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Cirrhosis

Definition

Cirrhosis is scarring of the liver and poor liver function. It is the final phase of chronic liver disease.

Alternative Names

Liver cirrhosis; Cryptogenic chronic liver disease

Causes, incidence, and risk factors

Cirrhosis is the end result of chronic liver damage caused by chronic liver diseases. Common causes of chronic liver disease in the United States include:

• Hepatitis C infection (long-term infection)
• Long-term alcohol abuse (see alcoholic liver disease)

Other causes of cirrhosis include:

• Autoimmune inflammation of the liver
• Disorders of the drainage system of the liver (the biliary system), such as primary biliary cirrhosis and primary sclerosing cholangitis
• Hepatitis B (long-term infection)
• Medications
• Metabolic disorders of iron and copper (hemochromatosis and Wilson's disease)
• Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH)

Symptoms

Symptoms may develop gradually, or there may be no symptoms.

When symptoms do occur, they can include:

• Abdominal indigestion or pain
• Confusion or problems thinking
• Impotence, loss of interest in sex, and breast development (gynecomastia) in men
• Nausea and vomiting
• Nosebleeds or bleeding gums
• Pale or clay-colored stools
• Small, red spider-like blood vessels on the skin
• Swelling or fluid buildup of the legs (edema) and in the abdomen (ascites)
• Vomiting blood or blood in stools
• Weakness
• Weight loss
• Yellow color in the skin, mucus membranes, or eyes (jaundice)

Signs and tests

During a physical examination the health care provider may find:

• An enlarged liver or spleen
• Excess breast tissue
• Expanded (distended) abdomen, as a result of too much fluid
• Reddened palms
• Red spider-like blood vessels on the skin
• Smaller (contracted) fingers
• Small testicles
• Widened (dilated) veins in the abdomen wall
• Yellow eyes or skin (jaundice)

Tests can reveal liver problems including:

• Anemia (detected on a CBC)
• Clotting problems
• Liver function problems (detected on liver function tests)
• Low serum albumin

The following tests may be used to evaluate the liver:

• Computed tomography (CT) of the abdomen
• Magnetic resonance imaging (MRI) of the abdomen
• Endoscopy to check for dilated veins (varices) in the esophagus or stomach
• Ultrasound of the abdomen

A liver biopsy confirms cirrhosis.

Some patients will be screened for liver cancer every 6 months. Your doctor will use a blood test to check for levels of alpha fetoprotein and will do an imaging test (ultrasound, MRI, or CT scan).

Treatment

All patients with cirrhosis can benefit from certain lifestyle changes, including:

• Stop drinking alcohol.
• Limit salt in the diet.
• Eat a nutritious diet.
• Get vaccinated for influenza, hepatitis A and hepatitis B, and pneumococcal pneumonia (if recommended by your doctor).
• Tell your doctor about all prescription and nonprescription medications, and any herbs and supplements you take now or are thinking of taking.

Other treatment options are available for the complications of cirrhosis:

• Bleeding varices -- upper endoscopy with banding and sclerosis
• Excess abdominal fluid (ascites) -- take diuretics, restrict fluid and salt, and remove fluid (paracentesis)
• Coagulopathy -- blood products or vitamin K
• Confusion or encephalopathy -- lactulose medication and antibiotics
• Infections -- antibiotics

A procedure called transjugular intrahepatic portosystemic shunt (TIPS) is sometimes needed for bleeding varices or ascites.

When cirrhosis progresses to end-stage liver disease, patients may be candidates for a liver transplant.

Support Groups

You can often ease the stress of illness by joining a support group whose members share common experiences and problems. See liver disease - support group.

Expectations (prognosis)

Cirrhosis is caused by irreversible scarring of the liver. Once cirrhosis develops, it is not possible to heal the liver or return its function to normal. It is a serious condition that can lead to many complications.

A gastroenterologist or liver specialist (hepatologist) should help evaluate and manage complications. Cirrhosis may result in the need for a liver transplant.

Complications

• Bleeding disorders (coagulopathy)
• Buildup of fluid in the abdomen (ascites) and infection of the fluid (bacterial peritonitis)
• Enlarged veins in the esophagus, stomach, or intestines that bleed easily (esophageal varices)
• Increased pressure in the blood vessels of the liver (portal hypertension)
• Kidney failure (hepatorenal syndrome)
• Liver cancer (hepatocellular carcinoma)
• Mental confusion, change in the level of consciousness, or coma (hepatic encephalopathy)

Calling your health care provider

Call your health care provider if:

• You develop symptoms of cirrhosis

Call your provider, go to the emergency room, or call the local emergency number (such as 911) if you have:

• Abdominal or chest pain
• Abdominal swelling or ascites that is new or suddenly becomes worse
• A fever (temperature greater than 101 °F)
• Diarrhea
• New confusion or a change in alertness, or it gets worse
• Rectal bleeding, vomiting blood, or blood in the urine
• Shortness of breath
• Vomiting more than once a day
• Yellowing skin or eyes (jaundice) that is new or suddenly becomes worse

Prevention

Don't drink alcohol heavily. If you find that your drinking is getting out of hand, seek professional help.

Measures for preventing the transmission of hepatitis B or C include:

• Avoid sexual contact with a person who has acute or chronic hepatitis B or C.
• Use a condom and practice safe sex.
• Avoid sharing personal items, such as razors or toothbrushes.
• Do not share drug needles or other drug paraphernalia (such as straws for snorting drugs).
• Clean blood spills with a solution containing 1 part household bleach to 10 parts water.

References

Garcia-Tsao G, Lim JK; Members of Veterans Affairs Hepatitis C Resource Center Program. Management and treatment of patients with cirrhosis and portal hypertension: recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program. Am J Gastroenterol. 2009;104:1802-1829.

Schuppan D, Afdhal NH. Liver cirrhosis. Lancet. 2008;371:838-851.

Mehta G, Rothstein KD. Health maintenance issues in cirrhosis. Med Clin North Am. 2009;93:901-915.