Cirrhosis - When the Liver Finally Loses the Battle

People other than health-care professionals who are directly involved with trying to save the lives of alcoholics have no concept of the agony, destruction, degradation, and just plain waste caused by this disease. The following article is definitely not for the 'faint of heart, but if you want a feel for what really happens when an alcoholic finally dies from his or her disease, then continue reading.

Cirrhosis is a condition where the liver is reduced to a non-functioning shriveled knot after years of drinking.

First, I need to make a disclaimer. Though I worked with physicians in academic settings for many years, I am not a trained physician, and I have absolutely no clinical experience (i.e., experience treating patients). Therefore, the following observations, other than the definitions and material taken from references as general as Harrison's Principles of Internal Medicine, medical dictionaries, The Merck Manual of Medical Information, and the Physician's Desk Reference, are taken from experience with health professionals who do. However, to be fair, I need to add that I took my bachelor's degree in biology, served in the training department of three drug companies, and worked as a clinical research associate setting up and monitoring drug studies. Academic medicine has been a major part of my life for over 40 years.

A Healthy liver is capable of metabolizing about an ounce of alcohol per hour. Anytime a person drinks at exactly that rate he or she is matching the rate at which the liver can handle alcohol, so they are about "breaking even." Humphrey Bogart figured this out early in his career. He was famous for being able to drink all night without appearing drunk. What he did was pace his drinking so that he was drinking at the same rate that his liver broke down the alcohol.

The liver, as the principle detoxifying organ in the body, responds to alcohol the way it does to any other poison. It tries to protect the body by minimizing the amount of alcohol that enters the blood stream where it can travel to other organs and cause damage. The individual, in the meantime, is drinking for some reason. Maybe that reason is to relax, or to go to sleep, to loosen anxiety in social situations, or just to "get high." In a real sense a battle is going on here between the individual and his or her liver. In other words, while the person is trying to achieve some effect from the alcohol on his or her body and/or brain, the person's liver is trying to prevent the alcohol from getting to the body and/or brain!

The liver's first strategy in this strange battle is to just metabolize the alcohol by using the enzyme alcohol dehydrogenase. We humans make this enzyme naturally because alcohol does occur in foods due to fermentation of any vegetable matter. However, the amount of alcohol occurring naturally is infinitesimal compared to the amounts present in, say one beer. If the rate of consumption stays low, then this ploy by the liver works. This is what made Bogart's system work. The person's liver "cleaves" the alcohol molecule with the same enzyme over and over again until ultimately the alcohol molecule is converted to simple vinegar and water, which is then urinated out of the body. It is also excreted in small amounts through the sweat glands, which is why the families and friends of alcoholics all describe that characteristic sweet smell of alcohol that lingers around alcoholics.

However, if the individual "ups the ante" on the liver by tossing down alcoholic drinks faster in order to achieve the desired effect, then the liver has to resort to more drastic measures. What the liver does is allow as little alcohol as possible into the bloodstream by temporarily storing the alcohol, untouched within itself, in little storage units called vacuoles. The liver's strategy is like this; it creates a vacuole, a tiny opening within its own tissue to store the alcohol...sort of like a Baggie. This is actually quite clever. After the person stops drinking, the liver can metabolize the poison at its leisure. This is what is happening during a hangover. So the strategy here is to just hold the alcohol temporarily intact within the liver. It is basically a delaying tactic.

Unfortunately, every such episode results in a tiny hairline scar when the liver tissue seals up the little internal "Baggie." The scar is in effect a zipper. That zipper is a fine line of scar tissue, which is lighter in color than normal liver tissue, and less supple (i.e., it is hard like any other scar tissue). After decades of creating these little baggies, more and more of the liver looks like scar tissue. At autopsy, livers of alcoholics are shrunken pale masses of hard tissue. This scarred liver tissue was, in the end, totally incapable of performing the liver's vital functions.

We are now entering an area that is about as complicated as any medical subject, because the liver is on a minute-to-minute basis performing the body's chemical operations on a level commiserate with that of the brain performing its mental and regulatory operation. But for the sake of clarity, the focus here needs to stay on the issue of blood flow to and from the liver.

Cirrhosis...The Final Days.

A healthy liver is like a healthy city. In a healthy city, traffic moves into and out of the city. It flows smoothly and rapidly. Imagine this liver-city with two major freeways entering from above and below. The one from the intestines with its blood loaded with nutrients brings in all the raw materials the liver uses in its various manufacturing plant to create just about everything the rest of the body needs to survive: the blood itself, complex proteins to build and repair cells, and, most important to this story, what physicians term "clotting factors." Clotting factors are a complicated range of cells and organic chemicals that basically plug up any holes that appear in the body.

The big freeway coming from the north, the hepatic artery, delivers a steady stream from the heart and lungs. Here is the good clean oxygen-laden blood to stoke the furnaces of the plants doing the manufacturing throughout the liver. This blood is under high pressure, having just left the muscular chamber of the left ventricle of the heart, and has been cleansed of waste gases like carbon dioxide and metabolic wastes that accumulated during the last pass the blood took through the body.

In a cirrhotic liver, both major freeways are constantly backed up with traffic, because the fatty tissue and scarring has blocked vessels throughout the liver...not only the major highways themselves, but even the thousands of smaller highways and short-cuts the liver has been using for years trying to keep itself working.

So how does this all result in the symptoms of cirrhosis? Let's just focus here on those two freeways. Blood carrying only partially digested nutrients from the intestines is forced into the general circulation without the benefit of the liver's detoxification system. This material is called bilirubin. It is in some respects like liquid fecal material. Bilirubin itself is a red pigment that is left over after red blood cells are destroyed.

This material being pumped throughout the bloodstream doesn't make your body feel very good. For example, when it is pumped through the brain, the patient becomes very tired and very grumpy. VERY grumpy. Also, bilirubin is what makes the skin appear bright yellow. This is jaundice. I saw a patient once who was as bright a yellow as a school bus during a training session in internal medicine my company sponsored at Hahnaman General Hospital in Philadelphia.

Moving now to the other freeway, the nearest vessels available for the backup of the hepatic artery are those lining the esophagus. When all of that blood that should be going into the liver backs up into the small vessels lining the esophagus the pressure gets so great that they start to rupture. This causes what the medical professions terms esophageal varices. This is when the medical profession is faced with a losing battle, and some really tough decisions.

Remember those clotting factors normally made by the liver? They are needed now more than ever. The first rupture of a good-sized vessel relieves the high blood pressure and creates another problem...a sudden DROP in blood pressure. Right away physicians start looking to find the biggest holes and pumping in units of blood from the hospital blood bank. In the back of their minds they know that every unit of this precious blood is going to be flushed quickly out through some holes somewhere. The most common place is through the bowel. Most people do not realize how much blood there is in a human being. This can end up all over everything!

At some point the physician is faced with alcoholism's ultimate bad choice; either continue keeping this person alive using other peoples' donated blood, or stop the whole process and allow the patient to bleed out and die. Almost every hospital runs with a shortage of blood, but teaching hospitals, cancer centers, and most government-operated hospitals are just ALWAY in a panic for more blood. The family is right down the hall, and asking questions almost constantly. There are no good choices.

As I stated at the outset of this writing, being associated in any way with death due to alcoholism is not for the faint of heart.

Alcoholism is still rampant all over the world. The tragedy is that, while there is no cure at the moment, there are ways that the disease can be managed. The highest success rate for five-year sobriety remains the AA program, based on the 12 steps. As family members of alcoholics, we also have a support groups based on the same 12-steps program called Al-Anon and ACOA (Adult Children of Alcoholics). Whether you have the disease of alcoholism yourself, or are close to someone who does, there is still hope as long as there is breath. Call one of these programs immediately. You can find AA in the very beginning of any telephone book, and you can reach Al-Anon at 1-888-4AL-ANON or on their excellent web site at

Cirrhosis can be lethal, especially when it has been allowed to progress without treatment. If you live with a family member who drinks routinely and heavily, and if this person begins to exhibit some of the symptoms mentioned earlier, it is important that you get that person to medical attention. As an Al-Anon, we go to great lengths to avoid being an enabler to an alcoholic, but you need to understand that, once alcoholism reaches this point in its progression, it is as life threatening as a loaded gun in the hand of a suicidal individual.

Call 911!

Lastly, in Al-Anon one of our "Do's and Don'ts" is to "...learn the facts about alcoholism." You can help others do just that by passing this article to friends and family who might need the information, to 12-step program friends, to treatment centers, health-care professionals, or anybody whom it might help.

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