Cirrhosis

Overview

Cirrhosis is a late stage of scarring (fibrosis) of the liver caused by many forms of liver diseases and conditions, such as hepatitis and chronic alcoholism.

Each time your liver is injured — whether by disease, excessive alcohol consumption or another cause — it tries to repair itself. In the process, scar tissue forms. As cirrhosis progresses, more and more scar tissue forms, making it difficult for the liver to function (decompensated cirrhosis). Advanced cirrhosis is life-threatening.

The liver damage done by cirrhosis generally can't be undone. But if liver cirrhosis is diagnosed early and the cause is treated, further damage can be limited and, rarely, reversed.

Symptoms

Cirrhosis often has no signs or symptoms until liver damage is extensive. When signs and symptoms do occur, they may include:

• Fatigue
• Easily bleeding or bruising
• Loss of appetite
• Nausea
• Swelling in your legs, feet or ankles (edema)
• Weight loss
• Itchy skin
• Yellow discoloration in the skin and eyes (jaundice)
• Fluid accumulation in your abdomen (ascites)
• Spiderlike blood vessels on your skin
• Redness in the palms of the hands
• For women, absent or loss of periods not related to menopause
• For men, loss of sex drive, breast enlargement (gynecomastia) or testicular atrophy
• Confusion, drowsiness and slurred speech (hepatic encephalopathy)

When to see a doctor

Make an appointment with your doctor if you have any of the signs or symptoms listed above.

Causes

A wide range of diseases and conditions can damage the liver and lead to cirrhosis.

Some of the causes include:

• Chronic alcohol abuse
• Chronic viral hepatitis (hepatitis B, C and D)
• Fat accumulating in the liver (nonalcoholic fatty liver disease)
• Iron buildup in the body (hemochromatosis)
• Cystic fibrosis
• Copper accumulated in the liver (Wilson's disease)
• Poorly formed bile ducts (biliary atresia)
• Alpha-1 antitrypsin deficiency
• Inherited disorders of sugar metabolism (galactosemia or glycogen storage disease)
• Genetic digestive disorder (Alagille syndrome)
• Liver disease caused by your body's immune system (autoimmune hepatitis)
• Destruction of the bile ducts (primary biliary cirrhosis)
• Hardening and scarring of the bile ducts (primary sclerosing cholangitis
• Infection, such as syphilis or brucellosis
• Medications, including methotrexate or isoniazid

Risk factors

• Drinking too much alcohol. Excessive alcohol consumption is a risk factor for cirrhosis.
• Being overweight. Being obese increases your risk of conditions that may lead to cirrhosis, such as nonalcoholic fatty liver disease and nonalcoholic steatohepatitis.
• Having viral hepatitis. Not everyone with chronic hepatitis will develop cirrhosis, but it's one of the world's leading causes of liver disease.

Complications

Complications of cirrhosis can include:

• High blood pressure in the veins that supply the liver (portal hypertension). Cirrhosis slows the normal flow of blood through the liver, thus increasing pressure in the vein that brings blood to the liver from the intestines and spleen.
• Swelling in the legs and abdomen. The increased pressure in the portal vein can cause fluid to accumulate in the legs (edema) and in the abdomen (ascites). Edema and ascites also may result from the inability of the liver to make enough of certain blood proteins, such as albumin.
• Enlargement of the spleen (splenomegaly). Portal hypertension can also cause changes to and swelling of the spleen, and trapping of white blood cells and platelets. Decreased white blood cells and platelets in your blood can be the first sign of cirrhosis.
• Bleeding. Portal hypertension can cause blood to be redirected to smaller veins. Strained by the extra pressure, these smaller veins can burst, causing serious bleeding. Portal hypertension may cause enlarged veins (varices) in the esophagus (esophageal varices) or the stomach (gastric varices) and lead to life-threatening bleeding. If the liver can't make enough clotting factors, this also can contribute to continued bleeding.
• Infections. If you have cirrhosis, your body may have difficulty fighting infections. Ascites can lead to bacterial peritonitis, a serious infection.
• Malnutrition. Cirrhosis may make it more difficult for your body to process nutrients, leading to weakness and weight loss.
• Buildup of toxins in the brain (hepatic encephalopathy). A liver damaged by cirrhosis isn't able to clear toxins from the blood as well as a healthy liver can. These toxins can then build up in the brain and cause mental confusion and difficulty concentrating. With time, hepatic encephalopathy can progress to unresponsiveness or coma.
• Jaundice. Jaundice occurs when the diseased liver doesn't remove enough bilirubin, a blood waste product, from your blood. Jaundice causes yellowing of the skin and whites of the eyes and darkening of urine.
• Bone disease. Some people with cirrhosis lose bone strength and are at greater risk of fractures.
• Increased risk of liver cancer. A large proportion of people who develop liver cancer have pre-existing cirrhosis.
• Acute-on-chronic cirrhosis. Some people end up experiencing multiorgan failure. Researchers now believe this is a distinct complication in some people who have cirrhosis, but they don't fully understand its causes.

Prevention

Reduce your risk of cirrhosis by taking these steps to care for your liver:

• Do not drink alcohol if you have cirrhosis. If you have liver disease, you should avoid alcohol.
• Eat a healthy diet. Choose a plant-based diet that's full of fruits and vegetables. Select whole grains and lean sources of protein. Reduce the amount of fatty and fried foods you eat.
• Maintain a healthy weight. An excess amount of body fat can damage your liver. Talk to your doctor about a weight-loss plan if you are obese or overweight.
• Reduce your risk of hepatitis. Sharing needles and having unprotected sex can increase your risk of hepatitis B and C. Ask your doctor about hepatitis vaccinations.

If you're concerned about your risk of liver cirrhosis, talk to your doctor about ways you can reduce your risk.

Diagnosis

People with early-stage cirrhosis of the liver usually don't have symptoms. Often, cirrhosis is first detected through a routine blood test or checkup. To help confirm a diagnosis, a combination of laboratory and imaging tests is usually done.

Tests

Your doctor may order one or more tests that may suggest a problem with your liver, including:

• Laboratory tests. Your doctor may order blood tests to check for signs of liver malfunction, such as excess bilirubin, as well as for certain enzymes that may indicate liver damage. To assess kidney function, your blood is checked for creatinine. You'll be screened for the hepatitis viruses. Your international normalized ratio (INR) is also checked for your blood's ability to clot.

  Based on the blood test results, your doctor may be able to diagnose the underlying cause of cirrhosis. He or she can also use blood tests to help identify how serious your cirrhosis is.

• Imaging tests. Magnetic resonance elastography (MRE) may be recommended. This noninvasive advanced imaging test detects hardening or stiffening of the liver. Other imaging tests, such as MRI, CT and ultrasound, may also be done.
• Biopsy. A tissue sample (biopsy) is not necessarily needed for diagnosis. However, your doctor may use it to identify the severity, extent and cause of liver damage.

If you have cirrhosis, your doctor is likely to recommend regular diagnostic tests to monitor for signs of disease progression or complications, especially esophageal varices and liver cancer. Noninvasive tests are becoming more widely available for monitoring.

Treatment

Treatment for cirrhosis depends on the cause and extent of your liver damage. The goals of treatment are to slow the progression of scar tissue in the liver and to prevent or treat symptoms and complications of cirrhosis. You may need to be hospitalized if you have severe liver damage.

Treatment for the underlying cause of cirrhosis

In early cirrhosis, it may be possible to minimize damage to the liver by treating the underlying cause. The options include:

• Treatment for alcohol dependency. People with cirrhosis caused by excessive alcohol use should try to stop drinking. If stopping alcohol use is difficult, your doctor may recommend a treatment program for alcohol addiction. If you have cirrhosis, it is critical to stop drinking since any amount of alcohol is toxic to the liver.
• Weight loss. People with cirrhosis caused by nonalcoholic fatty liver disease may become healthier if they lose weight and control their blood sugar levels.
• Medications to control hepatitis. Medications may limit further damage to liver cells caused by hepatitis B or C through specific treatment of these viruses.
• Medications to control other causes and symptoms of cirrhosis. Medications may slow the progression of certain types of liver cirrhosis. For example, for people with primary biliary cirrhosis that is diagnosed early, medication may significantly delay progression to cirrhosis.

Other medications can relieve certain symptoms, such as itching, fatigue and pain. Nutritional supplements may be prescribed to counter malnutrition associated with cirrhosis and to prevent weak bones (osteoporosis).

Treatment for complications of cirrhosis

Your doctor will work to treat any complications of cirrhosis, including:

• Excess fluid in your body. A low-sodium diet and medication to prevent fluid buildup in the body may help control ascites and swelling. More-severe fluid buildup may require procedures to drain the fluid or surgery to relieve pressure.

• Portal hypertension. Certain blood pressure medications may control increased pressure in the veins that supply the liver (portal hypertension) and prevent severe bleeding. Your doctor will perform an upper endoscopy at regular intervals to look for enlarged veins in the esophagus or stomach (varices) that may bleed.

  If you develop varices, you likely will need medication to reduce the risk of bleeding. If you have signs that the varices are bleeding or are likely to bleed, you may need a procedure (band ligation) to stop the bleeding or reduce the risk of further bleeding. In severe cases, you may need a small tube — a transjugular intrahepatic portosystemic shunt — placed in your vein to reduce blood pressure in your liver.

• Infections. You may receive antibiotics or other treatments for infections. Your doctor also is likely to recommend vaccinations for influenza, pneumonia and hepatitis.
• Increased liver cancer risk. Your doctor will likely recommend periodic blood tests and ultrasound exams to look for signs of liver cancer.
• Hepatic encephalopathy. You may be prescribed medications to help reduce the buildup of toxins in your blood due to poor liver function.

Liver transplant surgery

In advanced cases of cirrhosis, when the liver ceases to function, a liver transplant may be the only treatment option. A liver transplant is a procedure to replace your liver with a healthy liver from a deceased donor or with part of a liver from a living donor. Cirrhosis is one of the most common reasons for a liver transplant. Candidates for liver transplant have extensive testing to determine whether they are healthy enough to have a good outcome following surgery.

Historically, those with alcoholic cirrhosis have not been liver transplant candidates because of the risk that they will return to harmful drinking after transplant. Recent studies, however, suggest that carefully selected people with severe alcoholic cirrhosis have post-transplant survival rates similar to those of liver transplant recipients with other types of liver disease.

For transplant to be an option if you have alcoholic cirrhosis, you would need:

• To find a program that works with people who have alcoholic cirrhosis
• To meet the requirements of the program, which would include lifelong commitment to alcohol abstinence as well as other requirements of the specific transplant center

Potential future treatments

Scientists are working to expand current treatments for cirrhosis, but success has been limited. Because cirrhosis has numerous causes and complications, there are many potential avenues of approach. A combination of increased screening, lifestyle changes and new medications may improve outcomes for people with liver damage, if started early.

Researchers are working on therapies that will specifically target liver cells, helping to slow or even reverse the fibrosis that leads to cirrhosis. While no targeted therapy is quite ready, the framework for developing such treatments is in place, and progress is accelerating.

Lifestyle and home remedies

If you have cirrhosis, be careful to limit additional liver damage:

• Don't drink alcohol. Whether your cirrhosis was caused by chronic alcohol use or another disease, avoid alcohol. Drinking alcohol may cause further liver damage.
• Eat a low-sodium diet. Excess salt can cause your body to retain fluids, worsening swelling in your abdomen and legs. Use herbs for seasoning your food, rather than salt. Choose prepared foods that are low in sodium.
• Eat a healthy diet. People with cirrhosis can experience malnutrition. Combat this with a healthy plant-based diet that includes a variety of fruits and vegetables. Choose lean protein, such as legumes, poultry or fish. Avoid raw seafood.
• Avoid infections. Cirrhosis makes it more difficult for you to fight off infections. Protect yourself by avoiding people who are sick and washing your hands frequently. Get vaccinated for hepatitis A and B, influenza, and pneumonia.
• Use over-the-counter medications carefully. Cirrhosis makes it more difficult for your liver to process drugs. For this reason, ask your doctor before taking any medications, including nonprescription drugs. Avoid drugs such as aspirin and ibuprofen (Advil, Motrin IB, others). If you have liver damage, your doctor may recommend you avoid acetaminophen (Tylenol, others) or take it in low doses for pain relief.

Alternative medicine

A number of alternative medicines have been used to treat liver diseases. Milk thistle (silymarin) is the most widely used and best studied.

However, there is not enough evidence of benefit from clinical trials to recommend use of any herbal products to treat liver cirrhosis. In addition, some alternative medications may harm the liver. Talk with your doctor if you're interested in trying alternative medicine to help you cope with cirrhosis.

Preparing for an appointment

If you have cirrhosis, you may be referred to a doctor who specializes in the digestive system (gastroenterologist) or the liver (hepatologist).

Here's some information to help you get ready for your appointment and what to expect from your doctor.

What you can do

• Be aware of any pre-appointment restrictions, such as diet restrictions on the day before your appointment.
• Write down your symptoms, including when they started and how they may have changed or worsened over time.
• Take a list of all your medications, as well as any vitamins or supplements.
• Write down your key medical information, including other diagnosed conditions.
• Bring results of medical tests done so far, including digital copies of CT, MRI or ultrasound images and biopsy slides if a liver biopsy has been done.
• Write down key personal information, including any recent changes or stressors in your life.
• Take a family member or friend along to help you remember things.
• Write down questions to ask your doctor.

Questions to ask your doctor

Preparing a list of questions can help you make the most of your time. Some basic questions to ask your doctor include:

• What is most likely causing my cirrhosis?
• Is there a way to slow or stop my liver damage?
• What are my treatment options?
• Are there medications or supplements that can hurt my liver?
• What signs and symptoms of complications should I watch for?
• I have other health conditions. How can I best manage them together?

Don't hesitate to ask additional questions during your appointment.

What to expect from your doctor

Be prepared to answer questions your doctor is likely to ask, including:

• When did you first begin experiencing symptoms?
• Have your symptoms been continuous or occasional?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?
• How often do you drink alcohol?
• Have you been exposed to or taken toxic drugs?
• Do you have a family history of liver disease, hemochromatosis or obesity?
• Have you ever had viral hepatitis?
• Have you ever had jaundice?
• Have you ever had a blood transfusion or used injection drugs?
• Do you have any tattoos?