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20-September-2008 09:55:49 - Cirrhosis Redirected from Liver cirrhosis Cirrhosis Classification and external resources Cirrhosis leading to hepatocellular carcinoma autopsy specimen. ICD-10 K70.3, K71.7, K74. ICD-9 571 DiseasesDB 2729 eMedicine med/3183 radio/175 MeSH D008103 Liver cirrhosis as seen on an axial CT of the abdomen. Liver cirrhosis as seen on an axial CT of the abdomen. Cirrhosis is a consequence of chronic liver disease characterized by replacement of liver tissue by fibrous scar tissue as well as regenerative nodules lumps that occur as a result of a process in which damaged tissue is regenerated,123 leading to progressive loss of liver function. Cirrhosis is most commonly caused by alcoholism and hepatitis C, but has many other possible causes. Ascites fluid retention in the abdominal cavity is the most common complication of cirrhosis and is associated with a poor quality of life, increased risk of infection, and a poor long-term outcome. Other potentially life-threatening complications are hepatic encephalopathy confusion and coma and bleeding from esophageal varices. Cirrhosis is generally irreversible once it occurs, and treatment generally focuses on preventing progression and complications. In advanced stages of cirrhosis the only option is a liver transplant. The word cirrhosis derives from Greek kirrhos, meaning tawny the orange-yellow colour of the diseased liver. While the clinical entity was known before, it was René Laennec who gave it the name cirrhosis in his 1819 work in which he also describes the stethoscope.4 Contents 1 Signs and symptoms 2 Complications 3 Causes 4 Diagnosis 4.1 Lab findings 4.2 Imaging 4.3 Endoscopy 4.4 Pathology 5 Grading 6 Pathophysiology 7 Treatment 7.1 Treating underlying causes 7.2 Preventing further liver damage 7.3 Preventing complications 7.3.1 Ascites 7.3.2 Esophageal variceal bleeding 7.3.3 Hepatic encephalopathy 7.3.4 Hepatorenal syndrome 7.3.5 Spontaneous bacterial peritonitis 7.4 Transplantation 7.5 Decompensated cirrhosis 8 Epidemiology 9 References 10 External links Signs and symptoms Some of the following signs and symptoms may occur in the presence of cirrhosis or as a result of the complications of cirrhosis. Many are nonspecific and may occur in other diseases and do not necessarily point to cirrhosis. Likewise, the absence of any does not rule out the possibility of cirrhosis. Spider angiomata or spider nevi. Vascular lesions consisting of a central arteriole surrounded by many smaller vessels due to an increase in estradiol. These occur in about 1/3 of cases.5 Palmar erythema. Exaggerations of normal speckled mottling of the palm, due to altered sex hormone metabolism. Nail changes. Muehrcke's nails - paired horizontal bands separated by normal color due to hypoalbuminemia low production of albumin. Terry's nails - proximal two thirds of the nail plate appears white with distal one-third red, also due to hypoalbuminemia Clubbing - angle between the nail plate and proximal nail fold 180 degrees Hypertrophic osteoarthropathy. Chronic proliferative periostitis of the long bones that can cause considerable pain. Dupuytren's contracture. Thickening and shortening of palmar fascia that leads to flexion deformities of the fingers. Thought to be due to fibroblastic proliferation and disorderly collagen deposition. It is relatively common 33% of patients. Gynecomastia. Benign proliferation of glandular tissue of male breasts presenting with a rubbery or firm mass extending concentrically from the nipples. This is due to increased estradiol and can occur in up to 66% of patients. Hypogonadism. Manifested as impotence, infertility, loss of sexual drive, and testicular atrophy due to primary gonadal injury or suppression of hypothalamic or pituitary function. Liver size. Can be enlarged, normal, or shrunken. Splenomegaly increase in size of the spleen. Due to congestion of the red pulp as a result of portal hypertension. Ascites. Accumulation of fluid in the peritoneal cavity giving rise to flank dullness needs about 1500 mL to detect flank dullness. It may be associated with hydrocele and penile flomation swelling of the penile shaft in men. Caput medusa. In portal hypertension, the umbilical vein may open. Blood from the portal venous system may be shunted through the periumbilical veins into the umbilical vein and ultimately to the abdominal wall veins, manifesting as caput medusa. Cruveilhier-Baumgarten murmur. Venous hum heard in epigastric region on examination by stethoscope due to collateral connections between portal system and the remnant of the umbilical vein in portal hypertension. Fetor hepaticus. Musty odor in breath due to increased dimethyl sulfide. Jaundice. Yellow discoloring of the skin, eye, and mucus membranes due to increased bilirubin at least 2-3 mg/dL or 30 mmol/L. Urine may also appear dark. Asterixis. Bilateral asynchronous flapping of outstretched, dorsiflexed hands seen in patients with hepatic encephalopathy. Other. Weakness, fatigue, anorexia, weight loss. Complications As the disease progresses, complications may develop. In some people, these may be the first signs of the disease. Bruising and bleeding due to decreased production of coagulation factors. Jaundice due to decreased processing of bilirubin. Itching pruritus due to bile products deposited in the skin. Hepatic encephalopathy - the liver does not clear ammonia and related nitrogenous substances from the blood, which are carried to the brain, affecting cerebral functioning: neglect of personal appearance, unresponsiveness, forgetfulness, trouble concentrating, or changes in sleep habits. Sensitivity to medication due to decreased metabolism of the active compounds. Hepatocellular carcinoma is primary liver cancer, a frequent complication of cirrhosis. It has a high mortality rate. Portal hypertension - blood normally carried from the intestines and spleen through the hepatic portal vein flows more slowly and the pressure increases; this leads to the following complications: Ascites - fluid leaks through the vasculature into the abdominal cavity. Esophageal varices - collateral portal blood flow through vessels in the stomach and esophagus. These blood vessels may become enlarged and are more likely to burst. Problems in other organs. Cirrhosis can cause immune system dysfunction, leading to infection. Signs and symptoms of infection may be aspecific are more difficult to recognize e.g. worsening encephalopathy but no fever. Fluid in the abdomen ascites may become infected with bacteria normally present in the intestines spontaneous bacterial peritonitis. Hepatorenal syndrome - insufficient blood supply to the kidneys, causing acute renal failure. This complication has a very high mortality over 50%. Hepatopulmonary syndrome - blood bypassing the normal lung circulation shunting, leading to cyanosis and dyspnea shortness of breath, characteristically worse on sitting up.6 Portopulmonary hypertension - increased blood pressure over the lungs as a consequence of portal hypertension.6 Causes Kimberly Pittman Cirrhosis has many possible causes; sometimes more than one cause is present in the same patient. In the Western World, chronic alcoholism and hepatitis C are the most common causes. Alcoholic liver disease ALD. Alcoholic cirrhosis develops in 15% of individuals who drink heavily for more than a decadecitation needed. There is great variability in the amount of alcohol needed to cause cirrhosis as little as 3-4 drinks a day in some men and 2-3 in some womencitation needed. Alcohol seems to injure the liver by blocking the normal metabolism of protein, fats, and carbohydrates. Patients may also have concurrent alcoholic hepatitis with fever, hepatomegaly, jaundice, and anorexia. AST and ALT are both elevated but less than 300 IU/L with a AST:ALT ratio 2.0, a value rarely seen in other liver diseases. Liver biopsy may show hepatocyte necrosis, Mallory bodies, neutrophilic infiltration with perivenular inflammation. Chronic hepatitis C. Infection with this virus causes inflammation of and low grade damage to the liver that over several decades can lead to cirrhosis. Can be diagnosed with serologic assays that detect hepatitis C antibody or viral RNA. The enzyme immunoassay, EIA-2, is the most commonly used screening test in the US. Chronic hepatitis B. The hepatitis B virus is probably the most common cause of cirrhosis worldwide, especially South-East Asia, but it is less common in the United States and the Western world. Hepatitis B causes liver inflammation and injury that over several decades can lead to cirrhosis. Hepatitis D is dependent on the presence of hepatitis B, but accelerates cirrhosis in co-infection. Chronic hepatitis B can be diagnosed with detection of HBsAG 6 months after initial infection. HBeAG and HBV DNA are determined to assess whether patient will need antiviral therapy. Non-alcoholic steatohepatitis NASH. In NASH, fat builds up in the liver and eventually causes scar tissue. This type of hepatitis appears to be associated with diabetes, protein malnutrition, obesity, coronary artery disease, and treatment with corticosteroid medications. This disorder is similar to that of alcoholic liver disease but patient does not have an alcohol history. Biopsy is needed for diagnosis. Primary biliary cirrhosis. May be asymptomatic or complain of fatigue, pruritus, and non-jaundice skin hyperpigmentation with hepatomegaly. There is prominent alkaline phosphatase elevation as well as elevations in cholesterol and bilirubin. Gold standard diagnosis is antimitochondrial antibodies with liver biopsy as confirmation if showing florid bile duct lesions. It is more common in women. Primary sclerosing cholangitis. PSC is a progressive cholestatic disorder presenting with pruritus, steatorrhea, fat soluble vitamin deficiencies, and metabolic bone disease. There is a strong association with inflammatory bowel disease IBD, especially ulcerative colitis. Diagnosis is best with contrast cholangiography showing diffuse, multifocal strictures and focal dilation of bile ducts, leading to a beaded appearance. Non-specific serum immunoglobulins may also be elevated. Autoimmune hepatitis. This disease is caused by the immunologic damage to the liver causing inflammation and eventually scarring and cirrhosis. Findings include elevations in serum globulins, especially gamma globulins. Therapy with prednisone +/- azathioprine is beneficial. Cirrhosis due to autoimmune hepatitis still has 10-year survival of 90%+. There is no specific tool to diagnose autoimmune but it can be beneficial to initiate a trial of corticosteroids. Herary hemochromatosis. Usually presents with family history of cirrhosis, skin hyperpigmentation, diabetes mellitus, pseudogout, and/or cardiomyopathy, all due to signs of iron overload. Labs will show fasting transferrin saturation of 60% and ferritin 300 ng/mL. Genetic testing may be used to identify HFE mutations. If these are present, biopsy may not need to be performed. Treatment is with phlebotomy to lower total body iron levels. Wilson's disease. Autosomal recessive disorder characterized by low serum ceruloplasmin and increased hepatic copper content on liver biopsy. May also have Kayser-Fleischer rings in the cornea and altered mental status. Alpha 1-antitrypsin deficiency AAT. Autosomal recessive disorder. Patients may also have COPD, especially if they have a history of tobacco smoking. Serum AAT levels are low. Recombinant AAT is used to prevent lung disease due to AAT deficiency. Cardiac cirrhosis. Due to chronic right sided heart failure which leads to liver congestion. Galactosemia Glycogen storage disease type IV Cystic fibrosis Drugs or toxins Certain parasitic infections such as schistosomiasis Diagnosis The gold standard for diagnosis of cirrhosis is a liver biopsy, through a percutaneous, transjugular, laparoscopic, or fine-needle approach. Histologically cirrhosis can be classified as micronodular, macronodular, or mixed, but this classification has been abandoned since it is nonspecific to the etiology, it may change as the disease progresses, and serological markers are much more specific. However, a biopsy is not necessary if the clinical, laboratory, and radiologic data suggests cirrhosis. Furthermore, there is a small but significant risk to liver biopsy, and cirrhosis itself predisposes for complications due to liver biopsy.7 Lab findings The following findings are typical in cirrhosis: Aminotransferases - AST and ALT are moderately elevated, with AST ALT. However, normal aminotransferases do not preclude cirrhosis. Alkaline phosphatase - usually slightly elevated. GGT - correlates with AP levels. Typically much higher in chronic liver disease from alcohol. Bilirubin - may elevate as cirrhosis progresses. Albumin - levels fall as the synthetic function of the liver declines with worsening cirrhosis since albumin is exclusively synthesized in the liver Prothrombin time - increases since the liver synthesizes clotting factors. Globulins - increased due to shunting of bacterial antigens away from the liver to lymphoid tissue. Serum sodium - hyponatremia due to inability to excrete free water resulting from high levels of ADH and aldosterone. Thrombocytopenia - due to both congestive splenomegaly as well as decreased thrombopoietin from the liver. However, this rarely results in platelet count 50,000/mL. Leukopenia and neutropenia - due to splenomegaly with splenic margination. Coagulation defects - the liver produces most of the coagulation factors and thus coagulopathy correlates with worsening liver disease. Other laboratory studies performed in newly diagnosed cirrhosis may include: Serology for hepatitis viruses, autoantibodies ANA, anti-smooth muscle, anti-mitochondria, anti-LKM Ferritin and transferrin saturation markers of iron overload, copper and ceruloplasmin markers of copper overload Immunoglobulin levels IgG, IgM, IgA - these are non-specific but may assist in distinguishing various causes Cholesterol and glucose Alpha 1-antitrypsin Imaging Ultrasound is routinely used in the evaluation of cirrhosis, where it may show a small and nodular liver in advanced cirrhosis along with increased echogenicity with irregular appearing areas. Ultrasound may also screen for hepatocellular carcinoma, portal hypertension and Budd-Chiari syndrome by assessing flow in the hepatic vein. A new type of device, the FibroScan transient elastography, uses elastic waves to determine liver stiffness which theoretically can be converted into a liver score based on the METAVIR scale. The FibroScan produces an ultrasound image of the liver from 20-80mm along with a pressure reading in kPa. The test is much faster than a biopsy usually last 2.5-5 minutes and is completely painless. It shows reasonable corellation with the severity of cirrhosis.8 Other tests performed in particular circumstances include abdominal CT and liver/bile duct MRI MRCP. Endoscopy Gastroscopy endoscopic examination of the esophagus, stomach and duodenum is performed in patients with established cirrhosis to exclude the possibility of esophageal varices. If these are found, prophylactic local therapy may be applied sclerotherapy or banding and beta blocker treatment may be commenced. Rarely diseases of the bile ducts, such as primary sclerosing cholangitis, can be causes of cirrhosis. Imaging of the bile ducts, such as ERCP or MRCP MRI of biliary tract and pancreas can show abnormalities in these patients, and may aid in the diagnosis. Pathology Macroscopically, the liver may be initially enlarged, but with progression of the disease, it becomes smaller. Its surface is irregular, the consistency is firm and the color is often yellow if associates steatosis. Depending on the size of the nodules there are three macroscopic types: micronodular, macronodular and mixed cirrhosis. In micronodular form Laennec's cirrhosis or portal cirrhosis regenerating nodules are under 3 mm. In macronodular cirrhosis post-necrotic cirrhosis, the nodules are larger than 3 mm. The mixed cirrhosis consists in a variety of nodules with different sizes. Microscopically, cirrhosis is characterized by regeneration nodules, surrounded by fibrous septa. In these nodules, regenerating hepatocytes are disorderly disposed. Portal tracts, central veins and the radial pattern of hepatocytes are absent. Fibrous septa are important and may present inflammatory infiltrate lymphocytes, macrophages If it is a secondary biliary cirrhosis, biliary ducts are damaged, proliferated or distended - bile stasis. These dilated ducts contain inspissated bile which appear as bile casts or bile thrombi brown-green, amorphous. Bile retention may be found also in the parenchyma, as the so called bile lakes.9 Grading The severity of cirrhosis is commonly classified with the Child-Pugh score. This score uses bilirubin, albumin, INR, presence and severity of ascites and encephalopathy to classify patients in class A, B or C; class A has a favourable prognosis, while class C is at high risk of death. It was devised in 1964 by Child and Turcotte and modified in 1973 by Pugh et al.10 More modern scores, used in the allocation of liver transplants but also in other contexts, are the Model for End-Stage Liver Disease MELD score and its pediatric counterpart, the Pediatric End-Stage Liver Disease PELD score. The hepatic venous pressure gradient, i.e. the difference in venous pressure between afferent and efferent blood to the liver, also determines severity of cirrhosis, although hard to measure. A value of 16 mm or more means a greatly increased risk of dying.11 Pathophysiology The liver plays a vital role in synthesis of proteins e.g. albumin, clotting factors and complement, detoxification and storage e.g. vitamin A. In addition, it participates in the metabolism of lipids and carbohydrates. Cirrhosis is often preceded by hepatitis and fatty liver steatosis, independent of the cause. If the cause is removed at this stage, the changes are still fully reversible. The pathological hallmark of cirrhosis is the development of scar tissue that replaces normal parenchyma, blocking the portal flow of blood through the organ and disturbing normal function. Recent research shows the pivotal role of stellate cell, a cell type that normally stores vitamin A, in the development of cirrhosis. Damage to the hepatic parenchyma leads to activation of the stellate cell, which becomes contractile called myofibroblast and obstructs blood flow in the circulation. In addition, it secretes TGF-β1, which leads to a fibrotic response and proliferation of connective tissue. Furthermore, it disturbs the balance between matrix metalloproteinases and the naturally occurring inhibitors TIMP 1 and 2, leading to matrix breakdown and replacement by connective tissue-secreted matrix.12 The fibrous tissue bands septa separate hepatocyte nodules, which eventually replace the entire liver architecture, leading to decreased blood flow throughout. The spleen becomes congested, which leads to hypersplenism and increased sequestration of platelets. Portal hypertension is responsible for most severe complications of cirrhosis. Treatment Generally, liver damage from cirrhosis cannot be reversed, but treatment could stop or delay further progression and reduce complications. A healthy diet is encouraged, as cirrhosis may be an energy-consuming process. Close follow-up is often necessary. Antibiotics will be prescribed for infections, and various medications can help with itching. Laxatives, such as lactulose, decrease risk of constipation; their role in preventing encephalopathy is limited. Treating underlying causes Alcoholic cirrhosis caused by alcohol abuse is treated by abstaining from alcohol. Treatment for hepatitis-related cirrhosis involves medications used to treat the different types of hepatitis, such as interferon for viral hepatitis and corticosteroids for autoimmune hepatitis. Cirrhosis caused by Wilson's disease, in which copper builds up in organs, is treated with chelation therapy e.g. penicillamine to remove the copper. Preventing further liver damage Regardless of underlying cause of cirrhosis, alcohol and acetaminophen, as well as other potentially damaging substances, are discouraged. Vaccination of susceptible patients should be considered for Hepatitis A and Hepatitis B. Preventing complications Ascites Main article: Ascites Salt restriction is often necessary, as cirrhosis leads to accumulation of salt sodium retention. Diuretics may be necessary to suppress ascites. Esophageal variceal bleeding Main article: Esophageal varices For portal hypertension, propranolol is a commonly used agent to lower blood pressure over the portal system. In severe complications from portal hypertension, transjugular intrahepatic portosystemic shunting is occasionally indicated to relieve pressure on the portal vein. As this can worsen encephalopathy, it is reserved for those at low risk of encephalopathy, and is generally regarded only as a bridge to liver transplantation or as a palliative measure. Hepatic encephalopathy Main article: Hepatic encephalopathy High-protein food increases the nitrogen balance, and would theoretically increase encephalopathy; in the past, this was therefore eliminated as much as possible from the diet. Recent studies show that this assumption was incorrect, and high-protein foods are even encouraged to maintain adequate nutrition. Hepatorenal syndrome Main article: Hepatorenal syndrome The hepatorenal syndrome is defined as a urine sodium less than 10 mmol/L and a serum creatinine 1.5 mg/dl or 24 hour creatinine clearance less than 40 ml/min after a trial of volume expansion without diuretics.13 Spontaneous bacterial peritonitis Main article: Spontaneous bacterial peritonitis Cirrhotic patients with ascites are at risk of spontaneous bacterial peritonitis. Transplantation Main article: Liver transplantation If complications cannot be controlled or when the liver ceases functioning, liver transplantation is necessary. Survival from liver transplantation has been improving over the 1990s, and the five-year survival rate is now around 80%, depending largely on the severity of disease and other medical problems in the recipient.14 In the United States, the MELD score online calculator15 is used to prioritize patients for transplantation. Transplantation necessitates the use of immune suppressants ciclosporin or tacrolimus. Decompensated cirrhosis In patients with previously stable cirrhosis, decompensation may occur due to various causes, such as constipation, infection of any source, increased alcohol intake, medication, bleeding from esophageal varices or dehydration. It may take the form of any of the complications of cirrhosis listed above. Patients with decompensated cirrhosis generally require admission to hospital, with close monitoring of the fluid balance, mental status, and emphasis on adequate nutrition and medical treatment - often with diuretics, antibiotics, laxatives and/or enemas, thiamine and occasionally steroids, acetylcysteine and pentoxifylline. Administration of saline is generally avoided as it would add to the already high total body sodium content that typically occurs in cirrhosis. Epidemiology Cirrhosis and chronic liver disease were the 10th leading cause of death for men and the 12th for women in the United States in 2001, killing about 27,000 people each year.16 Also, the cost of cirrhosis in terms of human suffering, hospital costs, and lost productivity is high. Established cirrhosis has a 10-year mortality of 34-66%, largely dependent on the cause of the cirrhosis; alcoholic cirrhosis has a worse prognosis than primary biliary cirrhosis and cirrhosis due to hepatitis. The risk of death due to all causes is increased twelvefold; if one excludes the direct consequences of the liver disease, there is still a fivefold increased risk of death in all disease categories.17 Little is known on modulators of cirrhosis risk, apart from other diseases that cause liver injury such as the combination of alcoholic liver disease and chronic viral hepatitis, which may act synergistically in leading to cirrhosis. Studies have recently suggested that coffee consumption may protect against cirrhosis, especially alcoholic cirrhosis.18 References ^ Cirrhosis - MayoClinic.com. ^ Liver Cirrhosis. Review of Pathology of the Liver. ^ Pathology Education: Gastrointestinal. ^ Roguin A 2006. Rene Theophile Hyacinthe Laënnec 1781-1826: the man behind the stethoscope. Clinical medicine research 4 3: 230-5. PMID 17048358. ^ Li CP, Lee FY, Hwang SJ, et al 1999. Spider angiomas in patients with liver cirrhosis: role of alcoholism and impaired liver function. Scand. J. Gastroenterol. 34 5: 520-3. doi:10.1080/003655299750026272. PMID 10423070. ^ a b Rodriguez-Roisin R, Krowka MJ, Herve P, Fallon MB; ERS Task Force Pulmonary-Hepatic Vascular Disorders PHD Scientific Committee. Pulmonary-Hepatic vascular Disorders PHD. Eur Respir J 2004;24:861-80. PMID 15516683. ^ Grant, A; Neuberger J 1999. Guidelines on the use of liver biopsy in clinical practice. Gut 45 Suppl 4: 1-11. PMID 10485854. The main cause of mortality after percutaneous liver biopsy is intraperitoneal haemorrhage as shown in a retrospective Italian study of 68,000 percutaneous liver biopsies in which all six patients who died did so from intraperitoneal haemorrhage. Three of these patients had had a laparotomy, and all had either cirrhosis or malignant disease, both of which are risk factors for bleeding. ^ Foucher J, Chanteloup E, Vergniol J, et al 2006. Diagnosis of cirrhosis by transient elastography FibroScan: a prospective study. Gut 55 3: 403-8. doi:10.1136/gut.2005.069153. PMID 16020491. ^ Pathology atlas, cirrhosis. ^ Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg 1973;60:646-9. PMID 4541913. ^ Single portal pressure measurement predicts survival in cirrhotic patients with recent bleeding D Patch, a A Armonis, a C Sabin, b K Christopoulou, a L Greenslade,a A McCormick, a R Dick, a A K Burroughsa ^ Iredale JP. Cirrhosis: new research provides a basis for rational and targeted treatments. BMJ 2003;327:143-7. Fulltext. PMID 12869458. ^ Ginés P, Arroyo V, Quintero E, et al 1987. Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites. Results of a randomized study. Gastroenterology 93 2: 234-41. PMID 3297907. ^ E-medicine liver transplant outlook and survival rates ^ Cosby RL, Yee B, Schrier RW 1989. New classification with prognostic value in cirrhotic patients. Mineral and electrolyte metabolism 15 5: 261-6. PMID 2682175. ^ Anderson RN, Smith BL 2003. Deaths: leading causes for 2001. National vital statistics reports: from the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System 52 9: 1-85. PMID 14626726. ^ Sørensen HT, Thulstrup AM, Mellemkjar L, et al 2003. Long-term survival and cause-specific mortality in patients with cirrhosis of the liver: a nationwide cohort study in Denmark. Journal of clinical epidemiology 56 1: 88-93. doi:10.1016/S0895-43560200531-0. PMID 12589875. ^ Klatsky AL, Morton C, Udaltsova N, Friedman GD 2006. Coffee, cirrhosis, and transaminase enzymes. Arch. Intern. Med. 166 11: 1190-5. doi:10.1001/archinte.166.11.1190. PMID 16772246. External links Cirrhosis of the Liver at the National Digestive Diseases Information Clearinghouse NDDIC. NIH Publication No. 04-1134, December 2003. 1 at the National Library of Medicine and the National Institutes of Health. Medline Plus: Cirrhosis - also called: Hepatic fibrosis v d e Digestive system - Digestive disease - Gastroenterology primarily K20-K93, 530-579 Upper GI tract Esophagus Esophagitis Candidal - Boerhaave syndrome - UES Zenker's diverticulum - LES Barrett's esophagus, Mallory-Weiss syndrome - Esophageal motility disorder Nutcracker esophagus, Achalasia, Diffuse esophageal spasm, GERD - Esophageal stricture Stomach Peptic gastric ulcer - Gastritis Atrophic, Ménétrier's disease - Gastroenteritis - Dyspepsia - Pyloric stenosis - Achlorhydria - Gastroparesis - Gastroptosis - Portal hypertensive gastropathy - Gastric antral vascular ectasia - Gastric dumping syndrome Intestinal Duodenum/ileum Peptic duodenal ulcer - Duodenitis - Ileitis Enteritis colitis/ enterocolitis noninfective: IBD Crohn's disease, Ulcerative colitis - noninfective gastroenteritis infective: Pseudomembranous colitis Vascular Abdominal angina - Mesenteric ischemia - Ischemic colitis - Angiodysplasia Malabsorption Coeliac - Tropical sprue - Blind loop syndrome - Whipple's - Short bowel syndrome - Steatorrhea Motility/ functional Ileus/Bowel obstruction Intussusception, Volvulus - Constipation - Diarrhea Functional colonic disease IBS, Intestinal pseudoobstruction/Ogilvie syndrome Rectum/anus Proctalgia fugax - Anal fissure/Anal fistula - Anal abscess - Rectal prolapse - Proctitis Radiation proctitis Other Diverticulitis/Diverticulosis - Megacolon/Toxic megacolon - Appendicitis Accessory Liver Hepatitis Viral hepatitis, Autoimmune hepatitis, Alcoholic hepatitis - Cirrhosis PBC - Fatty liver NASH - vascular Hepatic veno-occlusive disease, Portal hypertension, Nutmeg liver - Alcoholic liver disease - Liver failure Hepatic encephalopathy, Acute liver failure - Liver abscess - Hepatorenal syndrome - Peliosis hepatis Gallbladder Gallstones - common bile duct Choledocholithiasis, Biliary dyskinesia - Cholecystitis - Cholesterolosis - Rokitansky-Aschoff sinuses - Postcholecystectomy syndrome Biliary tree Cholangitis PSC, Ascending - Cholestasis/Mirizzi's syndrome - Biliary fistula - Haemobilia Pancreatic Pancreatitis Acute, Chronic, Herary - Pancreatic pseudocyst - Exocrine pancreatic insufficiency - Pancreatic fistula Hernia Diaphragmatic: Congenital diaphragmatic - Hiatus Abdominal hernia: Inguinal Indirect, Direct - Umbilical - Incisional - Femoral Obturator hernia Peritoneal Peritonitis Spontaneous bacterial peritonitis - Hemoperitoneum - Pneumoperitoneum GI bleeding Upper Hematemesis, Melena - Lower Hematochezia See also congenital, neoplasia Retrieved from http://en..org/wiki/Cirrhosis Categories: Gastroenterology | Hepatology | Alcohol abuseHidden categories: All articles with statements | Articles with statements since June 2008 Views Article Discussion this page History Personal tools Log in / create account Navigation Main page Contents Featured content Current events Random article Search Go Search Interaction Community portal Recent changes Contact Donate to Help Toolbox What links here Related changes Upload file Special pages Printable version Permanent link Cite this page Languages العربية Bân-lâm-gú Dansk Deutsch Español Esperanto Euskara Ù?ارسی Français Hrvatski Ã?slenska Italiano עברית Latina Lingála МакедонÑ?ки Nederlands 日本語 ‪Norsk bokmÃ¥l‬ Polski Português РуÑ?Ñ?кий Shqip SlovenÅ¡Ä?ina СрпÑ?ки / Srpski Suomi Svenska Türkçe ä¸æ–‡ This page was last modified on 20 August 2008, at 16:21
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