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.

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 complications include:

• Decreased urine output
• Pale or clay colored stools
• Nosebleeds or bleeding gums
• Abdominal fullness, pain, and indigestion
• Fevers
• Impotence and loss of interest in sex
• Bleeding hemorrhoids
• 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 Complications section).

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 system) 
• 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
• Genetic factors

Certain medical conditions, such as:

• Hemochromatosis
• Wilson's disease
• 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 cirrhosis.

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 procedure.

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.

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)
• Liver transplant

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.

Dietary Restrictions

Protein

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.

Sodium (salt)

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.

Limiting Fluids

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

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.

Shellfish

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.

Dietary Supplements

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.

Antioxidants

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

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 the liver.

Carnitine

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 (SAMe)

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 disease.

Spirulina

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.

Other

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 needed.

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 Supplements).

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:

• Nux vomica
• Staphysagria
• Belladonna
• Stramonium
• Chelidonium
• Zincum
• Carduus marianus 

Remedies that may be recommended for hepatitis include:

• Aconitum
• Belladonna
• Chelidonium
• China
• Lycopodium
• Mercurius
• Phosphorus 

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 weakened liver.

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 women.

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 tissues)
• Liver cancer
• Kidney failure
• Osteoporosis
• Insulin resistance
• Gallstones

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.

Abittan CS, Lieber CS. Alcoholic liver disease. Curr Treat Options Gastroenterol. 1999;2(1):72-80.

Agency for Healthcare Research and Quality. Milk thistle: effects on liver disease and cirrhosis and clinical adverse effects. Summary, evidence report/technology assessment: number 21, September 2000. Accessed at: http://www.ahrq.gov/clinic/milktsum.htm on October 15, 2002.

American Liver Foundation. Cirrhosis: Many Causes. Accessed at http://www.liverfoundation.org on November 10, 2002.

American Liver Foundation. Diet and your liver. Accessed at http://www.liverfoundation.org on November 10, 2002.

American Liver Foundation. What are the myths vs. facts about alcohol and the liver? Accessed at http://www.liverfoundation.org on November 10, 2002

Angulo P, Lindor KD. Treatment of nonalcoholic fatty liver: present and emerging therapies. Semin Liver Dis. 2001;21(1):81-88.

Asai A, Miyazawa T. Dietary curcuminoids prevent high-fat diet-induced lipid accumulation in rat liver and epididymal adipose tissue. J Nutr. 2001;131(11):2932-2935.

Barak AJ, Beckenhauer HC, Tuma DJ. Betaine, ethanol, and the liver: a review. Alcohol. 1996; 13(4): 395-398.

Chitturi S, Farrell GC. Herbal hepatotoxicity: an expanding but poorly defined problem. J Gastroenterol Hepatol. 2000;15(10):1093-1099.

Corbett R, Menez JF, Flock HH, Leonard BE. The effects of chronic ethanol administration on rat liver and erythrocyte lipid composition: modulatory role of evening primrose oil. Alcohol Alcohol. 1991;26(4);459-464.

Day CP. Who gets alcoholic liver disease: nature or nurture? J R Coll Physicians Lond. 2000;34(6):557-562.

Fauci AS, Braunwald E, Isselbacher KJ, et al., eds. Harrison's Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998:1704-1710.

Ferenci P, Dragosics B, Dittrich H, et al. Randomized controlled trial of silymarin treatment in patients with cirrhosis of the liver. J Hepatol. 1989;9:105-113.

Gorban EM, Orynchak MA, Virstiuk NG, Kuprash LP, Panteleimonov TM, Sharabura LB. [Clinical and experimental study of spirulina efficacy in chronic diffuse liver diseases.] Lik Sprava. 2000(6):89-93.

Gruenwald J, Brendler T, Jaenicke C, et al., eds. PDR for Herbal Medicines. Montvale, NJ: Medical Economics Co; 1998:1138-1139.

Imai K, Nakachi K. Cross sectional study of effects of drinking green tea on cardiovascular and liver diseases. BMJ. 1995;310(6981):693-695.

Langmead L, Rampton DS. Review article: herbal treatment in gastrointestinal and liver disease--benefits and dangers. [Review]. Aliment Pharmacol Ther. 2001;15(9):1239-1252.

Lieber CS. Liver disease by alcohol and hepatitis C: early detection and new insights in pathogenesis lead to improved treatment. Am J Addict. 2001;10 Suppl:29-50.

Loguercio C, Nardi G, Argenzio F, et al. Effect of S-adenosyl-L-methionine administration on red blood cell cysteine and glutathione levels in alcoholic patients with and without liver disease. Alcohol Alcohol. 1994;29(5):597-604.

Luper S. A review of plants used in the treatment of liver disease: part two. [Review]. Altern Med Rev. 1999;4(3):178-188.

Mato JM, Camara J, Fernandez de Paz J. S-adenosylmethionine in alcoholic liver cirrhosis: a randomized, placebo-controlled, double-blind, multicenter clinical trial. J Hepatol. 1999;30:1081-1089.

National Digestive Diseases Information Clearinghouse. Cirrhosis of the liver. 2000; NIH Publication No. 00-1134. Accessed at http://www.health.org on November 15, 2002.

Sachan DS, Rhew TH, Ruark RA. Ameliorating effects of carnitine and its precursors on alcohol-induced fatty liver. Am J Clin Nutr. 1984;39:738-744.

Schoenborn CA, Adams PF. Alcohol use among adults: United States, 1997-98. CDC Advance Data. 2001;324:1-20.

Seeff LB, Lindsay KL, Bacon BR, Kresina TF, Hoofnagle JH. Complementary and alternative medicine in chronic liver disease. Hepatology. 2001 Sep;34(3):595-603.

Ullman D. The Consumer's Guide to Homeopathy. New York, NY: Penguin Putnam; 1995:314-317.

Vintro AQ, Krasnoff JB, Painter P. roles of nutrition and physical activity in musculoskeletal complications before and after liver transplantation. AACN Clin Issues. 2002;13(2):333-347.