The preceding discussions outline the various forms of
cirrhosis that may be encountered in the elderly population.
Cirrhosis is not uncommon in older patients. Although it has been stated that most
cirrhosis in the elderly is due to alcohol, these assumptions are perhaps overestimations. In the authors' experience, many older patients are inappropriately labeled with
alcoholic liver disease--presumed guilty until proven otherwise--and have subsequently been shown to have nonalcoholic
liver disease. Careful investigation is required. Hepatotoxic
drug exposure (e.g., to
alpha methyldopa,
nitrofurantoin, or
isoniazid) should be ruled out, and
hepatitis B and
hepatitis C serology obtained.
Primary biliary cirrhosis may occur in both sexes, and thus antimitochondrial antibody should be assayed. Severe
heart disease may result in cardiac
cirrhosis in the elderly, with
ascites and
hepatomegaly.
Alpha 1-antitrypsin deficiency,
primary sclerosing cholangitis, idiopathic
hemochromatosis, and chronic
autoimmune hepatitis may result in advanced
cirrhosis in the elderly; appropriate serum studies should be obtained. If questions remain and if
therapy may be changed, liver biopsy can be performed. A recent study suggested, however, that the risk of
hemorrhage from liver biopsy in the elderly may be increased, especially if
malignancy is present. The era of treatment for
liver diseases has arrived.
Colchicine,
methotrexate,
ursodeoxycholic acid, and others have shown promise in the treatment of PBC,
primary sclerosing cholangitis, and
alcoholic liver disease.
Corticosteroids may be lifesaving in autoimmune
liver disease. Phlebotomy remains the treatment of choice for
hemochromatosis in any age group.
Interferons and other
antiviral agents are being used in chronic type B and type C
hepatitis. Treatment of the complications of
cirrhosis in the elderly may be safely accomplished. Advanced age is not a
contraindication to variceal
sclerotherapy.
Vasopressin, however, may be contraindicated in the elderly patient if there is an underlying history of atherosclerotic coronary or
peripheral vascular disease. Large-volume paracentesis and peritoneal venous shunting can afford symptomatic relief of
ascites, even in the geriatric population. Finally, as noted previously, advanced age is no longer to be considered an absolute
contraindication for
liver transplantation. The evaluation of
liver disease in the elderly may be diagnostically challenging, and its treatment rewarding.