Cirrhosis (say "suh-ROH-sus")
is a very serious condition in which scarring damages the
liver. The liver is a large organ that is part of the
digestive system. It does a wide range of complex jobs that are vital for life.
For example, the liver:
Makes many important substances, including
bile to help digest food and
clotting factors to help stop bleeding.
Controls the amounts of sugar, protein, and fat in the
bloodstream.
Stores important vitamins and minerals, including
iron.
Filters poisons from the blood.
Breaks down
(metabolizes) alcohol and many drugs.
When a person has cirrhosis, scar tissue (fibrosis) replaces healthy tissue and prevents the
liver from working as it should. For example, the liver may stop producing
enough clotting factors, which can lead to bleeding and bruising. Bile and
poisons may build up in the blood. Scarring can also cause high blood pressure
in the vein that carries blood from the intestines through the liver (portal hypertension). This can lead to severe bleeding
in the digestive tract and other serious problems.
Cirrhosis can
be deadly. But early treatment can help stop damage to the liver.
What causes cirrhosis?
Cirrhosis can have many
causes. Some of the main ones include:
Long-term, heavy use of alcohol. This is the
most common cause of cirrhosis in the United States. Alcoholic cirrhosis can
develop after 10 or more years of heavy drinking (5 or more drinks a day for a
man or 3 or more drinks a day for a woman).1 See
a picture to learn
what is one drink.
Chronic
viral hepatitis. Cirrhosis develops in about 10 to 20
out of 100 people with long-term (chronic) viral hepatitis (mainly hepatitis B
or C).2 Often it takes up to 20 years or longer
for cirrhosis to develop from hepatitis. It may happen much sooner in people
with viral hepatitis who drink a lot of alcohol.
Autoimmune diseases, such as autoimmune hepatitis or
primary sclerosing cholangitis (PSC). In some people, the
immune system attacks the liver, causing inflammation
that leads to cirrhosis.
Blocked bile ducts. A disease
called primary biliary cirrhosis develops when the ducts that carry bile out of
the liver become inflamed and blocked. The exact cause is unknown, but it may
be related to a problem with the immune system.
Inherited
diseases, such as
Wilson's disease,
cystic fibrosis, or
hemochromatosis. Cirrhosis can also be caused by a
condition called alpha1-antitrypsin deficiency, in which a protein collects in
the liver and causes damage.
Less common causes of cirrhosis include severe reactions
to medicines or long-term exposure to poisons, such as arsenic. Some people
have cirrhosis without an obvious cause.
What are the symptoms?
You may not have symptoms
in the early stages of cirrhosis. As it progresses, it can cause a number of
symptoms, including:
Fluid
buildup in the legs, called edema (say "ih-DEE-muh"), and in the belly, called
ascites (say "uh-SIGH-teez").
Bleeding in the stomach or in the
esophagus, the tube that leads from the mouth to the stomach.
Confusion.
How is cirrhosis diagnosed?
The doctor will start
with a physical exam and questions about your symptoms and past health. If the
doctor suspects cirrhosis, you may have blood tests and imaging tests, such as
an
ultrasound or
CT scan. These tests can help your doctor find out
what is causing the liver damage and how severe it is.
To confirm
that you have cirrhosis, the doctor may do a
liver biopsy. This means he or she will use a needle
to take a sample of liver tissue for testing.
How is it treated?
It is important to get treated
for cirrhosis as soon as possible. Treatment cannot cure cirrhosis, but it can
sometimes prevent or delay further liver damage. Treatment may include
medicines, surgery, or other options, depending on what caused your cirrhosis
and what problems it is causing.
There are things you can do to
help limit the damage to your liver and control the symptoms:
Do not drink any alcohol. If you don't stop
completely, liver damage may quickly get worse.
Talk to your
doctor before you take any medicines. This includes both
prescription and over-the-counter drugs, vitamins, supplements, and herbs.
Drugs that can be dangerous include acetaminophen (such as Tylenol) and
anti-inflammatory drugs such as aspirin and ibuprofen (Advil or Motrin, for
example).
Make sure your
immunizations are up-to-date. You are at higher risk
for infections.
Follow a
low-sodium diet. This can help prevent fluid buildup,
a common problem in cirrhosis that can become life-threatening.
Symptoms may not appear until a problem is severe, so it
is important to see your doctor for regular checkups and lab tests. You may
also need testing to check for possible problems such as:
Enlarged veins, called varices (say
"VAIR-uh-seez"), in the digestive tract. Varices can bleed.
Liver
cancer. People with cirrhosis are at higher risk for liver cancer.
If cirrhosis becomes life-threatening, then
liver transplant may be an option. But transplant is
expensive, organs are hard to find, and it doesn't always work. For these
reasons, doctors have to decide who would get the most benefit from a liver
transplant. Ask your doctor what steps you can take now to improve your overall
health so you can be a good candidate for transplant.
If your
cirrhosis is getting worse, you may choose to get care that focuses on your
comfort and dignity.
Palliative care can provide support and symptom relief
so you can make the most of the time you have left. You may also want to make
important end-of-life decisions, such as writing a
living will. It can be comforting to know that you
will get the type of care you want.
It can be hard to face having
cirrhosis. If you feel very sad or hopeless, be sure to tell your doctor. You
may be able to get counseling or other types of help. Think about joining a
support group. Talking with other people who have cirrhosis can be a big
help.
Small red spots and tiny lines on the skin called spider
angiomas.
Bleeding from enlarged veins (varices) in the digestive
tract.
Bruising easily.
Weight loss and muscle
wasting.
Belly pain or discomfort.
Frequent
infections.
Confusion.
Complications of cirrhosis
Cirrhosis occurs when
substantial amounts of scar tissue replace normal tissue in the liver. The scar
tissue may block the proper flow of blood from the intestines through the
liver, leading to increased pressure in the veins that supply this area (portal
vein system). This condition is called
portal hypertension. Portal hypertension can lead to
other complications, which may include:
Fluid buildup in the abdominal cavity (ascites). Ascites is the most common complication of
portal hypertension caused by cirrhosis.
Bleeding from enlarged
veins (varices) in the digestive tract. This is called
variceal bleeding. Variceal bleeding, especially in
the esophagus and stomach, is a major cause of illness and death in people who
have cirrhosis.
Increased spleen size. This can lead to a low blood
platelet count.
Altered brain function
(encephalopathy). Encephalopathy usually only occurs in
people who have advanced portal hypertension. But having a procedure to help
reduce portal hypertension (shunting) can
increase the risk of developing encephalopathy.
Hepatorenal
syndrome. Kidney (renal) failure can occur in cases of advanced liver disease
stemming from cirrhosis. Usually, liver failure is the condition that threatens
a person's life. But in some cases the liver disease may be stable, while
kidney problems are life-threatening. A liver transplant may be necessary to
cure renal failure caused by cirrhosis.1
Hepatopulmonary syndrome. Portal
hypertension caused by cirrhosis can cause lung (pulmonary) problems, such as
widening of the blood vessels in the lungs. This widening causes the blood to
move too swiftly through the lungs to pick up enough oxygen. Liver
transplantation is the most effective treatment for this
condition.
Hepatic hydrothorax. Cirrhosis can cause fluid to build
up between the lungs and the chest (pleural effusion) and press on the
lungs. Treatment can include taking medicines such as
diuretics, restricting salt in the diet, and using
procedures to remove the fluid.
People who have cirrhosis may be at increased risk for
developing
gallstones.3 The more
severe your liver disease, the higher your risk of developing
gallstones.
People who have cirrhosis also are at increased risk
of developing liver cancer, mainly
hepatocellular carcinoma.
Cirrhosis is a
potentially life-threatening condition that occurs when inflammation and
scarring damage the
liver. A physical examination and medical history will
be done first to assess symptoms of liver disease, to see whether liver disease
is severe enough to cause signs of cirrhosis, and to help determine possible
causes of liver damage.
A combination of tests may be used to
diagnosis cirrhosis when a physical examination and medical history suggest
that the condition may be present. Blood tests may help your doctor check for
inflammation of the liver, assess liver function, and diagnose the cause of
cirrhosis. Other tests provide images of the liver to look for tumors and
blocked
bile ducts and can be used to evaluate liver size and
blood flow through the liver.
Liver biopsy,
in which a sample of liver tissue is removed and analyzed, also may be done. It
is the only test that can confirm a diagnosis of cirrhosis.
Blood tests that assess liver function
Measuring
the levels of certain chemicals produced by the liver can help evaluate
remaining liver function. Blood tests may be used to measure:
Albumin and total serum protein. Albumin is a type of protein. Liver disease can cause a
decrease in protein levels in the blood.
Bilirubin.
Bilirubin is produced when the liver breaks down hemoglobin, the
oxygen-carrying substance in red blood cells. Cirrhosis may cause elevated
bilirubin levels, which causes
jaundice.
Blood tests for inflammation of the liver
Blood
tests may be done to look at levels of liver enzymes. These tests can help show
whether there is ongoing liver inflammation, although some people with
cirrhosis have normal liver enzymes. The blood tests include:
Aspartate aminotransferase (AST). An increased AST level (also called SGOT) may
indicate injury to the liver and the death of liver cells.
Alanine aminotransferase (ALT). An increased ALT level
(also called SGPT) also may indicate injury to the liver and the death of liver
cells.
Lactate dehydrogenase (LDH). An increased LDH level
also may indicate injury to the liver and the death of liver
cells.
Gamma-glutamyl transpeptidase (GGT). An increased level of
GGT is seen with alcohol use or diseases of the bile ducts. The level of GGT
also may increase with the use of certain medicines, such as dilantin and
phenobarbital. But GGT may increase without inflammation.
Blood tests that may diagnose a cause of cirrhosis
Tests that may be done to check for conditions that may cause cirrhosis
include:
Serum
ceruloplasmin testing, which may help diagnose
Wilson's disease.
Alpha1-antitrypsin
level. This may diagnose a condition in which people lack this protein
(alpha1-antitrypsin deficiency).
Tests that provide an image of the liver
Imaging
tests can check for tumors and blocked bile ducts and can be used to evaluate
liver size and blood flow through the liver. These tests include:
Other tests also may be done to
confirm a diagnosis of cirrhosis or to look for possible complications. These
include:
Liver biopsy, the only test that can directly confirm a diagnosis of
cirrhosis. Examination of liver tissue also may show signs of inflammation. A
liver biopsy may be done by inserting a needle between two of the right lower
ribs to remove a sample of liver tissue. The tissue sample is then
analyzed.
Paracentesis, to help diagnose the
cause of fluid buildup in the abdominal cavity (ascites) or to
detect infection in the abdominal fluid (spontaneous bacterial peritonitis). Paracentesis is a procedure in which a needle is inserted
through the abdominal wall to remove fluid from the abdominal cavity. The fluid
can then be analyzed.
Endoscopy, to
look for enlarged veins (varices) in the digestive tract that could cause
variceal bleeding. Endoscopy allows a doctor to
examine the inside of organs, canals, and cavities in the body using a thin,
flexible, lighted viewing instrument called an endoscope.
Endoscopic retrograde cholangiopancreatogram (ERCP),
to look inside the tubes (bile ducts) that drain the liver, pancreas, and
gallbladder. ERCP may be done if your doctor thinks a condition called primary
sclerosing cholangitis (PSC) might be leading to your liver problems.
Cirrhosis is a
potentially life-threatening condition that occurs when inflammation and
scarring damage the
liver. No treatment will cure cirrhosis or repair
scarring in the liver that has already occurred. But treatment can sometimes
prevent or delay further liver damage. The main components of treatment
include:
Treating the cause of cirrhosis, when possible,
to prevent further liver damage.
Avoiding substances that may
further damage the liver, especially alcohol.
Preventing and
treating the symptoms and complications of cirrhosis.
Having a
liver transplant if your liver damage becomes severe, as long as you are a
suitable candidate for liver transplantation and a liver is available.
Initial treatment
If you have just been diagnosed
with
cirrhosis, which occurs when inflammation and scarring
damage the liver, your doctor will recommend that you:
Stop drinking alcohol. You need to quit
completely.
Talk to your doctor about all medicines you take,
including nonprescription drugs such as acetaminophen, ibuprofen (Advil or
Motrin) and naproxen (Aleve).
Begin following a low-sodium diet if
fluid retention is occurring. Reducing your sodium intake can help prevent
fluid buildup in your abdomen (ascites) and chest. For more
information, see:
Taking these steps may help prevent complications and
further damage to your liver and help you control symptoms.
Initial treatment of cirrhosis will also include treatment for any
complications that have already developed. You may need medications, surgery,
or other treatment, depending on what complications you have.
Ongoing treatment
Cirrhosis is a
potentially life-threatening condition that occurs when inflammation and
scarring damage the liver. Ongoing treatment for the disease focuses on
watching for, trying to prevent, and treating symptoms and
complications.
You must continue to:
Avoid all alcohol.
Make sure your
doctor knows all of the medicines you are taking, including nonprescription
drugs.
Begin or stay on a low-sodium diet if fluid retention begins
occurring or continues, to help reduce fluid buildup and its complications. For
more information, see:
Depending on what complications develop, you may need
medicines, surgeries, or other treatments.
Fluid buildup in the
abdomen (ascites) is one of the most common problems for people
with cirrhosis and can become life-threatening if it is not controlled.
Following a low-sodium diet can help reduce fluid buildup in the abdomen. But
you may also need:
Diuretic medicines, such as
spironolactone and furosemide, to help eliminate fluid that has built up in the
abdomen and other parts of the body. These medicines can help both prevent and
treat problems with ascites. Your doctor may prescribe a diuretic for you to
take over the long term.
Paracentesis with or without a protein
(albumin) infusion. Paracentesis is a procedure in which a needle is inserted
through the abdominal wall to remove fluid from the abdominal cavity. It may be
used to treat severe ascites that is causing symptoms and is not responding to
standard treatment with diuretics and a low-sodium diet.
Antibiotics, such as ciprofloxacin (Cipro) or
cefotaxime (Claforan), if you develop a bacterial infection in your abdomen
(spontaneous bacterial peritonitis, or SBP) as a result of fluid
buildup.
Bleeding from enlarged veins in the digestive tract
(variceal bleeding) is another common and potentially
life-threatening problem for people with cirrhosis. It is particularly
important to avoid aspirin and NSAIDs if you have variceal bleeding or are at
high risk for it. You may also need:
Beta-blocker medicines, such as
propranolol and nadolol. These medicines decrease the risk of variceal bleeding
caused by
portal hypertension. Beta-blockers may help lower the
pressure in the portal veins, which can reduce your risk of having a first
episode of variceal bleeding. These medicines also may be used to reduce the
risk of recurrent bleeding.
Vasoconstrictor medicines. These medicines are used to treat a sudden (acute) episode of
variceal bleeding. They reduce blood flow through the portal veins by
temporarily narrowing the blood vessels. Somatostatin and octreotide are
medicines commonly used in the United States.
Endoscopic variceal banding or sclerotherapy. These techniques may be used to treat
and prevent variceal bleeding in the esophagus. In the past, sclerotherapy was
the main treatment for a first episode of variceal bleeding, but it is now used
mostly in emergency situations. Most doctors now prefer variceal banding
because it works as well as sclerotherapy to stop bleeding and has fewer
complications.4, 1
Shunts. These procedures redirect the
flow of blood through other areas of the body. One type of shunt is a
transjugular intrahepatic portosystemic shunt (TIPS).
This procedure may be used to treat variceal bleeding that does not respond to
other less invasive or less risky forms of treatment.
Balloon
tamponade, also called a Sengstaken-Blakemore tube. Insertion of a
Sengstaken-Blakemore tube is a temporary treatment that may be done to stop
severe variceal bleeding and help stabilize your condition before another
therapy is tried or before you can be moved to a facility that can perform
treatment. It also may be done if nothing else has worked to stop bleeding. A
doctor inserts and inflates a balloon in the stomach. The balloon presses
against the enlarged veins to stop bleeding. This treatment is rarely
necessary.
Changes in mental function (encephalopathy) may
develop when the liver cannot filter poisons from the bloodstream, especially
substances produced by bacteria in the large intestine. As these toxins build
up in your blood, they can affect your brain function. To prevent or treat
encephalopathy, you may need to:
Take
lactulose, a medicine that helps prevent the buildup
of ammonia and other natural toxins in the large intestine.
Eat a
modest amount of protein. Your body needs protein to function well but, if your
liver damage is severe, your body may not be able to use protein properly,
which can contribute to the buildup of harmful toxins. A
registered dietitian can help you learn to eat a
healthy diet.
Avoid sedative medicines, such as sleeping pills,
antianxiety medicines, and narcotics. These can make symptoms of encephalopathy
worse.
Working with your doctor to monitor your condition is
also important, especially because symptoms may not start until a problem has
become severe. In addition to regular checkups and lab tests with your doctor,
you also need periodic screening for enlarged veins (varices) and liver cancer
(hepatocellular carcinoma).
The American College of Gastroenterology
recommends screening for varices with endoscopy for all people who have
cirrhosis. If your initial screening does not find any varices, you can be
screened again in 1 to 2 years. If you already have large varices, you may need
more frequent screening and treatment with beta-blocker medicines to try to
prevent future bleeding episodes. If you have had an episode of variceal
bleeding, you may need more frequent screening and beta-blocker medicine, or
your doctor may recommend variceal banding to help prevent future
bleeding.
Screening for liver cancer should take place every 6
months to 1 year. The usual screening is a combination of alpha-fetoprotein
testing and liver ultrasound. Research is continuing to find more precise
screening tools. One tool that shows promise for detecting liver cancer is
computed tomography (CT).5Magnetic resonance imaging (MRI) may also be
useful.
Cirrhosis is usually a progressive condition. Before your
condition becomes severe, you may want to talk to your doctor about future
treatment possibilities. In particular, you may want to discuss:
Whether you will be a good candidate for a
liver transplant if your disease becomes advanced. Talk about what steps you
can take now to improve your overall health so that you can increase your
chances of being considered a suitable candidate.
What level of
medical intervention you want as you approach the end of life. Some people want
every possible medical treatment to sustain life. Others prefer measures to
maintain comfort without prolonging life. Advanced cirrhosis can affect your
brain function, so it makes sense to consider these issues while you are still
able to make and communicate decisions.
Treatment if the condition gets worse
Cirrhosis is a
potentially life-threatening condition that occurs when inflammation and
scarring damage the liver. As cirrhosis and liver damage get worse, you may
develop more problems with fluid buildup in the abdomen (ascites), bleeding
from enlarged veins in the digestive tract (variceal bleeding),
changes in mental function (encephalopathy), and
other complications. You may need a combination of medicines, surgeries, and
other treatments, depending on the nature and severity of the problems.
Receiving a liver from an organ donor (liver transplantation) is the only
treatment that will restore normal liver function and cure
portal hypertension. Liver transplantation is usually
considered only when liver damage is severe and threatening your life. Most
people who receive liver transplants have end-stage cirrhosis and severe
complications of portal hypertension.
Liver transplant surgery is
very expensive. You may have to wait a long time for a transplant because so
few organs are available. Even if a transplant occurs, it may not be
successful. With these things in mind, doctors must decide who will benefit
most from receiving a liver transplant.
Liver transplantation may be an option if you
have end-stage cirrhosis and are a good candidate for the surgery. Good
candidates include those who:
Have not abused alcohol or illegal drugs
for the previous 6 months.
Have a good support system of family and
friends.
Can stay on a complicated regimen of post-transplant
medicines to prevent the body from rejecting the liver.
Liver transplant may not be a good option if
you have other serious medical conditions (such as heart or lung conditions)
that reduce your chance of surviving surgery or that would reduce your life
expectancy even if you received a new liver.
Palliative care
If your cirrhosis gets worse, you
may want to think about
palliative care. Palliative care is a kind of care for
people who have illnesses that do not go away and often get worse over time. It
is different than care to cure your illness, called curative treatment.
Palliative care focuses on improving your quality of life—not just in your
body, but also in your mind and spirit. Palliative care can be combined with
curative care.
Palliative care may help you manage symptoms or
side effects from treatment. It could also help you cope with your feelings
about living with a long-term illness, make future plans concerning your
medical care, or help your family better understand your illness and how to
support you.
If you are interested in palliative care, talk to
your doctor. He or she may be able to manage your care or refer you to a doctor
who specializes in this type of care.
If you have not already made
decisions about the issues that may arise at the end of life, consider doing so
now. Many people find it helpful and comforting to state their health care
choices in writing (with an advance directive such as a living will) while they
are still able to make and communicate these decisions. You may also think
about who you would choose as your health care agent to make and carry out
decisions about your care if you were unable to speak for yourself. For more
information, see the topics:
If you made some health care decisions earlier in your
disease, you may want to revisit them with your family and your doctor to make
sure they still represent what you want.
A time may come when
your goals change from treating or curing an illness to maintaining comfort and
dignity. Your primary doctor will be able to address questions or concerns
about maintaining comfort when cure is no longer an option. Hospice care health
professionals can provide palliative care and comforting surroundings for
someone who is preparing to die.
Cirrhosis is a
potentially life-threatening condition that occurs when inflammation and
scarring damage the liver. The following lifestyle changes may reduce symptoms
caused by complications of the disease and may slow the development of new
liver damage.
Giving up alcohol
In the United States, drinking
excessive amounts of alcohol is the most common cause of cirrhosis. If you are
diagnosed with cirrhosis, it is extremely important that you stop drinking
alcohol completely, even if alcohol was not the cause of your cirrhosis. If you
do not stop, liver damage may quickly become worse. For information about how
to quit drinking if you need help, see the topic
Alcohol Abuse and Dependence.
Changing your diet
Changes in your diet may be
necessary, such as restricting the amount of salt or protein you
consume.
If your body is retaining fluid, the most important
dietary change you need to make is to reduce your sodium intake by reducing the
amount of salt in your diet. People with liver damage tend to retain sodium.
This can contribute to fluid buildup in your abdomen (ascites), the most
common complication of cirrhosis. For more information, see:
If you are at risk for altered mental function (encephalopathy) because of advanced liver disease,
your doctor may want you to temporarily limit the amount of protein you eat.
You will still need protein in your diet to be well nourished, but you may need
to get most of your protein from vegetable sources (rather than animal sources)
and to avoid eating large amounts of protein at one time.
Avoiding harmful medicines
Some medicines should
be used carefully or avoided by people who have cirrhosis. For example,
acetaminophen (such as Tylenol) can accelerate liver damage if you have
cirrhosis but you are still drinking alcohol.
Nonsteroidal anti-inflammatory drugs (such as
ibuprofen and aspirin) increase the risk of
variceal bleeding if you have enlarged veins (varices)
in the digestive tract. Talk to your doctor or pharmacist about what medicines
are safe for you.
Certain prescription medicines used to treat
other conditions may be harmful if you have cirrhosis. Make sure your doctor
knows all the medicines you are taking.
Improving your general health
Taking other steps
to improve your overall health may help you cope with the symptoms of
cirrhosis.
Stop smoking. Quitting tobacco use will
improve your overall health, which may help make you a better candidate for a
liver transplant if you need one.
Your doctor may encourage you to
take a multivitamin. Do not take one containing extra iron unless your doctor
tells you to, and do not take iron supplements.
Brush and floss
your teeth daily to avoid dental problems that could lead to infection (abscess). Be gentle when you floss. to avoid making
your gums bleed.
Make sure you have been vaccinated against:
Influenza (flu). Get a flu shot every year. People with cirrhosis are at increased
risk for serious complications from the flu.
Pneumococcus(What is a PDF document?),
which can cause pneumonia or abdominal infection (peritonitis).
Ask your doctor how often you should be revaccinated.
Using complementary and alternative medicines wisely
In general, you should avoid most herbal and other supplements, which may
make liver disease worse.
Kava is particularly bad for people with liver
problems.
Limited research has shown that the herbal supplement
milk thistle may help protect the liver, but other research has not shown a
benefit.6 Milk thistle will not reverse existing liver
damage, and it will not cure infection with the hepatitis B or hepatitis C
virus. Talk to your doctor about whether you should try milk thistle (or any
other alternative treatment).
Making decisions about end stages of life
Cirrhosis can be a progressive, fatal condition. You may want to consider
discussing health care and other legal issues that may arise near the end of
life.
Many people find it helpful and comforting to state their
health care choices in writing (with an advance directive or living will) while
they are still able to make and communicate these decisions. Some people want
every possible medical treatment to sustain life, while others prefer measures
to maintain their comfort without prolonging life. It may be helpful to think
about what kind of medical treatment you want. Also think about whom to choose
as your health care agent to make and carry out decisions about your care if
you become unable to speak for yourself.
A time may come when your goals change from treating or
curing an illness to maintaining comfort and dignity. Your primary health
professional will be able to address questions or concerns about maintaining
comfort when cure is no longer an option. Hospice care health professionals can
provide palliative care and comforting surroundings for someone who is
preparing to die.
Bataller R, Gines P (2005). Cirrhosis of the
liver. In DC Dale, DD Federman, eds., ACP Medicine,
section 4, chap. 9. New York: WebMD.
Centers for Disease Control and Prevention
(1998). Recommendations for prevention and control of hepatitis C virus (HCV)
infection and HCV-related chronic disease. MMWR,
47(RR-19): 1–39.
Conte D, et al. (1999). Close relation between
cirrhosis and gallstones. Archives of Internal Medicine,
159(1): 49–52.
Menon KV, Kamath PS (2000). Managing the complications
of cirrhosis. Mayo Clinic Proceedings, 75(5):
501–509.
National Cancer Institute (2007). Hepatocellular Cancer PDQ: Screening—Health Professional Version. Available online:
http://www.cancer.gov/cancertopics/pdq/screening/hepatocellular/healthprofessional.
Agency for Healthcare Research and Quality (2000).
Milk Thistle: Effects on Liver Disease and Cirrhosis and Clinical Adverse Effects. Summary. Evidence Report/Technology Assessment
No. 21 (AHRQ Publication No. 01–E024). Rockville, MD: Agency for Healthcare
Research and Quality. Available online:
http://www.ahrq.gov/clinic/epcsums/milktsum.htm.
Other Works Consulted
Angulo P, Lindor KD (2006). Primary biliary
cirrhosis. In M Feldman et al., eds., Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 8th ed., vol. 2, pp. 1885–1898.
Philadelphia: Saunders Elsevier.
Chung RT, Podolsky DK (2005). Cirrhosis and its
complications. In DL Kasper et al., eds., Harrison's Principles of Internal Medicine, 16th ed., vol. 2, pp. 1858–1869. New York:
McGraw-Hill.
Dambro MR (2006). Cirrhosis of the liver. In MR
Dambro, ed., Griffith's 5-Minute Clinical Consult, pp.
242–243. Philadelphia: Lippincott Williams and Wilkins.
Talwalkar JA, Lindor KD (2006). Primary biliary
cirrhosis. In M Wolfe et al., eds., Therapy of Digestive Disorders, 2nd ed., pp. 579–587. Philadelphia: Saunders Elsevier.
Carithers RL, McClain C (2006). Alcoholic liver
disease. In M Feldman et al., eds., Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 8th ed., vol. 2, pp. 1771–1792.
Philadelphia: Saunders.
This information does not replace the advice of a doctor. Healthwise disclaims any warranty or liability for your use of this information. Your use of this information means that you agree to the Terms of Use. How this information was developed to help you make better health decisions.This information does not replace the advice of a doctor. Healthwise disclaims any warranty or liability for your use of this information. Your use of this information means that you agree to the Terms of Use. How this information was developed to help you make better health decisions.
