Hepatitis C affects approximately 2.7 million Americans, according to the Centers for Disease Control and Prevention. The hepatitis C virus attacks the liver and may interfere with its ability to function properly if the infection persists. CDC reports that 5 to 20 percent of people with untreated hepatitis C eventually develop severe liver scarring, or cirrhosis, after 20 to 30 years. Cirrhosis is divided into two categories. Compensated cirrhosis involves extensive scarring but enough healthy tissue remains to allow the liver to function. Decompensated cirrhosis occurs when scarring becomes so severe that the liver starts to fail and complications develop. Liver scarring accelerates and the risk for cirrhosis from hepatitis C increases after age 45. Symptoms of decompensated liver disease may include abdominal pain, swelling, bruising, bloody stools and fatigue.
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The liver breaks down old red blood cells, generating a byproduct called bilirubin. A normal liver further metabolizes bilirubin, but a failing liver lags behind with this important job. As it builds up in the body, bilirubin causes yellowing of the skin and whites of the eyes, called jaundice. Other skin changes associated with decompensated liver disease include reddening of the palms, whitening of the nails and generalized itchiness.
As liver failure progresses, enlarged veins often develop in the trunk of the body because blood cannot flow easily through the scarred liver, causing a backup. This is called portal hypertension. Veins swell to accommodate the blood flow backup, and some are visible under the skin. Distended veins radiating from the belly button across the abdomen are common with liver failure. Tiny blood vessels seen on the skin surface of the upper body or face are called spider angiomas because they resemble small red spiders.
Abdominal and Digestive System Symptoms
An uncomfortable symptom of decompensated cirrhosis is a fluid-filled, swollen abdomen -- a condition called ascites. Portal hypertension causes the fluid to accumulate in the abdomen. It can also lead to poor kidney function, which further contributes to swelling. Ascites causes discomfort from pressure on other organs in and around the abdominal cavity.
Other digestive system symptoms may include nausea, vomiting and decreased appetite. Stool changes can occur, including light-colored or fatty stools. Bloody or black stools usually indicate intestinal bleeding due to stressed veins in the intestinal tract. Much like the veins in the skin, veins in the esophagus can become enlarged from portal hypertension. These distended veins are called esophageal varices. Up to 40 percent of people with hepatitis C-related have varices, according to a December 2006 study published in "Gastrointestinal Endoscopy." Enlarged veins can also occur along the rectum and anus, causing large hemorrhoids. These fragile veins can bleed profusely if they rupture.
Decompensated liver disease from hepatitis C can cause problems with the clotting ability of the blood. With cirrhosis, there is decreased production of blood clotting factors normally produced by the liver. This makes it difficult for any sort of bleeding to stop spontaneously. Additionally, backed up blood from the liver causes the spleen to swell and retain platelets, other components of the blood that help it to clot. This further contributes to bleeding issues. Swelling of the spleen also causes it to retain red blood cells, which can lead to anemia.
People with decompensated liver disease might notice multiple bruises or petechiae -- tiny purple or red spots from bleeding under the skin. Nosebleeds and bleeding from esophageal or intestinal varices are dangerous in people with liver failure, as a reduced ability to form blood clots makes it difficult to stop the bleeding.
A failing liver cannot filter and detoxify the blood normally, so toxic substances collect in the bloodstream. One of the toxic substances the liver normally breaks down is a compound called ammonia. Excess ammonia and other toxins in the blood interfere with normal brain function. This condition is called hepatic encephalopathy.
Symptoms of early encephalopathy include sleeping too much or too little, poor attention span, moodiness and sluggishness or drowsiness. As encephalopathy worsens, friends and family may notice personality changes, confusion and even violent, aggressive or bizarre behavior. Another common sign is an uncontrollable flapping tremor of the hands. In the most severe state, people with hepatic encephalopathy can be completely unaware of their surroundings and might slip into a coma.
Several other signs and symptoms can occur in people with decompensated liver disease. Exhaustion and weakness are common due to anemia, toxin buildup and impaired processing of nutrients by the failing liver. Weight loss may occur, and muscles in the arms, legs and face can slowly waste away. However, buildup of fluid in the body tissues and abdomen may cause sudden weight gain. If some of this extra fluid collects in the lungs or severe ascites compresses the lungs, it can lead to shortness of breath.
Women with liver failure often have irregular menstrual cycles, or their periods may stop completely. Men commonly develop enlarged breasts and notice shrinkage of the testicles. These changes occur because liver failure causes an imbalance in sex hormones levels. Both men and women may notice a loss of body hair, also from abnormal levels of sex hormones.
People who suffer from decompensated liver failure must monitor their condition closely. Seek immediate medical attention for new or continued abdominal pain, fever, shortness of breath, rapid swelling in the body or decreased urination. Friends or family members should bring loved ones to a medical professional right away if they notice increased sleeping, agitation, confusion or drowsiness.
Medical advisor: Tina St. John, M.D.
REFERENCES & RESOURCES
- Centers for Disease Control and Prevention: Viral Hepatitis - Hepatitis C Information
- Hepatology: Now There Are Many (Stages) Where Before There Was One: In Search of a Pathophysiological Classification of Cirrhosis
- Drugs of Today: Working Together to Tackle HCV Infection: Ombitasvir/Paritaprevir/Ritonavir and Dasabuvir Combination
- World Journal of Hepatology: Hepatitis C: Treatment of Difficult to Treat Patients
- American Journal of Gastroenterology: Prevention and Management of Gastroesophageal Varices and Variceal Hemorrhage in Cirrhosis
- Gastrointestinal Endoscopy: The Prevalence and Risk Factors Associated With Esophageal Varices in Subjects With Hepatitis C and Advanced Fibrosis
- Journal of Hepatology: A Comparison of Fibrosis Progression in Chronic Liver Diseases
- HCV Advocate: HCSP Fact Sheet: What Is Cirrhosis?
- National Institute of Diabetes and Digestive and Kidney Diseases: Cirrhosis
- Merck Manual Professional Version: Cirrhosis
- HCV Advocate: Cirrhosis in Chronic Hepatitis C Infection
- Connections: The Liver's Role in Hormone Balance