Cirrhosis

Liver cirrhosis; Cryptogenic chronic liver disease.

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

The digestive system organs in the abdominal cavity include the liver, gallbladder, stomach, small intestine and large intestine.

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

Clubbing may result from chronic low blood-oxygen levels. This can be seen with cystic fibrosis, congenital cyanotic heart disease, and several other diseases. The tips of the fingers enlarge and the nails become extremely curved from front to back.

Symptoms may develop gradually, or there may be no symptoms.
When symptoms do occur, they can include:

Confusion or problems thinking
Impotence, loss of interest in sex, and breast development (gynecomastia) in men
Loss of appetite
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

A CT scan of the upper abdomen showing cirrhosis of the liver.

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
Small testicles
Widened (dilated) veins in the abdomen wall
Yellow eyes or skin (jaundice)

Tests can reveal liver problems including:

Anemia (detected on a complete blood count test)
Clotting problems
Liver function problems (detected on liver function tests)
Low blood 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 abnormal veins in the esophagus or stomach
Ultrasound of the abdomen

A liver biopsy confirms cirrhosis.
Some patients will be screened for liver cancer. 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).

The esophagus, stomach, large and small intestine, aided by the liver, gallbladder and pancreas convert the nutritive components of food into energy and break down the non-nutritive components into waste to be excreted.

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.

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.
Garcia-Tsao G. Cirrhosis and its sequelae. In: Goldman L, Ausiello D, eds. Cecil Medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 156.
Mehta G, Rothstein KD. Health maintenance issues in cirrhosis. Med Clin North Am. 2009;93:901-915.