ESSENTIALS OF DIAGNOSIS
Result of injury that leads to both fibrosis and regenerative nodules.
May be reversible if cause is removed.
The clinical features result from hepatic cell dysfunction, portosystemic shunting, and portal hypertension.
Cirrhosis is the result of hepatocellular injury that leads to both fibrosis and regenerative nodules throughout the liver. It is the eleventh leading cause of death globally and eighth leading cause of death in the United States. The prevalence rate is 0.27%, with an estimated 1.5 billion persons having chronic liver disease and 2.14 million liver-related deaths worldwide. Hospitalization rates for cirrhosis and portal hypertension are rising in the United States, and patients with chronic liver disease have longer hospital stays, more readmissions, and less access to post-acute care than patients with other chronic diseases. Causes include chronic viral hepatitis; alcohol; drug toxicity; autoimmune and metabolic liver diseases, including NAFLD; and miscellaneous disorders. Celiac disease appears to be associated with an increased risk of cirrhosis. Many patients have more than one risk factor (eg, chronic hepatitis and alcohol use) and likely genetic predisposition. Mexican Americans and Blacks have a higher frequency of cirrhosis than Whites because of a higher rate of risk factors. In persons at increased risk for liver injury (eg, heavy alcohol use, obesity, iron overload), higher coffee and tea consumption and statin use reduce the risk of cirrhosis. The risk of hospitalization or death due to cirrhosis has been reported to correlate with protein and cholesterol consumption and with hyperuricemia and inversely with carbohydrate consumption.
The most common histologic classification divides cirrhosis into micronodular, macronodular, and mixed forms. These are descriptive terms rather than separate diseases, and each form may be seen in the same patient at different stages of the disease. In micronodular cirrhosis—typical of alcohol-associated liver disease (Laennec cirrhosis)—the regenerative nodules (eFigure 16–17) are no larger than the original lobules, ie, approximately 1 mm in diameter or less. Macronodular cirrhosis is characterized by larger nodules, which can measure several centimeters in diameter and may contain central veins (eFigure 16–18). This form corresponds more or less to postnecrotic (posthepatitic) cirrhosis but does not necessarily follow episodes of massive necrosis and stromal collapse. Clinically, cirrhosis is considered to progress through three stages that correlate with the thickness of fibrous septa: compensated, compensated with varices, and decompensated (ascites, variceal bleeding, encephalopathy, or jaundice).
Micronodular cirrhosis: Trichome stain of a liver biopsy specimen from a 33-year-old man with cirrhosis shows regenerative nodules (circle) surrounded by fibrosis (arrows) bridging from portal tracts to adjacent portal tracts and central veins. (Used, with permission, from James P. Grenert, MD.)
Cirrhosis: macronodular and postnecrotic (low power).