Cirrhosis and Disability

The question arose this evening as to whether someone with alcoholic cirrhosis was allowed to claim disability. This following article would seem to confirm that disability IS allowable.

Craig

Cirrhosis is a chronic liver disease characterized by the progressive and irreversible destruction of liver tissue.

When exposed to an infectious agent, alcohol, or other toxic substances, liver cells (hepatocytes) may be killed faster than they can be replaced. Scar tissue replaces the liver cells that are lost causing the liver to initially increase in size to compensate for the loss of function. As the scar tissue formation continues, the liver is unable to compensate adequately and will then shrink in size.

There are numerous forms of cirrhosis that are distinguished by known or suspected cause, the tissue changes noted in liver biopsies, and the symptoms that an individual exhibits. Cirrhosis occurs as a result of viral infection; chronic exposure to alcohol, drugs, toxic substance; or in association with another disease.

Alcoholic cirrhosis is the most common type of cirrhosis in the US, occurring in nearly 15% of alcoholics. Hepatitis C is the second most common cause of cirrhosis. Although hepatitis B virus is probably the most common cause of cirrhosis in the world, it is a less common cause of cirrhosis in the US (“Cirrhosis of the Liver”)

The cause of primary biliary cirrhosis, which involves the inflammation of tiny ducts that carry bile within the liver, is unknown. It tends to affect women between the ages of 35 and 60. Cirrhosis may also result from the accumulation of excessive amounts of either iron (hemochromatosis) or copper (Wilson’s disease) within the liver, or as a result of a congenital error of metabolism, such as in alpha-1 antitrypsin enzyme deficiency.

Incidence and Prevalence: The overall incidence of cirrhosis in the US is approximately 360 per 100,000 population, or approximately 900,000 total individuals (“Cirrhosis of the Liver”). At least 26,000 deaths per year in the US can be attributed to cirrhosis of the liver. Additionally, the liver cancer associated with some types of cirrhosis accounts for another 10,000 deaths annually.

Diagnosis

History: The different forms of cirrhosis share many clinical signs and symptoms. Individuals may report loss of appetite, abdominal pain, weight loss, yellowing of the skin (jaundice), water retention (edema, ascites), and spider veins. Other signs and symptoms are unique to the type of cirrhosis.

Males with alcoholic cirrhosis may report an increase in breast size (gynecomastia) and a decrease in testicular size (testicular atrophy). Females may report menstrual irregularities or the complete cessation of menstruation (amenorrhea).

Physical exam: In primary biliary cirrhosis, the physical examination may be completely normal early on in the course of the disease. However, as the disease progresses, physical examination may reveal findings common to cirrhosis of all causes. These include increased skin pigmentation, intense itching (pruritus), dark urine, soft yellow spots of fat accumulation on the eyelids (xanthelasmas and xanthomas), an enlarged liver and spleen, and increased tissue at the end of the fingers (clubbing). Up to 40% of individuals with cirrhosis have no symptoms (asymptomatic), and the cirrhosis is discovered only on routine examination or autopsy.

Tests: In all cases, definitive diagnosis requires a liver biopsy in which a small piece of liver tissue is removed and examined microscopically for signs of inflammation, scarring, or infection. Other tests that may be performed include complete blood count (CBC), key liver enzymes, folate and vitamin B12 levels, serum chemistries, viral antibodies, serum immunoglobulin levels, and antibodies to DNA, smooth muscle, and mitochondria. Cholangiography (a procedure used to view the gallbladder duct and determine whether an obstruction is present) may be recommended for those individuals suspected of having primary biliary cirrhosis.

Treatment

Treatment is largely dependent upon the cause of the cirrhosis. Some methods of treating cirrhosis, regardless of the underlying cause, include dietary restrictions, such as placing an individual on a low-protein diet, supplementation with vitamins A, K, and D, and salt restrictions to reduce problems associated with fluid retention (ascites, edema), and diuretics. Individuals with alcoholic cirrhosis will be instructed to stop drinking alcohol immediately.

Individuals with primary biliary cirrhosis may be treated with antihistamines to relieve symptoms of itching, medications that bind bile salts, and anti-inflammatory drugs, such as corticosteroids. In addition, a liver transplant may be recommended for individuals with end-stage liver disease and ascites.

Prognosis

Although cirrhotic liver damage is permanent and irreversible, treatment is usually successful in prolonging life, decreasing morbidity, and preventing complications. Survival is a function of the severity of liver disease. Most individuals with cirrhosis will develop increasing jaundice, weakness, ascites, and portal hypertension within 5 years of diagnosis.

Individuals with alcoholic cirrhosis who stop drinking have a 5-year survival rate of 60%, while those who continue to drink have a 5-year survival rate of only 40%. Individuals with advanced alcoholic cirrhosis typically die sooner.

The 5-year mortality rate in individuals with primary biliary cirrhosis is approximately 33%. Asymptomatic patients generally survive longer.

Complications

Almost all forms of cirrhosis are associated with portal hypertension, esophageal bleeding, enlarged spleen, fluid retention (ascites and edema), and coma. Other complications may include portal vein thrombosis (blood clot formation), the development of liver tumors, altered drug metabolism, spontaneous bacterial peritonitis, and hepatic encephalopathy, in which the brain is poisoned by high blood levels of ammonia.

Return to Work (Restrictions / Accommodations)

A leave of absence, transfer to sedentary work, and increased rest periods may be needed. Since the condition is progressive, these individuals may need increasingly longer periods of time off of work and may have frequent hospitalizations. Eventually, most individuals will need to be on permanent disability status and will be unable to work at all.

Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual’s medical case.

Regarding diagnosis:

Does individual report loss of appetite, abdominal pain, weight loss, yellowing of the skin (jaundice), water retention (edema, ascites), and spider veins?

If male, has the breast size increased (gynecomastia) and the testicular size decreased (testicular atrophy)? If female, are there menstrual irregularities or the complete cessation of menstruation (amenorrhea)?

Does individual have increased skin pigmentation, intense itching (pruritus), dark urine, soft yellow spots of fat accumulation on the eyelids (xanthelasmas and xanthomas), an enlarged liver and spleen, and increased tissue at the end of the fingers (clubbing)?

Is individual asymptomatic?

Was liver biopsy performed and examined microscopically for signs of inflammation, scarring, or infection? Were other tests done such as a complete blood count (CBC), measuring key liver enzymes, folate and vitamin B12 levels, serum chemistries, viral antibodies, serum immunoglobulin levels, and antibodies to DNA, smooth muscle, and mitochondria? Cholangiography?

Was diagnosis of cirrhosis of the liver confirmed?

If diagnosis is uncertain, were other conditions with similar symptoms ruled out?

Regarding treatment:

Was treatment appropriate for the underlying cause of the cirrhosis? Was it effective?

Was individual instructed in dietary restrictions including low-protein and salt?

Did individual receive supplementation with vitamins A, K, and D?

Were symptoms of biliary cirrhosis effectively relieved through drug therapy?

Does individual with alcoholic cirrhosis understand the importance of not drinking alcoholic beverages?

Can individual stop drinking? Was individual referred to a community support group such as Alcoholics Anonymous (AA)?

Is individual a candidate for a liver transplant? On a national transplant list?

Regarding prognosis:

At what stage of the disease was cirrhosis diagnosed?

What is the expected outcome for this type and severity of cirrhosis?

Does individual have a coexisting condition such as advanced age, debilitation, poor nutritional status, cardiac or renal disease that may complicate treatment or impact recovery?

Have any complications developed?

If symptoms do not respond to treatment, does diagnosis need to be revisited?

Cited References

“Cirrhosis of the Liver.” National Digestive Diseases Information Clearinghouse. National Institute of Diabetes and Digestive and Kidney Diseases. 7 Sep. 2004 .