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.

• 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)

Excessive ingestion of alcohol, exposure to toxins and infectious agents

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

• 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

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.

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

• 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

• 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

• 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

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)

• 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

Effective either alone or as adjunctive therapy.

• 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.

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

May offer relief of symptoms, but needs to be prescribed by an experienced practitioner.

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.

May be helpful to alleviate symptoms and increase physiological functioning.

May help alleviate stress and lymph congestion.

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.

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.

• 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

Dependent on etiology, extent of damage, and success of intervention

Cirrhosis can jeopardize the chances for a healthy infant.

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