Cirrhosis is scarring of the liver that occurs as a result of chronic liver
disease. Scarring causes disruptions to the flow of blood and bile through the
liver and keeps the liver from working properly.
The liver is the largest organ in the body and it has many vital tasks to
perform. For example, it gets rid of or neutralizes toxins (such as poisons,
germs, and bacteria) in the blood and controls infection. The liver also
produces proteins that regulate blood clotting and bile that helps absorb fats
and fat-soluble vitamins.
When the liver does not work normally, many complications can develop.
Scarring of the liver, once it occurs, cannot be repaired. But because cirrhosis
progresses very slowly, early treatment can prevent further damage.
Signs and Symptoms
The signs and symptoms of cirrhosis can range from an absence of symptoms to
frank liver failure.
The most common symptoms include:
Fatigue and weakness
Loss of appetite, weight loss, and nausea
Small, red spider-like blood vessels under the skin
Yellowing of the skin and eyes (jaundice)
Redness of the palms of the hands (palmar erythema)
Swelling of the belly caused by fluid retention (ascites)
Swelling of the legs, feet, and back caused by fluid buildup
(edema)Breast development in males and, possibly, shrinking testicles
Whole body itching (called pruritus)
Mental confusion (called hepatic encephalopathy), caused by a buildup
in the blood of harmful toxins
Additional symptoms that may be associated with this disease or its
Decreased urine output
Pale or clay colored stools
Nosebleeds or bleeding gums
Abdominal fullness, pain, and indigestion
Impotence and loss of interest in sex
Vomiting blood (from esophageal varices [enlarged veins in the
esophagus] due to portal hypertension - build up of
pressure in the large vein supplying blood to the liver; see
The most common cause of liver disease in the United States is alcohol abuse.
Excessive amounts of alcohol over time cause liver damage in virtually
anyone, although not necessarily cirrhosis. Consuming 32 to 48 oz. of beer, 4 to
8 oz. of liquor, or 16 to 32 oz. of wine every day for 10 to 15 years or longer
increases your chances significantly of developing cirrhosis. How much alcohol
you drink, how regularly, and for how many years are more important factors than
the type of alcohol ingested. Approximately 5% of people in the United States
are alcoholics. Of these, 10% to 25% will develop liver disease.
Other causes of cirrhosis include:
Viral diseases -- hepatitis B and hepatitis C (these cause
inflammation of the liver and damage over many years)
Inherited diseases - such as cystic fibrosis
Autoimmune inflammation of the liver (the body's own immune system
attacks the liver)
Disorders of the drainage system of the liver (the biliary
Metabolic disorders of iron and copper (hemochromatosis and Wilson's
disease respectively) each of which can deposit in the liver
Medications and environmental toxins (rarely).
Related to Alcohol:
Women tend to develop liver disease at lower quantities of alcohol
intake than men
Obesity may increase your chances of developing alcoholic liver
disease because of fatty deposition in the liver
Certain medical conditions, such as:
Biliary system disorders
Immune system disorders of the liver
Chronic hepatitis B or C
Nonalcoholic steatohepatitis (NASH) - fatty
deposition in the liver due to conditions other than heavy alcohol use
Your doctor will take a detailed history to try to determine the cause of
your liver disease and to see if your symptoms might be related to something
else. Then, the doctor will examine you closely for certain physical
characteristics that clearly indicate liver injury. Visible signs include
yellowing (jaundice) of your eyes and skin, red spider-like blood vessels just
under the surface of your skin, and redness of your palms. Your doctor will feel
the size of your liver (which may be enlarged at early stages of liver damage,
but will shrink when scar tissue from cirrhosis sets in) and check for excess
breast tissue, small testicles in men, and a distended abdomen. An x-ray or
ultrasound may be done to look at the size of your liver and spleen. Your doctor
will order a blood test to measure your complete blood count (looking for
anemia), blood clotting factors, and liver function tests. Also, a liver biopsy
may be necessary to determine the extent of damage to the liver and, possibly,
to help figure out the underlying cause.
Avoid excessive intake of alcohol
Take precautions to avoid contracting hepatitis B and C (such as being
careful if your occupation exposes you to blood or blood products, practicing
safe sex, being immunized against hepatitis B)
See your doctor regularly if you have chronic hepatitis
Avoid inhaling chemicals or getting them on your skin
Cirrhosis is irreversible, but its progression and the
complications it causes can,
possibly, be avoided. Treatment is directed at addressing the underlying cause,
such as abstinence from alcohol, interferon or other medications to build up
your immune system if you have chronic viral hepatitis, or corticosteroids for
autoimmune hepatitis. Treatment of complications includes taking certain
medications for disorders of the brain
(encephalopathy) and infections,
dietary modifications to treat excess
abdominal fluid, and
surgery for bleeding or enlarged veins. In
certain cases liver transplant will be necessary.
If you have cirrhosis from any cause, it is important to abstain from
drinking alcohol to prevent further damage to the liver. If your cirrhosis is
caused by alcoholism, your provider will not only strongly urge you to stop
drinking, but will also counsel you about the risks you are taking if you
continue to drink. Your doctor may suggest Alcoholics Anonymous as a good place
to start your rehabilitation and maintain your abstinence.
Medications that may cause liver damage must also be stopped. For example,
acetaminophen, also called paracetamol (a common over the counter medication
used for headaches and pain) can cause liver damage if taken in large quantities
or by people who drink alcohol regularly.
If you work with chemicals, follow procedures to avoid inhaling them or
getting them on your skin.
Dietary changes, such as restricting
salt intake, may be necessary to treat complications of
Medications are prescribed to treat complications such as bleeding from
veins, infections in fluid accumulated in the abdomen, and damage to the brain
(encephalopathy) caused by toxins circulating in the blood.
Antibiotics- for treatment of infected
ascites (called peritonitis); treatment typically lasts 10 days and you may need
to be hospitalized if intravenous antibiotics are required.
Beta-blockers -- typically propranolol or nadolol, reduce the heart
rate and can lower the pressure in veins going to the liver. This helps to
reduce the likelihood of bleeding from these veins (called varices). If the
varices do bleed, you may need a special
Diuretics—usually spironolactone and
furosemide help to reduce fluid buildup; your doctor will use these very
cautiously as serious side effects due to electrolyte imbalances can occur.
Lactulose—reduces toxic levels of ammonia
that cause hepatic encephalopathy, which can result in disturbances in
consciousness or deep coma.
Somatostatin (a natural hormone) and similar (synthetic) agents, as
well as vasocontrictors - prevent bleeding from varices
by causing blood vessels to narrow.
Surgery and Other Procedures
A liver biopsy may be necessary to make a diagnosis of cirrhosis, determine
its cause, and to assess the extent of liver damage. Generally this procedure
involves inserting a needle through the abdominal wall to the liver to obtain
tissue samples. The greatest risk with this procedure is the potential to bleed;
therefore, if you have a clotting abnormality from liver disease, your doctor
will likely use a different method for obtaining a liver biopsy.
Surgery and surgical procedures may be required to stop and prevent certain
complications of cirrhosis. These situations include:
Endoscopic procedures to stop bleeding from varices in the esophagus
that are under pressure from liver failure. Endoscopy allows direct
visualization of the esophagus and the area that is bleeding.
Shunt placement to redirect blood from the liver to other parts of the
circulation; may be performed to alleviate portal hypertension (see
Complications) and stop
bleeding varices that were not controlled by the endoscopic procedure.
Drainage of excess fluid from the abdomen (called paracentesis)
Nutrition and Dietary Supplements
Malnutrition is often a problem for people with cirrhosis. An important
function of the liver is to convert food that we eat into stored energy needed
by the body to function properly. Also, the liver is responsible for removing
toxins from the body. For these reasons, eating a healthy diet is an important
part of treatment for cirrhosis. To avoid malnutrition, it is important to
maintain a well-balanced diet of 2,000 to 3,000 calories per day. Your diet
should be full of fresh fruit, vegetables, and whole grains. Your healthcare
provider may also talk with you about proper protein balance, limiting your
fluid intake, and salt restriction.
High-quality dietary protein may be particularly important for you if you
have buildup of fluid in the abdomen or swelling of the feet, legs, or back.
Protein also helps to repair muscle mass. However, too much protein can raise
ammonia levels and trigger hepatic encephalopathy (see
Complications). The type of
protein you eat, therefore, is very important. There is no limit on the amount
of vegetable protein (such as soy) you can have in your diet, but you will
likely need to restrict your intake of animal protein.
If you have fluid retention, you may be asked to cut your intake of sodium to
less than 2,000 mg a day because sodium encourages the body to retain water.
Avoiding processed and prepared foods will do a great deal to reduce your salt
intake because these foods are very high in sodium. Examples of such foods are
canned meats, soups, and vegetables, crackers, and cold cuts. Eat good amounts
of fresh foods, because they contain very little sodium. Instead of adding salt
to your food, try lemon juice or black pepper.
Fluid restriction may be necessary if you have ascites (fluid retention).
Your doctor will talk to you about limiting fluid intake and how to do this if
it is necessary.
Iron is an essential mineral. Excess iron not used by the body is stored in
the liver, bone marrow, spleen, and muscles. Too much iron can cause damage to
the liver. Avoid iron-rich foods, such as red meats, liver, and iron-fortified
cereals and do not cook with iron-coated cookware and utensils.
Uncooked shellfish should be avoided because it may carry a dangerous
bacteria called Vibrio vulnificus. If you are not sure how well shellfish is
cooked, do not eat it.
Given that the liver is responsible for metabolizing and detoxifying
substances that we ingest, extreme caution must be exercised when considering
taking supplements if you have liver disease. In fact, supplements should not be
taken without consent from your doctor. For any of the substances discussed
below, it is best to try to obtain them from foods.
There is some preliminary laboratory evidence that antioxidants, like vitamin
E and selenium, may help protect against liver damage and cirrhosis. For
example, low selenium levels may worsen the toxic effects of alcohol on the
liver. It is not clear, however, whether selenium supplementation can help
prevent or treat liver damage. Eating fresh fruits, vegetables, and whole grains
is a great way to include antioxidants in your diet.
Betaine is a nutrient that mainly helps your heart and blood vessels and also
helps to clear certain toxins from the body. Studies with rats have suggested
that betaine may help protect against fatty deposits in the liver, which can
occur from chronic alcohol use, protein malnutrition, obesity, poorly controlled
diabetes, and other causes. A few studies on people have also been conducted. In
one preliminary study, 10 people with fatty liver disease from causes other than
alcohol received betaine for up to one year. All of the participants had
improvement in liver function tests and a reduced amount of fat and other
changes in the liver itself. In another larger, better-designed study that took
place in Italy, nearly 200 patients received either betaine, in combination with
two other substances, or a placebo. Those who received the betaine combination
supplement had improved liver function, reduced fat in the liver, and diminished
abdominal pain. Further research is needed to confirm these findings and to see
whether it is the betaine that is specifically responsible for the benefit to
Carnitine is a substance produced in the liver and elsewhere that helps the
body convert fatty acids into energy. Some researchers speculate that alcohol
consumption reduces the ability of carnitine to function properly. This can lead
to a buildup of fat in the liver. Supplementation with carnitine has been shown
to prevent and reverse the damage caused by alcohol-induced fatty buildup in the
liver of animals. Studies on people are needed.
Omega-6 fatty acids
Preliminary research suggests that gamma-linolenic acid (GLA), an omega-6
essential fatty acid found in evening primrose oil (EPO) and borage seed oil,
may help lessen cravings for alcohol and prevent liver damage. More research is
needed in this area.
S-Adenosylmethionine or SAMe is a naturally occurring antioxidant that is
involved in many biochemical processes in the body. This compound has been under
investigation for many years in Europe for the treatment of liver disease.
Preliminary research suggests that it may provide protection against liver
damage and scarring and may improve survival rates in people with cirrhosis due
to alcohol abuse. Animal studies also suggest that SAMe may protect the liver
from damage after acetaminophen overdose. More research is needed to test the
safety and effectiveness of this supplement for preventing and treating liver
Spirulina is a type of blue-green algae found in many ponds and lakes. It is
considered a complete protein because well over half of it consists of amino
acids -- the building blocks of protein. There is some preliminary evidence that
spirulina may help protect against liver damage and cirrhosis in those with
chronic hepatitis. More research is needed in this area.
People with cirrhosis may be deficient in zinc and vitamin K. It is not known
whether supplementation with zinc is helpful in treating the disease, and while
vitamin K is often used to help prevent excessive bleeding in people in the
earlier stages of liver disease, it is generally not very helpful once cirrhosis
has set in.
The use of herbs is a time-honored approach to strengthening the body and
treating disease. Herbs, like medications, contain active substances that can
trigger side effects and interact with other herbs, supplements, or medications.
People with liver disease must be particularly careful because the liver
processes almost everything we ingest. For these reasons, herbs should be taken
with extreme care and only under the supervision of a practitioner knowledgeable
in the field of herbal medicine.
Celery Seed (Apium graveolens)
Ayurvedic physicians have used celery seed to treat people with certain
ailments of the liver. Plus, a few animal studies suggest that certain
ingredients in celery seed may have activity to help protect the liver from
damaging agents such as acetaminophen. Further scientific investigation is
Dandelion (Taraxacum officinale)
Dandelion is a natural diuretic and, therefore, has been used traditionally
by herbal specialists for a wide range of conditions requiring mild diuretic
treatment such as liver disease with excessive fluid.
Green Tea (Camellia sinensis)
Population-based studies have shown that men who drink more than 10 cups of
green tea per day are less likely to develop disorders of the liver. More
specifically, green tea may protect the liver from the damaging effects of toxic
substances such as alcohol. More rigorous scientific study would help clarify
safety and effectiveness of this use. Also, green tea has large amounts of
vitamin K and, therefore, may help replenish this necessary vitamin in the early
phases of liver damage (see earlier discussion in Nutrition and Dietary
Licorice root (Glycyrrhiza glabra)
Licorice root has been used in both Eastern and Western medicine to treat a
variety of illnesses, including liver disease. Although premature to draw
conclusions, some preliminary data from Japanese researchers suggests that
taking glycyrrhizin (an active component of licorice root) in combination with
cysteine and glycerine may prove useful for helping reduce the risk of cirrhosis
if you have hepatits C. Those participating in the study received these
substances intravenously. More research is warranted.
Milk thistle (Silybum marianum)
Milk thistle has been used since Greco-Roman times as an herbal remedy for a
variety of ailments, particularly liver problems. Today, many professional
herbalists recommend milk thistle extract for the prevention and/or treatment of
various liver disorders including viral hepatitis. Several scientific studies
lend support to this traditional use because they suggest that active substances
in milk thistle (particularly silymarin) protect the liver from damage caused by
viruses, toxins, alcohol, and certain drugs such as acetaminophen. However, in a
comprehensive review of studies on milk thistle by the U.S. Agency for
Healthcare Research and Quality (AHRQ), milk thistle improved liver function in
people with mild liver disease but was less effective for those with severe
liver disease such as cirrhosis.
Turmeric (Curcuma longa)
Animal studies provide evidence that turmeric may protect the liver from a
number of damaging substances such as carbon tetrachloride and acetaminophen.
Turmeric accomplishes this, in part, by helping to clear such toxins from the
body and by protecting the liver from damage. Research in people is needed.
Although few studies have examined the effectiveness of specific homeopathic
therapies, professional homeopaths may consider remedies, based on their
knowledge and experience, for reducing the physical addiction to alcohol and for
helping to treat hepatitis. Before prescribing a remedy, homeopaths take into
account a person's constitutional type. A constitutional type is defined as a
person's physical, emotional, and psychological makeup. An experienced homeopath
assesses all of these factors when determining the most appropriate treatment
for each individual.
Remedies that may be recommended for alcoholism include:
Remedies that may be recommended for hepatitis include:
Joining support groups in which members share common experiences and problems
can often help reduce the stress of a chronic illness such as cirrhosis. Check
with your doctor or area hospital for a group near you.
Acupuncture has shown potential as an effective treatment for addiction, like
alcohol addiction, according to a 1997 Consensus Statement by the National
Institutes of Health. Many addiction programs that currently offer acupuncture
report that people appear to "like acupuncture" and, in many cases, want to
continue with their detox program for longer periods of time when acupuncture is
provided as a treatment option. This is very important since attendance is
essential for the success of treatment.
Your healthcare provider will use caution when prescribing medications if you
have cirrhosis because many medications cause complications in someone with a
Similarly, certain herbs and supplements are known to cause harm to the liver
or cause complications that affect those with liver disease:
Kava kava (an herb used for anxiety and tension) can be toxic to the
liver and cause severe hepatitis and even liver failure if taken excessively.
Liver-related risks have prompted regulatory agencies in other countries,
including Germany, Switzerland, France, Canada, and the United Kingdom, to warn
consumers about the potential risks associated with kava use and to remove
kava-containing products from the marketplace. Similarly, the United States FDA
issued an advisory in March of 2002 regarding the potential risk of liver
failure associated with kava-containing products, but this herb has not been
taken off the market in this country.
Vitamin A in large quantities can be toxic to the liver.
Milk thistle should not be used by pregnant or breastfeeding
Prognosis and Complications
Complications from cirrhosis include:
Portal hypertension (buildup of pressure in the large vein supplying
blood to the liver)
Bleeding esophageal varices (enlarged veins at the lower end of the
esophagus that have a tendency to bleed; caused by portal hypertension)
Hepatic encephalopathy (brain disorder caused by toxins accumulating
in the brain), which causes forgetfulness and mental confusion; may lead to coma
Ascites (abdominal fluid retention) and bacterial peritonitis
(infection of the fluid)
Sepsis (presence of harmful organisms or their toxins in the blood or
Your healthcare provider will supervise and manage your condition over the
long term because cirrhosis can be serious and life-threatening, particularly if
you continue to drink.
With 25,000 people dying from liver failure in the United States each year,
cirrhosis is the seventh leading cause of death in this country. In addition,
having cirrhosis puts you at risk for developing liver cancer. The good news is
that with proper diet, medical management and avoidance of alcohol, you can
drastically slow down the rate of progression of liver damage.
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Review Date: December 2002
Reviewed By: Participants in the review process include: Shiva Barton, ND, Wellspace,
Cambridge, MA; Jacqueline A. Hart, MD, Department of Internal Medicine,
Newton-Wellesley Hospital, Boston, Ma and Senior Medical Editor A.D.A.M., Inc.;
Lonnie Lee, MD, Internal Medicine, Silver Springs, MD; Sherif H. Osman, MD,
President, Medical Staff Harford Memorial Hospital, Falston General Hospital,
Bel Air, MD.
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otherwise. No warranty, expressed or implied, is made in regard to the contents
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regarding dosage, precautions, warnings, interactions, and contraindications
before administering any drug, herb, or supplement discussed