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Cirrhosis

Topic Overview

What is cirrhosis?

Cirrhosis (say "suh-ROH-sus") is a very serious condition in which scarring damages the liver. The liver is a large organ that is part of the digestive system. It does a wide range of complex jobs that are vital for life. For example, the liver:

  • Makes many important substances, including bile to help digest food and clotting factors to help stop bleeding.
  • Filters poisons from the blood.
  • Breaks down (metabolizes) alcohol and many drugs.
  • Controls the amounts of sugar, protein, and fat in the bloodstream.
  • Stores important vitamins and minerals, including iron.

When a person has cirrhosis, scar tissue (fibrosis) replaces healthy tissue. This scar tissue prevents the liver from working as it should. For example, the liver may stop producing enough clotting factors, which can lead to bleeding and bruising. Bile and poisons may build up in the blood. Scarring can also cause high blood pressure in the vein that carries blood from the intestines through the liver (portal hypertension). This can lead to severe bleeding in the digestive tract and other serious problems.

Cirrhosis can be deadly. But early treatment can help stop damage to the liver.

What causes cirrhosis?

Cirrhosis can have many causes. Some of the main ones include:

Less common causes of cirrhosis include severe reactions to medicines or long-term exposure to poisons, such as arsenic. Some people have cirrhosis without an obvious cause.

What are the symptoms?

You may not have symptoms in the early stages of cirrhosis. As it gets worse, it can cause a number of symptoms, including:

  • Fatigue.
  • Small red spots and tiny lines on the skin called spider angiomas.
  • Bruising easily.
  • Heavy nosebleeds.
  • Weight loss.
  • Yellowing of the skin (jaundice).
  • Itching.
  • Swelling from fluid buildup in the legs (edema) and the abdomen (ascites).
  • Bleeding from enlarged veins in the digestive tract.
  • Confusion.

How is cirrhosis diagnosed?

The doctor will start with a physical exam and questions about your symptoms and past health. If the doctor suspects cirrhosis, you may have blood tests and imaging tests, such as an ultrasound or CT scan. These tests can help your doctor find out what is causing the liver damage and how severe it is.

To confirm that you have cirrhosis, the doctor may do a liver biopsy. This means that he or she will use a needle to take a sample of liver tissue for testing.

How is it treated?

Treatment may include medicines, surgery, or other options, depending on the cause of your cirrhosis and what problems it is causing. It is important to get treated for cirrhosis as soon as possible. Treatment cannot cure cirrhosis. But it can sometimes prevent or delay further liver damage.

There are things you can do to help limit the damage to your liver and control the symptoms:

  • Do not drink any alcohol. If you don't stop completely, liver damage may quickly get worse.
  • Talk to your doctor before you take any medicines. This includes both prescription and over-the-counter drugs, vitamins, supplements, and herbs. Medicines that can hurt your liver include acetaminophen (such as Tylenol) and other pain medicines such as aspirin, ibuprofen (such as Advil or Motrin), and naproxen (Aleve).
  • Make sure that your immunizations are up-to-date. You are at higher risk for infections.
  • Follow a low-sodium diet. This can help prevent fluid buildup, a common problem in cirrhosis that can become life-threatening.

Symptoms may not appear until a problem is severe. So it's important to see your doctor for regular checkups and lab tests. You may also need testing to check for possible problems such as enlarged veins in your digestive tract or liver cancer.

If cirrhosis becomes life-threatening, then a liver transplant may be an option. But a transplant is expensive, organs are hard to find, and it doesn't always work.

If your cirrhosis is getting worse, you may choose to get care that focuses on your comfort and dignity. Palliative care can provide support and symptom relief so you can make the most of the time you have left. You may also want to make important end-of-life decisions, such as writing a living will. It can be comforting to know that you will get the type of care you want.

It can be hard to face having cirrhosis. If you feel very sad or hopeless, be sure to tell your doctor. You may be able to get counseling or other types of help. Think about joining a support group. Talking with other people who have cirrhosis can be a big help.

Frequently Asked Questions

Learning about cirrhosis:

Being diagnosed:

Getting treatment:

Living with cirrhosis:

End-of-life issues:

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Symptoms

People who have cirrhosis sometimes don't have symptoms until liver damage is extensive. Symptoms of cirrhosis and its complications may include:

  • Fatigue.
  • Yellowing of the skin (jaundice).
  • Itching.
  • Swelling from fluid buildup in the legs (edema).
  • Bruising easily and having heavy nosebleeds.
  • Redness of the palms.
  • Small red spots and tiny lines on the skin called spider angiomas.
  • Weight loss and muscle wasting.
  • Belly pain or discomfort.
  • Frequent infections.
  • Confusion.

Complications of cirrhosis

Scar tissue from cirrhosis may block the proper flow of blood from the intestines through the liver. The scarring can lead to increased pressure in the veins that supply this area. This is called portal hypertension. It can lead to other complications, which may include:

  • Fluid buildup in the belly (ascites).
  • Bleeding from enlarged veins (varices) in the digestive tract. This is called variceal bleeding.
  • Increased spleen size. This can lead to a low blood platelet count.
  • Infection of the fluid in the belly (spontaneous bacterial peritonitis, or SBP).
  • Altered brain function (encephalopathy). This usually only occurs in people who have advanced portal hypertension.
  • Hepatorenal syndrome. Kidney (renal) failure can occur in cases of advanced liver disease.
  • Hepatopulmonary syndrome. Portal hypertension can cause lung problems, such as widening of the blood vessels in the lungs. This causes the blood to move too swiftly through the lungs to pick up enough oxygen.
  • Hepatic hydrothorax. Fluid can build up between the lungs and the chest (pleural effusion) and press on the lungs.

People who have cirrhosis also are at increased risk of getting liver cancer, mainly hepatocellular carcinoma.

Exams and Tests

Your doctor will do a physical exam and ask about your medical history to see if you have symptoms of liver disease and to help find out possible causes of liver damage.

If your doctor thinks you may have cirrhosis, you may have blood and imaging tests. You also may have a liver biopsy. This test can show for sure if you have cirrhosis.

Blood tests to check liver function

Measuring the levels of certain chemicals produced by the liver can show how well your liver is working. Blood tests may be used to measure:

Blood tests to check for inflammation of the liver

You may have blood tests to check your liver enzymes. These can help show whether you have had liver inflammation for a long time. These blood tests include:

Some people with cirrhosis have normal liver enzymes.

Blood tests to diagnose a cause of cirrhosis

Tests to check for conditions that may cause cirrhosis include:

Tests that show an image of the liver

Imaging tests can check for tumors and blocked bile ducts. They also can be used to look at liver size and blood flow through the liver. These tests include:

Other tests

Other tests also may be done to confirm cirrhosis or to look for possible complications. These include:

Treatment Overview

No treatment will cure cirrhosis or repair scarring in the liver that has already occurred. But treatment can sometimes prevent or delay further liver damage. Treatment involves lifestyle changes, medicines, and regular doctor visits. In some cases, you may need surgery for treatment of complications from cirrhosis.

Lifestyle changes

Your doctor will recommend some lifestyle changes to help prevent further liver damage.

  • Stop drinking alcohol. You need to quit completely.
  • Talk to your doctor about all of the medicines you take, including nonprescription drugs such as acetaminophen (for example, Tylenol), aspirin, ibuprofen (for example, Advil or Motrin), and naproxen (Aleve). These could increase the risk of liver damage and bleeding.
  • Get immunized (if you have not already) against hepatitis A(What is a PDF document?) and hepatitis B(What is a PDF document?), influenza, and pneumococcus(What is a PDF document?).
  • Begin following a low-sodium diet if you have fluid buildup (ascites). Reducing your sodium intake can help prevent fluid buildup in your belly and chest. For more information, see Home Treatment.

Treatment for complications of cirrhosis

Cirrhosis can cause other problems (complications) that need treatment with medicines or procedures. Complications include:

  • Fluid buildup in the belly (ascites). It can be deadly if it is not controlled. Treatment can include:
  • Bleeding from enlarged veins.Variceal bleeding in the digestive tract can be treated with:
  • Changes in mental function.Encephalopathy may occur when the liver cannot filter poisons from the bloodstream. As these toxins build up in your blood, they can affect your brain function. You may need to:
    • Eat a limited amount of protein. Too much protein can cause toxins to build up.
    • Take lactulose. This medicine helps prevent the buildup of ammonia and other toxins in the large intestine.
    • Avoid sedative medicines, such as sleeping pills, antianxiety medicines, and narcotics. These can make symptoms of encephalopathy worse.

Follow-up visits

It's important to work with your doctor to watch your condition, especially because symptoms may not start until a problem has become severe. In addition to regular checkups and lab tests, you will also need periodic screening for enlarged veins (varices) and liver cancer (hepatocellular carcinoma).

  • The American College of Gastroenterology recommends testing for varices with endoscopy for all people who have been diagnosed with cirrhosis. If your initial test does not find any varices, you can be tested again in 2 to 3 years. If you already have large varices, you may need more frequent testing and treatment with beta-blocker medicines to try to prevent future bleeding episodes.1
  • Testing to check for liver cancer usually takes place every 6 months. You will likely have a test for alpha-fetoprotein and a liver ultrasound or a magnetic resonance imaging test (MRI).

Liver transplant

Receiving a liver from an organ donor (liver transplant) is the only treatment that will restore normal liver function and cure portal hypertension. A liver transplant is usually considered only when liver damage is severe and threatening your life.

Before your condition becomes severe, you may want to talk to your doctor about whether you will be a good candidate for a liver transplant if your disease becomes advanced.

Liver transplant surgery is very expensive. You may have to wait a long time for a transplant, because so few organs are available. Even if a transplant occurs, it may not work. With these things in mind, doctors must decide who will benefit most from receiving a liver. Good candidates include those who have not abused alcohol or illegal drugs for the previous 6 months and those who have a good support system of family and friends.

Talk to your doctor about what steps you can take now to improve your overall health so that you can increase your chances of being considered a good candidate.

Palliative care

If your cirrhosis gets worse, you may want to think about palliative care. This is a kind of care for people who have illnesses that do not go away and often get worse over time. Palliative care focuses on improving your quality of life—not just in your body but also in your mind and spirit.

For more information, see the topic Palliative Care.

End-of-life issues

If you have not already made decisions about the issues that may arise at the end of life, consider doing so now. Many people find it helpful and comforting to state their health care choices in writing (with an advance directive such as a living will) while they are still able to make and communicate these decisions. You may also think about who you would choose as your health care agent to make and carry out decisions about your care if you were unable to speak for yourself. For more information, see the topics:

A time may come when your goals change from treating or curing an illness to maintaining comfort and dignity. Hospice care health professionals can provide palliative care and comforting surroundings for someone who is preparing to die.

For more information, see the topic Hospice Care.

Home Treatment

Lifestyle changes may reduce symptoms caused by complications of the disease and may slow new liver damage.

Giving up alcohol

If you are diagnosed with cirrhosis, it is extremely important that you stop drinking alcohol completely, even if alcohol was not the cause of your cirrhosis. If you don't stop, liver damage may quickly become worse. For information about how to quit drinking, see Alcohol Abuse and Dependence.

Changing your diet

You may need to limit the amount of salt or protein you eat.

If your body is retaining fluid, the most important dietary change you need to make is to reduce your sodium intake. You do this by reducing the amount of salt in your diet. People with liver damage tend to retain sodium. This can make fluid build up in your belly (ascites).

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If you are at risk for altered mental function (encephalopathy) because of advanced liver disease, your doctor may want you to limit the amount of protein you eat for a while. You will still need protein in your diet to be well nourished. But you may need to get most of your protein from vegetable sources (rather than animal sources).h And you may need to avoid eating large amounts of protein at one time.

Avoiding harmful medicines

Some medicines should be used carefully or not taken by people who have cirrhosis. For example, acetaminophen (such as Tylenol) can speed up liver damage. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs)—for example, ibuprofen (such as Motrin or Advil) and naproxen (Aleve)—increase the risk of variceal bleeding if you have enlarged veins (varices) in the digestive tract. NSAIDs can also raise your risk for ascites. Talk to your doctor or pharmacist about what medicines are safe for you.

Certain prescription medicines used to treat other conditions may be harmful if you have cirrhosis. Make sure your doctor knows all the medicines (including all nonprescription medicines, vitamins, herbs, and supplements) that you are taking.

Improving your general health

Taking other steps to improve your overall health may help you cope with the symptoms of cirrhosis.

  • Stop smoking. Quitting tobacco use will improve your overall health, which may help make you a better candidate for a liver transplant if you need one.
  • Your doctor may encourage you to take a multivitamin. Don't take one containing extra iron unless your doctor tells you to. And don't take an iron supplement unless your doctor recommends it.
  • Brush and floss your teeth daily to avoid dental problems that could lead to infection (abscess). Be gentle when you floss so you don't make your gums bleed.
  • Make sure you have been vaccinated against:
    • Influenza (flu). Get a flu shot every year. People with cirrhosis are at increased risk for serious complications from the flu.
    • Hepatitis A and hepatitis B.
    • Pneumococcus(What is a PDF document?), which can cause pneumonia or abdominal infection (peritonitis). Ask your doctor how often you should be revaccinated.

Using complementary and alternative medicines wisely

In general, you should avoid most herbal and other supplements, which may make liver disease worse. Kava is particularly bad for people who have liver problems.

Limited research has shown that the herbal supplement milk thistle may help protect the liver, but other research has not shown a benefit.2 Milk thistle will not reverse existing liver damage, and it will not cure infection with the hepatitis B or hepatitis C virus. Milk thistle should not be used by people who have complications from cirrhosis (such as variceal bleeding or ascites). Talk to your doctor about whether you should try milk thistle (or any other alternative treatment).

Other Places To Get Help

Organizations

American Gastroenterological Association
4930 Del Ray Avenue
Bethesda, MD  20814
Phone: (301) 654-2055
Fax: (301) 654-5920
Web Address: www.gastro.org
 

The American Gastroenterological Association is a society of doctors who specialize in the digestive system (gastroenterologists). This Web site can help you find a gastroenterologist in your area. They also have patient information on many gastrointestinal diseases and disorders.

American Liver Foundation (ALF)
39 Broadway, Suite 2700
New York, NY  10006
Phone: 1-800-GO-LIVER (1-800-465-4837)
Fax: (212) 483-8179
Web Address: www.liverfoundation.org
 

The American Liver Foundation (ALF) funds research and informs the public about liver disease. A nationwide network of chapters and support groups exists to help people with liver disease and their families. ALF also sponsors a national organ donor program to increase public awareness of the continuing need for organs.

National Digestive Diseases Information Clearinghouse
2 Information Way
Bethesda, MD  20892-3570
Phone: 1-800-891-5389
Fax: (703) 738-4929
TDD: 1-866-569-1162 toll-free
Email: nddic@info.niddk.nih.gov
Web Address: www.digestive.niddk.nih.gov
 

This clearinghouse is a service of the U.S. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the U.S. National Institutes of Health. The clearinghouse answers questions; develops, reviews, and sends out publications; and coordinates information resources about digestive diseases. Publications produced by the clearinghouse are reviewed carefully for scientific accuracy, content, and readability.


References

Citations

  1. Garcia-Tsao G, et al. (2007). Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. American Journal of Gastroenterology, 102(9): 2086–2102.
  2. Milk thistle (2005). Review of Natural Products. St. Louis: Wolters Kluwer Health.

Other Works Consulted

  • Angulo P, Lindor KD (2010). Primary biliary cirrhosis. In M Feldman et al., eds., Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 9th ed., vol. 2, pp. 1477–1488. Philadelphia: Saunders.
  • Talwalkar JA, Lindor KD (2006). Primary biliary cirrhosis. In M Wolfe et al., eds., Therapy of Digestive Disorders, 2nd ed., pp. 579–587. Philadelphia: Saunders Elsevier.
  • Bacon BR (2012). Cirrhosis and its complications. In DL Longo et al., eds., Harrison's Principles of Internal Medicine, 18th ed., vol. 2, pp. 2592–2602. New York: McGraw-Hill.
  • Bataller R (2008). Cirrhosis of the liver. In EG Nabel, ed., ACP Medicine, section 4, chap. 9. Hamilton, ON: BC Decker.
  • Carithers RL, McClain CJ (2010). Alcoholic liver disease. In M Feldman et al., eds., Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 9th ed., vol. 2, pp. 1383–1400. Philadelphia: Saunders.

Credits

By Healthwise Staff
Primary Medical Reviewer Adam Husney, MD - Family Medicine
Specialist Medical Reviewer W. Thomas London, MD - Hepatology
Last Revised January 17, 2012

Last Revised: January 17, 2012

Author: Healthwise Staff

Medical Review: Adam Husney, MD - Family Medicine & W. Thomas London, MD - Hepatology

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