What is cirrhosis?

Cirrhosis is the term used to describe a severely scarred liver. Scar tissue forms in the liver when the liver is healing from an injury. For example, heavy alcohol use can cause the liver to become inflamed, which can result in scar tissue developing in the liver. When the injury to the liver is chronic and persistent, scar tissue builds up over time. Eventually, the scarring becomes so severe that the liver is considered "cirrhotic." A person with a severely scarred liver is considered to have cirrhosis.

The liver can have some scar tissue and still perform its usual functions: producing proteins for blood clotting, producing albumin for maintaining fluid balances, and breaking down toxins and medications. However, a cirrhotic liver eventually will be unable to function normally, and the person with cirrhosis will become ill.Many factors can cause cirrhosis, most commonly long-term, heavy alcohol use and chronic hepatitis B and hepatitis C infection.

How do I know if I have cirrhosis if I feel well?

In the early stages of cirrhosis, you may not have any symptoms. The only way to know for sure is to get examined by your provider. Early diagnosis of cirrhosis can help prevent symptoms from developing.

It's also important to see your provider if you do have symptoms. These can include fluid buildup in the belly, swelling in the lower legs, small spidery-veins on your skin, easy bruising, itching, or shortness of breath. Your provider might be able to diagnose cirrhosis during an office examination. Sometimes, however, it may require blood tests, abdominal ultrasound, or a CT scan.

If I have cirrhosis, is there anything I can do to reverse it?

Cirrhosis is generally not considered to be reversible. However, there are different degrees of cirrhosis. "Compensated" cirrhosis means that a patient has cirrhosis but no complications such as fluid in the abdomen (ascites), disorientation or confusion (hepatic encephalopathy), or bleeding in the stomach or esophagus (variceal bleeding). A patient is considered to have "decompensated" cirrhosis if any of these complications are present.

If you are in a compensated state of cirrhosis, there are ways you can delay progression to a decompensated state:

It is more difficult to go in the reverse direction--from a decompensated state to a compensated state.

• If you routinely drink alcohol, stop drinking.
• If you are overweight or obese, lose weight and exercise more.
• If you have hepatitis C or hepatitis B and are eligible for treatment, get started on medications to try to clear the virus.
• If you drink alcohol, stop completely and permanently. With time, you may reverse to a compensated state.

Don't you have to be a drinker to get cirrhosis?

No, cirrhosis can result from many things, not just heavy drinking. When something attacks and damages the liver, liver cells are killed and scar tissue is formed. When the whole liver is scarred, it shrinks, hardens, and can stop working properly. This is called cirrhosis. Cirrhosis is the most severe stage of liver damage.

Heavy drinking is certainly one cause, but any condition or illness that affects the liver over a long period of time eventually could lead to cirrhosis. That includes hepatitis B, hepatitis C, non-alcoholic steatohepatitis, autoimmune hepatitis, primary biliary cirrhosis (PBC), and other diseases. Some people have more than one of these conditions (for example, alcohol use plus hepatitis B infection). Sometimes those combinations will speed up the development of cirrhosis.

If you have cirrhosis, won't you look yellow?

Cirrhosis is advanced scarring (fibrosis) in the liver. Many people who develop cirrhosis show no signs at all--they look exactly the same as they did before. For some people with cirrhosis, the scarring in the liver causes a buildup of bile and increases the level of bilirubin (a brownish-yellow substance found in bile) in the bloodstream. High bilirubin levels can make the skin appear yellow. So, although the skin of some people with cirrhosis may turn yellow, it does not happen to most people.

It is also important to know that a yellowish skin tone may be caused by cirrhosis, but it also could be caused by a different illness such as pancreatic cancer or colon cancer that has spread to the liver.

If you have cirrhosis, are there any medications you need to avoid?

Acetaminophen (Tylenol) is considered safe in limited doses (a maximum of 2,000 mg, or 2 grams, every 24 hours) and some experts recommend limiting Tylenol to 1,000 mg (1 gram) per day.

Non-steroidal anti-inflammatory drugs, such as aspirin, ibuprofen, naproxen, diclofenac, and piroxicam, should be avoided. These can cause reduced kidney function in patients with cirrhosis. Do not take these without first consulting your provider.

Iron supplements, in general, should be avoided. If you take a multivitamin, it should not contain iron.

There are many other medications with potential for causing liver injury, including certain antibiotics, high blood pressure medications, diabetes medications, hormones, and antiretrovirals. Patients who already have cirrhosis should be particularly cautious when starting to use them. Before taking any new medication--whether prescription or over-the-counter or herbal--discuss it with your health care provider.

Of course, the most important substance to avoid when you have cirrhosis is alcohol.

If you have cirrhosis from hepatitis C, are there certain tests that you need to have?

If you have cirrhosis, you should:

1. Get screened for liver cancer (hepatocellular carcinoma). Screening involves an ultrasound of the abdomen every 6 months.
2. Get tested for the presence of abnormal blood vessels in the esophagus or stomach that can lead to bleeding. These are called varices. Typically, this involves an EGD (upper GI endoscopy) procedure and it is recommended this test be done, on average, every 2 years.
3. Get blood tests 2-3 times per year to evaluate how your liver is doing. Typically, this involves blood cell counts, blood clotting measurements, liver enzyme tests, and tests of kidney function.
4. Have your MELD score calculated. Your provider can calculate this using the results of your blood tests. The MELD score represents the severity of your liver disease.

Rena K. Fox, MD

Cirrhosis can lead to malnutrition, meaning that your body is not getting the right amount of the vitamins, minerals, and other nutrients it needs to stay healthy. Research suggests that 50% to 90% of people with cirrhosis have malnutrition.

People with cirrhosis are at risk for malnutrition for several reasons. The symptoms of cirrhosis, such as nausea and vomiting, may cause people with cirrhosis to eat and drink less. Cirrhosis also affects how the liver works. When the liver isn’t working well, the body may have problems digesting foods and drinks or absorbing nutrients.

What you eat and drink is important. Your doctor may refer you to a registered dietitian to help create healthy meal plans that fit your nutrition needs.

Meal plans will vary depending on how severe cirrhosis is and other factors. Health care professionals can recommend a meal plan that will provide the amount of calories and nutrients, especially protein, that your body needs. Health care professionals may recommend that people who do not get enough nutrients, or who have low levels of some vitamins and minerals, take certain dietary supplements. If you have cirrhosis, talk with your doctor before taking dietary supplements, including herbal supplements.

Cirrhosis changes the way the body stores nutrients and uses them for energy. People with cirrhosis should avoid fasting, or going without food, for too long. Health care professionals may recommend

• having smaller, more frequent meals
• eating every 3 or 4 hours while awake
• having a snack before going to sleep at night or having an early breakfast after waking up

Ask your doctor about the cost of a registered dietitian’s services. If you have health insurance, check your insurance company’s website or call customer service to find out if they will pay for some or all of these services.

Avoid eating raw or undercooked shellfish, fish, and meat, and unpasteurized milk and milk products. Bacteria or viruses from these foods may cause severe infections in people with cirrhosis.

Your doctor may recommend limiting sodium in foods and drinks.

You should completely stop drinking alcohol because it can cause more liver damage.

Food

Healthy diet choices include fruit, vegetables, whole grains, lean protein sources, unsalted nuts and seeds and low-fat dairy products. Foods should be lower in sodium (salt). If lack of salt in your food effects taste, you can enhance the flavor with lemon or lime juice, vinegar, herbs and spices. Ketchup, pickles, olives, soy sauce, hot sauces and teriyaki sauce have a high sodium content and should be avoided. Restaurants, including fast food, add a lot of salt to their food so try to avoid them or ask for your meal to be prepared without salt.

Selecting foods with healthy fats is important. Choosing unsaturated fats instead of saturated fats and trans fats is a good first step. Unsaturated fats:

• include monosaturated, polyunsaturated and Omega3 fatty acids
• come from plant sources and fish and include avocado, nuts, olive oil, canola oil and safflower oil
• foods high in Omega3 fatty acids include salmon, tuna and mackerel

Saturated fats come from animal sources such as meat, poultry and full-fat dairy products. Trans fat is hard at room temperature such as in shortening, partially hydrogenated vegetable oils and stick margarine. Saturated and trans fats can be detrimental if you have cardiovascular disease or at risk such as in diabetes mellitus.

If your budget allows it, fresh fruits and vegetables, including the green leafy variety are the best. Canned fruit may have added sugary liquid. Canned vegetables may be loaded with salt. Frozen vegetables without sauces are similar to fresh produce. If your budget does not allow the fresh variety, canned fruits and vegetables should be rinsed thoroughly or look for varieties that specifically state no added salt or without sauces.

Whole grains include barley, brown rice, buckwheat, bulgur, millet, oatmeal and popcorn. Whole wheat bread, pasta and cereals without added sugar are key to a healthy diet. Whole grains are a great source of fiber and will also help constipation. If you are gluten intolerant, ask your provider or dietitian which of these to avoid.

Protein does not have to be restricted in liver disease but make sure that meat cuts like beef, pork and lamb have excess fat trimmed off. Skinless chicken and turkey, eggs, and low-fat dairy foods are good sources of protein. Special cuts of meat and organ meats such as tongue and gizzards are not healthy due to high fat content. Processed meats (sausage, bacon, hot dogs, deli meats) have a high sodium content and added chemicals, so avoid them. Beans and legumes such as garbanzos (chickpeas), black beans, soy beans, fava beans, kidney beans and lima beans are an economical source of protein. Nuts are a good source of protein but choose unsalted versions. Seeds such as quinoa, flaxseed, pumpkin seeds and wild rice are good sources of protein. Tofu is a good vegetarian option. Fresh fish is a healthy alternative to meat. Canned tuna (in water), canned salmon and eggs are economical. Frozen entrees may have a lot of salt, so check the label.

Choosing low-fat or fat-free dairy products is important in obesity and cardiovascular disease. Low-fat milk, ice cream and cheese are also important sources of calcium which is needed for good bone health. Best cheeses to include in a healthy diet are low-fat or fat-free cottage cheese or mozzarella cheese made with skim milk. There are also other varieties of cheese that are available as low fat and fat-free.

Beverages

It is important to drink 6 to 8 glasses of water each day. Beverages with sugar cause weight gain and are detrimental to good blood sugar control in diabetes. Two to three cups of brewed coffee each day has been shown by research to improve liver health. It is best to avoid all alcohol in liver disease since this causes a replacement of healthy tissue with scar tissue which can lead to cirrhosis. This includes avoiding all beer, wine, coolers, whiskey, gin, rum, brandy and liquors.

Nutritional Supplements

In early liver disease nutrition supplements are generally not necessary if you have a healthy diet.

Vitamins and Minerals

Vitamins are generally not needed if you eat a variety of healthy foods. An exception is in alcoholic liver disease when thiamine (vitamin B1), folic acid and a multivitamin (includes vitamins B2 and B6) should be taken. Vitamin C will be beneficial unless your diagnosis is hemochromatosis.

Woman over the age of 50 years and men over the age of 70 years may benefit from a calcium supplement. Ask your provider for recommendations.

Special Considerations

If you have Wilson's Disease, foods high in copper need to be eliminated from the diet. These foods include organ meats, shellfish, chocolate, nuts, mushrooms, kale, asparagus, parsley, potatoes with skin (both white and sweet), lima beans, soybean sprouts and spinach.

If you have Hemochromatosis, iron supplements, multivitamins with iron and Vitamin C supplements should be avoided.

Food

Healthy diet choices are the same in advanced liver disease (ALD) as for early liver disease: View the early liver disease section. When liver disease progresses, lack of appetite, nausea and vomiting can influence eating and result in malnutrition. Poor absorption and increased losses of nutrients also contribute to malnutrition. Protein is not restricted even with ALD but you should not consume protein in large amounts. The liver does not store energy well so eating smaller, more frequent meals (4-5 times per day) may be better tolerated.

ALD causes the kidneys to hold sodium (salt) which then results in your body holding more fluid thus increasing ascites (swollen abdomen) and swelling of the hands, legs and feet. Your provider may ask that you restrict your sodium intake to 2000 mg or less (1 teaspoon of salt contains approximately 2300mg sodium). Sodium in all foods and beverages must be calculated into this amount. Reading sodium content on packaging will be necessary. You should remember that the sodium content on the package is for the serving size indicated on the label, not for the entire amount of the package. If you have chronic kidney disease, salt substitutes should be avoided because they are high in potassium.

Beverages

Your provider will tell you if or when you need to restrict your fluid intake. If fluid is restricted it usually is 1500-2000 ml per day. A good way to track your fluid intake for a day is to fill a pitcher with the amount of water as your daily restriction. Every time you drink a beverage discard the same amount of fluid from the pitcher. Individuals are often prescribed diuretics (water pills) at this stage of liver disease so you may feel thirsty. If you are on a fluid restriction, there are tricks to relieve the thirsty feeling. Sugar-free frozen pops, sugar-free sour candy, sugar-free gelatin, sucking on lemon or lime slices and eating ice cold fruit and vegetables will help relieve thirst. Frozen grapes are a good option. Fluid from the sugar-free frozen pops and gelatin must be included in the daily allowance of fluid intake, as will the fluid in juicy fruit like watermelon. Refer to the BEVERAGE section in the early liver disease section for more guidance.

Nutritional Supplements

Nutrition supplements are recommended at the discretion of your provider. If your appetite will allow, a snack before bedtime is beneficial to maintain proper metabolism.

Vitamins and Minerals

As in early liver disease, Vitamin B1 and vitamin B2, which are included in most multivitamins, may be taken. Vitamin A may be taken, however, there is a fine line between not enough and too much. An excess amount of vitamin A can injure your already sick liver. Vitamin C supplement may be taken unless you have hemochromatosis. If you have jaundice (yellow skin and eyes), you may not only be low in fat soluble vitamins A and E but also vitamins D and K and may need special replacement.

Fatigue, muscle weakness and twitches and cramps of your arms, hands and feet may indicate magnesium deficiency in ALD. Your provider may order a blood test to determine magnesium level and, if low, a supplement will be ordered. ALD may also cause a zinc deficiency. Signs of a zinc deficiency include decreased appetite, decreased ability to fight infection, diarrhea and hair loss. A zinc supplement may be ordered by your provider. Muscle cramps can also be relieved with drinking either regular or diet tonic water because of the quinine content. It is important not to drink more than 4 ounces per day because of the high sodium content.

Special Considerations

If you have Wilson's Disease, foods high in copper need to be eliminated from the diet. These foods include organ meats, shellfish, chocolate, nuts, mushrooms, kale, asparagus, parsley, potatoes with skin (both white and sweet), lima beans, soybean sprouts and spinach.

If you have Hemochromatosis, iron supplements, multivitamins with iron and Vitamin C supplements should be avoided.