Cirrhosis

Definition

Cirrhosis is a chronic degenerative disease of the liver in which normal liver cells are damaged and then replaced by scar tissue. There are different types of cirrhosis that could afflict a person.

Description

Cirrhosis changes the structure of the liver and the blood vessels that nourish it. The disease reduces the liver's ability to manufacture proteins, complex carbohydrates, fats, cholesterol, and to process hormones, nutrients, medications, and poisons. Cirrhosis worsens over time and can become potentially life threatening.

Cirrhosis is the seventh leading cause of disease-related death in the United States. It is the third most common cause of death in adults between the ages of 45 and 65. It is twice as common in men as in women. The disease occurs in more than half of all malnourished chronic alcoholics, and kills about 25,000 people a year. In Asia and Africa, however, most deaths from cirrhosis are due to chronic hepatitis B.

A close-up image indicating biliary cirrhosis of the liver. (Custom Medical Stock Photo. Reproduced by permission.)

Types of cirrhosis

  • Portal, or nutritional cirrhosis. The most common form of the disease in the United States. About 30–50% of all cases of cirrhosis are this type. Nine out of every 10 people who have nutritional cirrhosis have a history of alcoholism. Portal cirrhosis is also called Laënnec's cirrhosis.
  • Biliary cirrhosis. Caused by liver bile-duct diseases that impede bile flow. Bile is formed in the liver and carried via the ducts to the intestines. Bile then helps digest fats in the intestines. Biliary cirrhosis can scar or block these ducts. It represents 15–20% of all cirrhosis.
  • Postnecrotic cirrhosis. Caused by chronic infections. This form of the disease affects up to 40% of all patients who have cirrhosis.
  • Pigment cirrhosis (hemochromatosis). Disorders like the inability to metabolize iron and similar disorders may cause pigment cirrhosis, which accounts for 5–10% of all instances of the disease.

Causes & symptoms

Causes and risk factors

Long-term alcoholism is the primary cause of cirrhosis in the United States. Men and women respond differently to alcohol. Although most men can safely consume two to five drinks a day, one to two drinks a day can cause liver damage in women. Individual tolerance to alcohol varies, but people who drink more and drink more often have a higher risk of developing cirrhosis. In some people, one drink a day can cause liver scarring.

Chronic liver infections, such as hepatitis B and particularly hepatitis C, are commonly linked to cirrhosis. People at high risk of contracting hepatitis B include those exposed to the virus through contact with blood and body fluids. This includes healthcare workers and intravenous (IV) drug users. In the past, people have contracted hepatitis C through blood transfusions. As of 2003, cirrhosis resulting from chronic hepatitis has emerged as a leading cause of death among HIV-positive patients; in Europe, about 30% of HIV-positive patients are coinfected with a hepatitis virus.

Liver injury, reactions to prescription medications, certain autoimmune disorders, exposure to toxic substances, and repeated episodes of heart failure with liver congestion can cause cirrhosis. A family history of diseases can genetically predispose a person to develop cirrhosis. These are:

  • a lack of a specific liver enzyme (alpha1-antitrypsin deficiency)
  • the absence of a milk-digesting enzyme (galactosemia)
  • an inability to convert sugars to energy (glycogen storage disease)
  • an absorption deficit in which excess iron is deposited in the liver, pancreas, heart, and other organs
  • a disorder characterized by accumulations of copper in the liver, brain, kidneys, and corneas (Wilson's disease)

Obesity has recently been recognized as a risk factor in nonalcoholic hepatitis and cirrhosis. Some surgeons are recommending as of 2003 that patients scheduled for weight-reduction surgery have a liver biopsy to evaluate the possibility of liver damage.

Symptoms

Symptoms of cirrhosis are usually caused by the loss of functioning liver cells or organ swelling due to scarring. The liver enlarges during the early stages of illness. Patients may experience:

  • anemia
  • bleeding gums
  • constipation
  • decreased interest in sex
  • diarrhea
  • dull abdominal pain
  • extremely dry skin and intense itching
  • fatigue
  • fever
  • fluid in the lungs
  • hallucinations
  • indigestion
  • lethargy
  • lightheadedness
  • loss of appetite
  • muscle weakness
  • musty breath
  • nausea
  • painful nerve inflammation (neuritis)
  • portal hypertension (this type of hypertension can be life threatening; it can cause veins to enlarge in the stomach and esophagus; the enlarged veins, called varices, can rupture and bleed massively)
  • redness of the palms of the hands
  • slurred speech
  • tremors
  • dark yellow or brown urine and black or bloody stools
  • vomiting
  • weakness
  • weight loss
  • yellowish whites of the eyes and skin, indicating the development of jaundice

As the disease progresses, other symptoms usually appear:

  • spleen enlarges and fluid collects in the abdomen (ascites) and legs (edema)
  • spider-like blood vessels appear on the chest and shoulders, and bruising becomes common
  • men sometimes lose chest hair; their breasts may grow and their testicles may shrink
  • women may have menstrual irregularities

If the liver loses its ability to remove toxins from the brain, the patient may have additional symptoms. The patient may become forgetful and unresponsive, neglect personal care, have trouble concentrating, and acquire new sleeping habits. These symptoms are related to ammonia intoxication and the failure of the liver to convert ammonia to urea. High protein intake in these patients can also lead to these symptoms.

Cirrhosis worsens over time and can become potentially life-threatening. This disease can cause:

  • excessive bleeding (hemorrhage)
  • impotence
  • liver cancer
  • coma due to accumulated ammonia and body wastes (liver failure)
  • sepsis (blood poisoning)
  • death

Diagnosis

A patient's medical history can reveal illnesses or lifestyles likely to lead to cirrhosis. Liver changes can be seen during a physical examination. A doctor who suspects cirrhosis may order blood and urine tests to measure liver function. Because only a small number of healthy cells are needed to carry out essential liver functions, test results may be normal even when cirrhosis is present.

In about 10 out of every 100 patients, the cause of cirrhosis cannot be determined. Many people who have cirrhosis do not have any symptoms (often called compensated cirrhosis). Their disease is detected during a routine physical or when tests for an unrelated medical problem are performed. This type of cirrhosis can also be detected when complications occur (decompensated cirrhosis).

Computed tomography scans (CT), ultrasound, and other imaging techniques can be used during diagnosis. They can help determine the size of the liver, indicate healthy and scarred areas of the organ, and detect gallstones. Cirrhosis is sometimes diagnosed during surgery or by examining the liver with a laparoscope. This viewing device is inserted into the patient's body through a tiny incision in the abdomen.

Liver biopsy is usually needed to confirm a diagnosis of cirrhosis. In this procedure, a tissue sample is removed from the liver and examined under a microscope in order to learn more about the organ's condition and to properly diagnose it.

A newer and less invasive test involves the measurement of hyaluronic acid in the patient's blood serum. As of 2003, however, the serum hyaluronic acid test is most useful in monitoring the progress of liver disease; it is unlikely to completely replace liver biopsy in the diagnosis of cirrhosis.

Treatment

Before starting on any alternative treatment program, patients should consult their doctor for monitoring of side effects and effectiveness of treatment. Any nutritional changes should be discussed with the primary care provider. Alternative treatments that may be of help to cirrhotic patients include nutritional and juice therapy, Western herbal therapy, traditional Chinese medicine, and homeopathy.

Nutritional therapy

To support liver function and slow down disease progression, a naturopath may recommend the following:

  • Avoid liver toxins. Cirrhotic patients must completely avoid alcohol. Alcohol accelerates liver failure and hastens death in cirrhotic patients. In addition, even over-thecounter drugs, such as acetaminophen (Tylenol), should be avoided because they can be toxic in cirrhotic patients.
  • Juice therapy helps the liver detoxify toxins from the body. Patients should mix one part of pure juice with one part of water before drinking.
  • Eat smaller meals. To avoid overworking the liver, five or six smaller, lighter meals per day are recommended.
  • Avoid fatty foods, especially those prepared with animal fats or hydrogenated oils and processed foods. These types of foods put additional demands on the liver.
  • Eat only lean proteins (containing no fats) and in limited amounts. Vegetable proteins, such as those found in legumes or tofu, and whole grains are preferred. High protein intake causes increases in ammonia levels in the blood, possibly resulting in mental confusion, and in severe cases, coma. However, do not severely limit protein intake, as this may cause protein deficiency and impair healing process.
  • Increase consumption of fruits and steamed vegetables. Fruits and vegetables are easy to digest, thus less work for the liver. In addition, they are good sources of vitamins, minerals, and antioxidants that help the liver detoxify and heal.
  • Practice intermittent fasting.
  • Take supplements that can improve digestion and help the liver heal and prevent further injury to the liver. They include pancreatic enzymes, milk thistle (Silybum marianum), lipotropic agents such as vitamin B6, vitamin B12, folic acid, choline, alpha lipoic acid, betaine, and methionine.

In 2001, several studies were compared to determine the effectiveness of milk thistle in treating cirrhosis and other liver diseases. The active component in milk thistle, silymarin, promotes liver protein synthesis. Studies appear to show improved survival among cirrhosis patients who use milk thistle (study subjects received 140 mg of silymarin three times a day).

Other therapies

Other types of therapies the patient may want to consider are naturopathic hydrotherapy, and ones that may improve immune function, including stress reduction, guided imagery, and massage.

Traditional Chinese medicine

Depending on a patient's specific condition, an expert Chinese herbalist may prescribe herbal remedies that may help improve liver function. Animal studies have shown that the following Chinese herbs may have protective effects on the liver:

  • Propolis
  • Bupleurum chinense is the most frequently used herb for a variety of liver diseases
  • Phellodendron wilsonii
  • Clementis chinensis
  • Solanum incanum
  • Ixeris chinensis
  • Gardenia jasminoides

Western herbal therapy

Patients should consult an experienced herbalist for specific herbal treatments. There has also been moderate evidence regarding the use of milk thistle in helping to alter the effects of cirrhosis; however, there is no conclusive data as of 2002.

Homeopathy

For homeopathic therapy, patients should consult a homeopathic physician who will prescribe specific remedies based on knowledge of the underlying cause.

Allopathic treatment

The goal of treatment is to cure or reduce the condition causing cirrhosis, prevent or delay disease progression, and prevent or treat complications.

Salt and fluid intake is often limited, and activity is encouraged. A diet high in calories and moderately high in protein can benefit some patients. Tube feedings or vitamin supplements may be prescribed if the liver continues to deteriorate. Patients are asked not to consume alcohol.

Medication

Iron supplements, diuretics, and antibiotics may be used for anemia, fluid retention, and ammonia accumulation associated with cirrhosis. Vasoconstrictors are sometimes needed to stop internal bleeding and antiemetics may be prescribed to control nausea.

Laxatives help the body absorb toxins and accelerate their removal from the digestive tract. Beta-blockers may be prescribed to control cirrhosis-induced portal hypertension. Interferon medicines may be used by patients with chronic hepatitis B and hepatitis C to prevent post-hepatic cirrhosis.

Surgery

Medication that causes scarring can be injected directly into veins to control bleeding from varices in the stomach or esophagus. Varices may require a special surgical procedure called balloon tamponade ligation to stop the bleeding. Surgery may be required to repair disease-related throat damage. It is sometimes necessary to remove diseased portions of the spleen and other organs.

The incidence of liver cancer related to cirrhosis in the United States has increased 75% since the early 1990s. Partial surgical removal of the liver in patients with early-stage cancer of the liver appears to be as successful as transplantation, in terms of the 5-year survival rate.

Liver transplants can benefit patients with advanced cirrhosis. However, the new liver will eventually become diseased unless the underlying cause of cirrhosis (such as alcoholism) is removed.

Supportive measures

A balanced diet promotes regeneration of healthy liver cells. Eating five or six small meals throughout the day should prevent the sick or bloated feeling patients with cirrhosis often have after eating. Alcohol and caffeine, which destroy liver cells, should be avoided, as should any other foods that upset the stomach. Patients with brain disease associated with cirrhosis should avoid excessive amounts of protein in the diet.

A patient can keep a food diary that describes what was eaten, when it was eaten, and how the patient felt afterwards. This diary can be useful in identifying foods that are hard to digest and in scheduling meals to coincide with the times the patient is most hungry.

Patients who have cirrhosis should weigh themselves every day and notify their doctor of a sudden gain of 5 lb (2.3 kg) or more within a one to two week period. A doctor should also be notified if symptoms of cirrhosis appear in anyone who has not been diagnosed with the disease. A doctor should also be notified if a patient diagnosed with cirrhosis:

  • vomits blood
  • passes black stools
  • seems confused or unresponsive
  • shows signs of infection (redness, swelling, tenderness, pain)

Expected results

Cirrhosis-related liver damage cannot be reversed, but further damage can be prevented by patients who:

  • eat properly
  • get enough rest
  • do not consume alcohol
  • remain free of infection

If the underlying cause of cirrhosis cannot be corrected or removed, scarring will continue. As scarring continues, the liver will fail, and the patient will probably die within five years. Patients who stop drinking after being diagnosed with cirrhosis can increase their likelihood of living more than a few years from 40% to 60–70%.

Prevention

Eliminating alcohol abuse could prevent 75–80% of all cases of cirrhosis.

Other preventive measures include:

  • maintaining a healthy diet that includes whole foods and grains, vegetable, and fruits
  • obtaining counseling or other treatment for alcoholism
  • taking precautions (practicing safe sex, avoiding dirty needles) to prevent hepatitis
  • getting immunizations against hepatitis if a person is in a high-risk group
  • receiving appropriate medical treatment quickly when diagnosed with hepatitis B or hepatitis C
  • having blood drawn at regular intervals to rid the body of excess iron from hemochromatosis
  • using medicines (chelating agents) to rid the body of excess copper from Wilson's disease
  • wearing protective clothing and following product directions when using toxic chemicals at work, at home, or in the garden

In 2001, research scientists identified the protein segment and method in which excess tissue grows in diseases like cirrhosis. With further study, the discovery might one day result in an oral or inhalable peptide for those with cirrhosis.

Resources

BOOKS

Andrews, Marcia, and Robert B. Cooper. Everything You Need to Know About Diseases. Springhouse, PA: Springhouse Corporation, 1997.

The Burton Goldberg Group. "Cirrhosis." In Alternative Medicine: The Definitive Guide. 2nd ed. Tiburon, CA: Future Medicine Publishing, Inc., 2002.

"Cirrhosis." Section 4, Chapter 41 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2002.

Editors of Time-Life Books. The Medical Advisor: The Complete Guide to Alternative & Conventional Treatments. Alexandria, VA: Time Life Inc., 1996.

"Liver Problems." In The Hamlyn Encyclopedia of Complementary Health. London: Reed Intl. Books Ltd.

Murray, Michael T., and Joseph E. Pizzorno. "Detoxification." In Encyclopedia of Natural Medicine. Rocklin, CA: Prima Publishing, 1998.

Pelletier, Kenneth R., MD. The Best Alternative Medicine, Part II, "CAM Therapies for Specific Conditions: Alcoholism." New York: Simon & Schuster, 2002.

PERIODICALS

Cha, C. H., L. Ruo, Y. Fong, et al. "Resection of Hepatocellular Carcinoma in Patients Otherwise Eligible for Transplantation." Annals of Surgery 238 (September 2003): 315–321.

Foreman, M. G., D. M. Mannino, and M. Moss. "Cirrhosis as a Risk Factor for Sepsis and Death: Analysis of the National Hospital Discharge Survey." Chest 124 (September 2003): 1016–1020.

Higuchi, H., and G. J. Gores. "Mechanisms of Liver Injury: An Overview." Current Molecular Medicine 3 (September 2003): 483–490.

Kamath, B. M., and D. A. Piccoli. "Heritable Disorders of the Bile Ducts." Gastroenterology Clinics of North America 32 (September 2003): 857–875.

Lin, Song-Chow, Yun-Ho Lin, Chin-Fa Chen, Chia-Yu Chung, and Shih-Hsien Hsu. "The Hepatoprotective and Therapeutic Effects of Propolis Ethanol Extract on Chronic Alcohol-induced Liver Injuries." American Journal of Chinese Medicine 25, no. 3–4 (1997): 325–332.

"Management of Alcoholic Hepatitis." Drug Therapy Bulletin 41 (July 2003): 49–52.

Moretto, M., C. Kupski, C. C. Mottin, et al. "Hepatic Steatosis in Patients Undergoing Bariatric Surgery and Its Relationship to Body Mass Index and Co-Morbidities." Obesity Surgery 13 (August 2003): 622–624.

"Peptides: Peptide Critical to Cirrhosis Development." Drug Discovery and Technology News 4, no. 11 (November 2001).

Phillips, M. G., V. R. Preedy, and R. D. Hughes. "Assessment of Prognosis in Alcoholic Liver Disease: Can Serum Hyaluronate Replace Liver Biopsy?" european Journal of Gastroenterology and Hepatology 15 (September 2003): 941–944.

Ristig, M., H. Drechsler, J. Crippin, et al. "Management of Chronic Hepatitis B in an HIV-Positive Patient with 3TC-Resistant Hepatitis B Virus." AIDS Patient Care and STDs 17 (September 2003): 439–442.

Walsh, Nancy. "Milk Thistle for Liver Disease (Alternative Medicine: An Evidence-Based Approach." Internal Medicine News (January 1, 2002): 10.

ORGANIZATIONS

American Liver Foundation. 1425 Pompton Ave., Cedar Grove, NJ 07009. (800) 465-4837. <http://www.liverfoundation.org>.

United Network for Organ Sharing. 1100 Boulders Parkway, Suite 500, P.O. Box 13770, Richmond, VA 23225-8770. (804) 330-8500. <http://www.unos.org>.

OTHER

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Cirrhosis of the Liver. April 200 [cited October 2002]. <http://www.niddk.nih.gov/health/digest/pubs/cirrhosi/cirrhosi.htm>.

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