What are the symptoms of a frail liver?

Symptoms of a Frail Liver (Cirrhosis with Frailty and Sarcopenia)

A frail liver, characterized by cirrhosis with associated frailty and sarcopenia, presents with symptoms including fatigue, muscle weakness, reduced physical activity, anorexia, early satiety, and increased susceptibility to complications like hepatic encephalopathy and ascites. 1

Physical Manifestations

• Muscle wasting and weakness: Reduced muscle mass (sarcopenia) and impaired muscle contractile function are hallmark features, resulting in decreased grip strength and overall physical performance 1
• Fatigue: One of the most common symptoms, often debilitating and affecting quality of life 2
• Physical frailty: Characterized by unintentional weight loss, self-reported exhaustion, weakness, slow walking speed, and low physical activity 1
• Reduced mobility: Patients often demonstrate slow walking speed and difficulty with activities requiring physical exertion 1
• Physical inactivity: Patients typically spend most waking hours sedentary, averaging only about 3,000 steps per day 1

Gastrointestinal and Nutritional Symptoms

• Anorexia: Decreased appetite due to multiple factors including early satiety, dysgeusia, and complications of portal hypertension 1
• Early satiety: Feeling full quickly after minimal food intake, often related to ascites 1
• Nausea and vomiting: Common symptoms that further contribute to poor nutritional intake 1
• Abdominal pain: May be present due to hepatomegaly or other complications 3
• Micronutrient deficiencies: Particularly deficiencies in vitamin D, zinc, magnesium, and fat-soluble vitamins, contributing to muscle dysfunction 1

Neuropsychiatric Symptoms

• Cognitive impairment: Ranging from subtle deficits to overt hepatic encephalopathy 1
• Depression: More common in frail patients with cirrhosis 2
• Poor psychological well-being: Reduced quality of life and increased psychological distress 2
• Sleep disturbances: Including drowsiness during daytime and disrupted sleep patterns 2

Metabolic and Systemic Manifestations

• Hypermetabolism: Accelerated starvation with early shift from glycogenolysis to gluconeogenesis 1
• Systemic inflammation: Elevated inflammatory markers (IL-1, IL-6, IL-10, C-reactive protein, TNF-α) 1
• Endocrine abnormalities: Including reduced testosterone levels in males and altered growth hormone function 1
• Increased susceptibility to infections: Due to immune dysfunction and systemic inflammation 4

Complications of Portal Hypertension

• Ascites: Fluid accumulation in the abdomen, contributing to anorexia and limited physical activity 1
• Hepatic encephalopathy: Neuropsychiatric manifestations ranging from subtle cognitive changes to coma 1
• Jaundice: Yellowing of skin and sclera, typically developing in end-stage disease 3
• Splenomegaly: Enlargement of the spleen due to portal hypertension 3

Functional Impairments

• Difficulty with activities of daily living (ADLs): Impaired ability to perform basic self-care tasks 1
• Reduced functional capacity: Difficulty with tasks requiring physical exertion 1
• Increased dependency: Need for assistance with daily activities 1
• Impaired quality of life: Overall reduction in health-related quality of life 2

Clinical Pitfalls and Important Considerations

• Obesity masking sarcopenia: Nearly one-third of obese patients with cirrhosis meet criteria for sarcopenia, which may be missed on physical examination 1
• Compound sarcopenia in older adults: Combination of aging-related and disease-related muscle loss, associated with higher mortality 1
• Variable presentation: Symptoms may vary widely; some patients with advanced cirrhosis may be relatively asymptomatic 3
• Increased mortality risk: Frail patients with cirrhosis have significantly higher mortality rates, particularly when awaiting liver transplantation 1
• Rapid deterioration potential: Patients with frailty and sarcopenia are at higher risk for acute-on-chronic liver failure with multiorgan dysfunction 4