Cirrhosis

Signs and Symptoms

Symptoms of cirrhosis can range from no symptoms to outright 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, or 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)
• Whole body itching (pruritus)
• Mental confusion caused by a buildup of toxins in the blood
• Vomiting blood from enlarged veins in the esophagus due to portal hypertension

Causes

The most common cause of liver disease in the United States is alcohol abuse. Drinking too much alcohol on a regular basis almost always causes liver damage, although not always cirrhosis. Drinking 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 greatly increases your chances of developing cirrhosis. How much alcohol you drink, how often, and for how many years are more important than what kind of alcohol you drink.

Other causes of cirrhosis include:

• Chronic hepatitis B or hepatitis C infection
• Inherited diseases, such as cystic fibrosis
• Autoimmune inflammation of the liver, when the body's own immune system attacks the liver
• Blocked bile ducts
• Nonalcoholic steatohepatitis (NASH), where inflammation and fat deposits build up in the liver and cause scar tissue to form
• Metabolic disorders of iron (hemochromatosis) and copper (Wilson's disease)
• Medications or exposure to toxic substances

Risk Factors

Women can develop liver disease even though they may drink less than men. Being overweight may also raise your chances of developing alcoholic liver disease because of fatty deposits in the liver. Other risk factors include:

• Age
• Inherited diseases, such as hemochromatosis and Wilson's disease
• Certain medical conditions, such as HIV
• Chronic hepatitis B or C infection
• Male gender
• Obesity

Diagnosis

Your doctor will take a detailed history to determine the cause of your liver disease, and to see if your symptoms might be related to something else. Then your doctor will examine you closely for signs of liver disease, including 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 press on your abdomen to feel the size of your liver. In the early stages of liver disease, the liver may be enlarged and firm, but it shrinks as scar tissue forms.

Your doctor may order other tests, such as blood tests to look for certain liver enzymes, a bilirubin test, an ultrasound, CT scan, MRI, or a liver biopsy.

Prevention

Drink alcohol only in moderation.

Take precautions to avoid getting hepatitis B and C, such as being careful if you are exposed to blood or blood products, practicing safe sex, and getting the hepatitis B vaccine.

See your doctor regularly if you have chronic hepatitis.

Treatment

Cirrhosis cannot be cured. But you can slow down the progression. Treatment depends on the underlying cause. Your doctor will also treat complications. In some cases a liver transplant may be needed.

Lifestyle

If you have cirrhosis from any cause, it is vital to not drink any alcohol to prevent further damage to the liver. If your cirrhosis is caused by alcoholism, your doctor may suggest Alcoholics Anonymous (AA) as a good place to start your rehabilitation.

You will also need to stop taking medications that may cause liver damage. For example, acetaminophen (Tylenol) can cause liver damage if you take large doses or if you regularly drink alcohol and take acetaminophen. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen or Aleve, and ibuprofen, Motrin, or Advil, can also damage the liver, as can some herbs and supplements. If you have liver disease, DO NOT take any over-the-counter medication, herbs, or supplements without checking with your doctor first.

You may need to make changes in your diet to treat complications of cirrhosis, such as lowering salt intake.

Medications

Medications can 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.

• Blood pressure medications (beta-blockers). To help lower blood pressure in the portal vein (portal hypertension), which brings blood to the liver from the intestine. Beta-blockers include propranolol (Inderal) and nadolol (Corgard).
• Sandostatin. May be given to stop bleeding vessels in the esophagus or stomach by causing blood vessels to narrow.
• Diuretics (water pills). To help reduce the amount of fluid in your abdomen or legs. Diuretics include spironolactone (Aldactone) and furosemide (Lasix).
• Lactulose. Given for brain and nervous system damage caused by a buildup of ammonia in the blood (hepatic encephalopathy). A damaged liver may not be able to clean the blood of ammonia. Lactulose, a synthetic sugar, can help stop your intestines from creating ammonia.
• Antibiotics. Given to lower infection rates, minimize bleeding, and improve survival.

Surgery and Other Procedures

You may need a liver biopsy to determine the cause of cirrhosis, and to check how much liver damage has occurred. Generally a liver biopsy involves inserting a needle through the abdominal wall to the liver to get tissue samples.

Surgery may be required to stop and prevent certain complications of cirrhosis:

• Endoscopic procedures to stop bleeding from blood vessels in the esophagus
• Placing a shunt to reroute blood from the liver, to lower portal hypertension
• Draining fluid from the abdomen (paracentesis)
• Liver transplant

Nutrition and Dietary Supplements

Malnutrition is often a problem for people with cirrhosis. One of the liver's important functions is to help convert food into stored energy, as well as to rid the body of toxins. For these reasons, eating a healthy diet is an important part of treatment for cirrhosis. You should be eating a well-balanced diet with plenty of fruits, vegetables, and whole grains. Your doctor may also talk with you about proper protein balance, and limiting your fluid and salt intake.

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 repair muscle mass. But too much protein can raise ammonia levels and trigger hepatic encephalopathy. In general, your doctor needs to determine how much protein is right for you. Your doctor may recommend eating vegetable protein such as soy, instead of animal protein.

Sodium (salt)

If you have fluid retention, you may need to eat less sodium since salt encourages the body to retain water. In addition to passing up the salt shaker, avoid foods high in salt, including processed and prepared foods, such as 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 for flavor.

Shellfish

Avoid raw shellfish, which may carry a bacteria called Vibrio vulnificus that can be dangerous to people with cirrhosis. If you are not sure how well shellfish is cooked, do not eat it.

Dietary Supplements

It is very important that you talk to your doctor before taking any supplement if you have liver disease, including the following:

• Antioxidants. Preliminary evidence suggests that antioxidants, including vitamin E and selenium, might help in treating primary biliary cirrhosis, a condition in which the bile ducts of the liver are slowly destroyed. However, a later double-blind, placebo-controlled study found no benefit from a combination of vitamins A, C, E, plus selenium, methionine, and co-enzyme Q10. While there is no evidence that taking these supplements will help, you can boost the amount of antioxidants you get by eating lots of fresh fruits, vegetables, and whole grains.
• Vitamin E. Preliminary evidence suggests that vitamin E, an antioxidant, may help some people with NASH. In the study, people with NASH received either 800 IU of a specific kind of vitamin E, the diabetes drug pioglitazone (Actos), or placebo. Of the people who took vitamin E, 43% showed improvement in all features of NASH except cirrhosis. More research is needed. You should not take vitamin E for NASH without your doctor's supervision.
• Betaine. Betaine is a nutrient that reduces homocysteine levels in the body, which are associated with heart disease and are higher in people with liver disease. Preliminary studies suggest that betaine might be helpful in treating nonalcoholic fatty liver disease and alcohol-induced cirrhosis. In one study, 10 people with fatty liver disease took betaine for up to 1 year and had better liver function tests and a reduced amount of fat and other changes in the liver itself. More research is needed, so ask your doctor before taking betaine.
• S-adenosylmethionine (SAMe). SAMe, a naturally-occurring antioxidant that is involved in many chemical processes in the body, is best known for its antidepressant effects. But it is also involved in the processes of the liver. People with liver disease have low levels of SAMe, and this may in turn lead to low levels of glutathione, a substance that helps the liver rid the body of toxins. Several studies show that taking SAMe may reduce symptoms of liver disease and normalize bilirubin and liver enzyme levels. However, most of the studies have been small and some have used intravenous (IV) SAMe. More studies are needed to determine what benefits SAMe might provide. SAMe interacts with a number of medications, including prescription antidepressants. So ask your doctor before taking SAMe.
• Branched chain amino acids (BCAAs). BCAAs, which are involved in synthesizing protein in the body, have shown promise in treating hepatic encephalopathy, a brain disorder caused by a buildup of toxins in the blood. Some studies suggest that taking BCAAs can help people with chronic hepatic encephalopathy improve liver function tests and motor ability. However, not all studies show a benefit. Ask your doctor before trying BCAAs.

Herbs

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. Pregnant and breastfeeding women should never take herbs or supplements unless expressly approved by their physicians.

People with liver disease must be particularly careful because the liver processes almost everything you take. For these reasons, you should take herbs with extreme care, and only under the supervision of your doctor.

Bupleurum (Bupleurum chinense). The Chinese herb Bupleurum has anti-inflammatory properties and has been used historically to treat liver disorders. In one study, a formulation that contained Bupleurum appeared to reduce the risk of liver cancer in people with cirrhosis. Bupleurum is not appropriate for pregnant women, people who have bleeding disorders, autoimmune disease, diabetes, or people who will be undergoing surgery.

Licorice root (Glycyrrhiza glabra) Licorice root has been used in both Eastern and Western medicine to treat a variety of illnesses, including liver disease. Some preliminary data from Japanese researchers suggests that taking glycyrrhizin (an active component of licorice root) along with cysteine and glycerine might help reduce the risk of cirrhosis if you have hepatitis C. However, the formula was delivered intravenously (IV). It is not known whether taking these substances by mouth would have any effect. More studies are needed. People with high blood pressure or those who take steroids, hormonal medications, digoxin (Lanoxin), diuretics (water pills), or blood thinners, such as warfarin (Coumadin), should not take licorice. Pregnant women and people with a history of hormone-related cancer should avoid licorice. Men with a history of libido problems or erectile dysfunction should use caution when taking licorice, as should anyone who has issues with their potassium levels. Speak with your doctor.

Milk thistle (Silybum marianum, standardized to 70 to 80% silymarin). Milk thistle contains components that may have estrogen-like effects in the body. So people with a history of hormone-sensitive conditions should use milk thistle with caution. People with ragweed allergies may be more likely than others to be allergic to milk thistle. The herb has been used since Greco-Roman times to treat liver problems. Several scientific studies lend support to this traditional use. They suggest that a substance in milk thistle (silymarin) can protect the liver from damage caused by viruses, toxins, alcohol, and certain drugs such as acetaminophen (Tylenol). However, the evidence is stronger for some conditions than others:

• Studies are mixed as to whether milk thistle improves liver function tests or the death rate for people with alcohol-induced cirrhosis.
• Studies are also mixed as to whether milk thistle improves liver function tests or quality of life for people with chronic active hepatitis B or C.
• Milk thistle may reduce liver damage caused by mushroom poisoning (due to Amanita phalloides, or death's cap mushroom).
• Milk thistle may help protect the liver against damage from exposure to industrial toxins.
• 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.
• People with ragweed allergies may also be allergic to milk thistle.

Cordyceps (Cordyceps sinensis). A type of mushroom used in traditional Chinese medicine to support the liver. Preliminary studies suggest it may help improve liver and immune system function in people with hepatitis B.

Homeopathy

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 to help treat hepatitis. Before prescribing a remedy, homeopaths take into account a person's constitutional type, includes your 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

Other Considerations

If you have cirrhosis, your doctor will use caution when prescribing medications because many medicines cause complications in people with liver disease.

Talk to your doctor before taking any herb or supplement if you have liver disease. Certain herbs and supplements are known to harm the liver or cause complications that affect people with liver disease, including.

• Kava kava. An herb used for anxiety and tension. It can be toxic to the liver and cause severe hepatitis and even liver failure in high doses.
• Vitamin A. In high doses it can be toxic to the liver.
• Mistletoe (Phoradendron leucarpum).
• Germander (Teucrium chamaedrys).
• European barberry (Berberis vulgaris).

Pregnancy

Pregnant or breastfeeding women should not use milk thistle or licorice.

Prognosis and Complications

Complications from cirrhosis include:

• Portal hypertension, which is the 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 (a brain disorder caused by buildup of toxins), which causes forgetfulness and mental confusion; may lead to coma
• Ascites, or abdominal fluid retention, and bacterial peritonitis (infection of the fluid)
• Sepsis, a potentially life-threatening immune system reaction to widespread infection that has spread to the bloodstream
• Liver cancer
• Kidney failure
• Osteoporosis
• Insulin resistance
• Bacterial infections

Cirrhosis can be serious and life threatening, especially if you continue to drink alcohol. The outcome of cirrhosis depends on the stage. 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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