidney injury. Pharmacotherapy for LC should be implemented in accordance with up-to-date guidelines and in conjunction with etiology management, nutritional optimization and patients’ education. The main treatment of uncomplicated ascites is diuretics such as spironolactone in combination with a loop one. Vasoconstrictors and albumin are recommended for the treatment of refractory ascites. In its turn antibiotics play a well-established role in the treatment and prevention of spontaneous bacterial peritonitis. The administration of vasopressor terlipressin and albumin is recommended for the treatment of hepatorenal syndrome. Pharmacological therapy of variceal bleeding aims to decrease the portal pressure by acting on its pathophysiological mechanisms such as increased hepatic vascular tone and splanchnic vasodilatation. Propranolol blocks the β-1 in the heart and the peripheral β-2 adrenergic receptors. β-1 blockade of cardiac receptors reduces heart rate, cardiac output and subsequently decreases flow into splanchnic circulation. β-2 blockade leads to unopposed α-1 adrenergic activity that causes splanchnic vasoconstriction and reduction of portal inflow. Both effects contribute to reduction in portal pressure. Carvedilol is more powerful in reducing hepatic venous pressure gradient than traditional nonselective β-blockers. Endoscopic treatment in many cases is used for the variceal bleeding (eg., ligation of the esophageal varices and tissue glue usage for the gastric varices). A shunt (transjugular intrahepatic portosystemic shunting – TIPS) is used to treat severe and often repeat variceal hemorrhage or refractory ascites. Non-selective β-blockers effectively reduce variceal re-bleeding risk in LC patients with moderate/large varices. Conclusions. Liver cirrhosis is one of the most dangerous multi-organ diseases of a human with multiple pathogenetic links, the causes of which invariably remain hepatitis viruses, alcohol, toxic substances, drugs, ultraviolet radiation, genetic factors, some chronic diseases of the internal organs. There are a number of classifications of liver cirrhosis – by morphology, etiology, severity, course, severity of hepatocellular insufficiency etc. Examination of this category of patients requires timeliness, scrupulousness, compliance with a comprehensive approach using modern clinical, laboratory and instrumental methods. During the objective examination of a patient a doctor traditionally draws attention to the presence of telangiectasia, palmar erythema, jaundice, “raspberry” tongue, scratching marks, gynecomastia in men, ascites and “caput medusae”, during the palpation the liver is enlarged, dense, with a sharp lower edge, spleen is enlarged. Among the laboratory methods, in addition to routine ones, the immunological tests are used, among the main instrumental examination – ultrasound, computed tomography, indirect elastometry of the liver or Fibroscan, esophagogastrofibroscopy, puncture biopsy of the liver, in particular modern ones – vibrational transient elastography and magnetic resonance elastography. Although liver cirrhosis is the final stage of liver disease, this diagnosis cannot be considered a verdict for a patient, because today there are quite effective treatments using the principles of differentiation – the impact on the etiological factor, liver state and comorbid lesions and their complications often allows if not to cure the patient, then to prevent the negative disease course. Among them, there are diet, the use of etiotropic drugs, intestinal sanitation, correction of clinical and laboratory syndromes, portal hypertension syndrome, endothelial and autonomic dysfunction as causes of comorbid lesions and their complications.