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Overview |
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Definition |
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Cirrhosis is characterized by irreversible chronic injury of the liver
manifested by hepatic fibrosis and small regenerative nodules; it is often a
subclinical condition diagnosed on the basis of the history, physical
examination, and biochemical and serologic tests. Approximately 10% of cases
have no known etiology (cryptogenic cirrhosis). Between 5% to 10% of people in
the U.S. are alcoholics; of these, 10% to 15% will develop liver
disease. |
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Etiology |
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- Average daily consumption of alcohol (32 to 48 oz. of beer, 4 to 8
oz. of liquor, 16 to 32 oz. of wine) for 10 years or more is associated with an
increased incidence of alcoholic cirrhosis. The amount and duration of alcohol
ingestion are more important than the type of alcoholic beverage
ingested.
- Drugs and toxins (e.g., alcohol, methotrexate, isoniazid,
methyldopa)
- Infectious diseases (e.g., hepatitis B and C, brucellosis,
echinococcosis, schistosomiasis, toxoplasmosis)
- Inherited and metabolic disorders (e.g., Wilson's disease,
hemochromatosis, protoporphyria, galactosemia, glycogen storage disease,
alpha1-antitrypsin deficiency, tyrosinosis, hereditary fructose
intolerance)
- Biliary obstruction (e.g., carcinoma, chronic pancreatitis,
sclerosing cholangitis)
- Cardiovascular diseases (e.g., chronic right heart failure,
Budd-Chiari syndrome, veno-occlusive disease)
- Miscellaneous causes (e.g., sarcoidosis, jejunoileal
bypass)
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Risk Factors |
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Excessive ingestion of alcohol, exposure to toxins and infectious
agents |
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Signs and Symptoms |
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The clinical manifestations of cirrhosis can range from an absence of
symptoms (10% to 20% of patients) to hepatic failure.
- Hepatomegaly and splenomegaly
- Jaundice
- Peripheral edema
- Weakness, malaise
- Anorexia and weight loss
- Abdominal pain or gastrointestinal complaints
- Gastroesophageal varices and bleeding
- Hepatic encephalopathy
- Ascites with portal hypertension
- Spider angiomas and palmar erythema
- Testicular atrophy and gynecomastia (in men)
- Menstrual irregularities (in women)
- Parotid
enlargement
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Differential
Diagnosis |
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- Nodular regenerative hyperplasia
- Congenital hepatic fibrosis
- Acute or chronic viral hepatitis
- Diabetes mellitus
- Biliary obstruction, lymphatic obstruction
- Drug toxicity
- Bacterial infections
- Primary biliary or cardiac cirrhosis
- Wilson's disease
- Hemochromatosis
- Hepatic schistosomiasis
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Diagnosis |
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Physical Examination |
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The three most common hepatic findings in alcoholics are fatty liver,
alcoholic hepatitis, and cirrhosis. Patients with fatty liver may have abdominal
pain, mild icterus, or gastrointestinal symptoms but they may also present
asymptomatically. Patients with alcoholic hepatitis may present with anorexia,
nausea, vomiting, weight loss, abdominal pain, hepatomegaly, splenomegaly,
ascites, and jaundice. Patients with alcoholic cirrhosis may present
asymptomatically (10% to 20%) or with signs of chronic liver disease such as
ascites, gastrointestinal bleeding, encephalopathy, spider angiomas, palmar
erythema, parotid enlargement, testicular atrophy, gynecomastia, menstrual
disorders, and muscle wasting. |
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Laboratory Tests |
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A patient with significant liver injury may have normal
results.
- Elevated serum aspartate aminotransferase
- Hyperbilirubinemia, hypoalbuminemia, and hyperglobulinemia
- Elevated alkaline phosphatase
- Prolonged prothrombin time
- Hypomagnesemia, hypophosphatemia, and hypokalemia
- Respiratory alkalosis
- Anemia (from folic acid and vitamin B12 deficiency), gastrointestinal
blood loss, or toxic effects of alcohol on bone
marrow
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Pathology/Pathophysiology |
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- Fibrosis and regenerative nodules
- With fatty liver—large droplets of fat in
the hepatocyte
- With alcoholic hepatitis—hepatocellular
necrosis, alcoholic hyalin (Mallory bodies), increased intralobular connective
tissue in the space of Disse, central vein sclerosis, infiltration by
polymorphonuclear leukocytes
- With alcoholic cirrhosis—portal and central
areas are linked by dense bands of connective tissue, severe scarring in the
central areas, hypersplenism or bone marrow suppression, leading to
thrombocytopenia, leukopenia, and
anemia
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Imaging |
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- Ultrasonography—to exclude biliary
obstruction, confirm hepatosplenomegaly, and detect textural
abnormalities
- Endoscopic retrograde cholangiopancreatography
(ERCP)—to rule out biliary tract disease by determining
patency of the biliary tree
- Computed tomography—to determine severity of
hepatic encephalopathy, liver size, and density in
hemochromatosis
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Other Diagnostic
Procedures |
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- Percutaneous needle biopsy—to distinguish
the severity of the liver damage and to evaluate patients who do not drink but
present with clinical manifestations of liver disease
- Paracentesis—to diagnose cirrhotic ascites,
ruling out other disorders
- Cholangiography for duct obstruction
- Laparoscopic liver
biopsy
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Treatment Options |
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Treatment Strategy |
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Remove/reduce the effects of the cause, prevent further damage if possible,
and prevent/manage complications. Surgery is limited to procedures for portal
hypertension and complete liver transplantation.
- Well-balanced diet (2,000 to 3,000
kcal/day)—for malnutrition
- Protein restriction—to reduce ammonia
production in colon in patients with hepatic encephalopathy, yet ensure adequate
protein
- Salt and water restriction—to help manage
ascites (no more than 1.2 g of sodium and 1 liter of water per
day)
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Drug Therapies |
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- Colchicine (0.6 mg bid)—to slow progression
of disease
- Diuretics—for ascites (e.g., spironolactone
[Aldactone] 100 to 400 mg/day; furosemide, 40 to 120 mg/day). Caution must be
used with diuretics so as not to cause electrolyte abnormalities, hypovolemia,
and death.
- Neomycin (1 g every six hours)—to reduce
ammonia production in intestine that causes encephalopathy
- Lactulose (65 g/dL every two hours)—to
reduce serum ammonia levels and improve hepatic encephalopathy
- Other specific drugs based on complications and
etiology
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Complementary and Alternative
Therapies |
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Effective either alone or as adjunctive therapy. |
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Nutrition |
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- B-complex: B1 (50 to 100 mg), B2 (50 mg), B3 (25 mg), B5 (100 mg), B6
(50 to 100 mg), B12 (100 to 1,000 mcg), folate (400 mcg/day) to prevent
deficiencies common in liver disease
- Antioxidants: vitamin C (1,000 to 3,000 mg/day), vitamin E (400 to
800 IU/day), and selenium (200 mcg/day) reduce toxic effects of alcohol/drugs
and prevent fatty acid oxidation.
- Essential fatty acids are anti-inflammatory; dietary manipulation
includes reducing animal fats and increasing fish and nuts. A mix of omega-6
(evening primrose) and omega-3 (flaxseed) may be best (1 tbsp. oil/day or 1,000
to 1,500 mg/day). Watch clotting times.
- Choline, lecithin, methionine (1 g each/day) for fat
absorption
- Carnitine (300 mg/day) prevents fatty liver
- Glutathione (500 mg bid) helps remove ammonia from the brain, a
complication of cirrhosis
- Vitamin K is necessary for blood clotting; often depleted in
cirrhosis.
- Desiccated liver (500 mg tid) helps to provide nutrition to promote
liver repair.
- Protein restriction to 45 g/day without development of negative
nitrogen balance as long as a minimum of 400 g of carbohydrates is ingested
daily.
- A change from animal to vegetable protein may be
helpful.
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Herbs |
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Ascertain a diagnosis before pursuing treatment. Herbs may be used as dried
extracts (capsules, powders, teas), glycerites (glycerine extracts), or
tinctures (alcohol extracts). Unless otherwise indicated, teas should be made
with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or
flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be
used singly or in combination as noted.
Due to the high doses required and the need to avoid alcohol, the preferred
form of these herbs is powdered.
- Milk thistle (Silybum marianum): 100 mg tid prevents free
radical damage in the liver, stimulates regeneration of hepatocytes, aids in
digestion of fats, effective in treating cirrhosis
- Barberry (Berberis vulgaris): 250 to 500 mg/day corrects
metabolic abnormalities in liver cirrhosis
- Catechin (Uncaria gambir): 400 mg tid, is antioxidant,
antiviral, and helps to regenerate liver
tissue
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Homeopathy |
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May offer relief of symptoms, but needs to be prescribed by an experienced
practitioner. |
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Physical Medicine |
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Castor oil pack. Used externally, castor oil is a powerful anti-inflammatory.
Apply oil directly to skin, cover with a clean soft cloth (e.g., flannel) and
plastic wrap. Place a heat source (hot water bottle or heating pad) over the
pack and let sit for 30 to 60 minutes. For best results, use for three
consecutive days. Apply pack over liver. Preliminary study shows immune
enhancement in healthy patients, historic use to stimulate hepatic
function. |
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Acupuncture |
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May be helpful to alleviate symptoms and increase physiological
functioning. |
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Massage |
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May help alleviate stress and lymph
congestion. |
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Patient Monitoring |
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Patients need long-term management because of the serious life-threatening
complications associated with cirrhosis. Repeated liver tests are necessary,
with frequency based on the relative stability of the
patient. |
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Other
Considerations |
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Prevention |
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The incidence of alcoholic cirrhosis is directly related to the ingestion of
alcohol. Approximately 10% to 20% of alcoholics develop cirrhosis. To prevent
some other forms of cirrhosis, patients must practice safe sex and avoid IV drug
use. |
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Complications/Sequelae |
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- Portal hypertension and its subsequent complications due to
collateral flow from the portal venous system
- Bleeding esophageal varices
- Hypersplenism
- Ascites
- Hepatorenal syndrome
- Hepatic encephalopathy
- Liver failure
- Hepatocellular carcinoma
- Bacterial peritonitis
- Other infections
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Prognosis |
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Dependent on etiology, extent of damage, and success of
intervention |
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Pregnancy |
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Cirrhosis can jeopardize the chances for a healthy
infant. |
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References |
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Bartram T. Encyclopedia of Herbal Medicine. Dorset, England: Grace
Publishers; 1995:295.
Bone K. Clinical Applications of Ayurvedic and Chinese Herbs.
Queensland, Australia: Phytotherapy Press; 1996:69.
Branch WT. Office Practice of Medicine. 3rd ed. Philadelphia, Pa: WB
Saunders Co; 1994:326-338.
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.
Gruenwald J, Brendler T, Jaenicke C, et al., eds. PDR for Herbal
Medicines. Montvale, NJ: Medical Economics Co; 1998:1138-1139.
Marshall AW, Graul RS, Morgan MY, Sherlock S. Treatment of alcohol-related
liver disease with thioctic acid: a six month randomized double-blind trial.
Gut.1982;23:1088-1093.
Mowrey DB. The Scientific Validation of Herbal Medicine. New Canaan,
Conn: Keats Publishing; 1986:179.
Murray MT, Pizzorno JE. Encyclopedia of Natural Medicine. 2nd ed.
Rocklin, Calif: Prima Publishing; 1998:211-220.
Walker LP, Brown EH. The Alternative Pharmacy. Paramus, NJ: Prentice
Hall; 1998:394.
Wyngaarden JB, Smith LH Jr, Bennett JC, eds. Cecil Textbook of Medicine.
19th ed. Philadelphia, Pa: WB Saunders Co;
1992:786-795. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |