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Cirrhosis

Topic Overview

What is cirrhosis?

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:

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:

  • Extreme tiredness and weakness.
  • Nosebleeds and easy bruising.
  • Weight loss.
  • Belly pain or discomfort.
  • Yellowing of the skin (jaundice).
  • Itching.
  • 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 examination 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 ASA 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. Hospice 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 an advance care plan (also called an advance directive or 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 counselling or other types of help. Think about joining a support group. Talking with other people who have cirrhosis can be a big help.

Frequently Asked Questions

Learning about cirrhosis:

Being diagnosed:

Getting treatment:

Living with cirrhosis:

End-of-life issues:

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  Alcohol Problems: How to Stop Drinking
  Cirrhosis: Eating a low-salt diet

Symptoms

People who have cirrhosis sometimes do not have symptoms until liver damage is extensive. Symptoms of cirrhosis and its complications may include:

  • Fluid buildup in the legs (edema) and the abdomen (ascites).
  • Fatigue.
  • Yellowing of the skin (jaundice).
  • Itching (pruritus).
  • Profuse nosebleeds (epistaxis).
  • Redness of the palms.
  • 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.
  • Infection of the fluid in the belly (spontaneous bacterial peritonitis, or SBP).
  • 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 needed to cure renal failure caused by cirrhosis.
  • 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 also are at increased risk of developing liver cancer, mainly hepatocellular carcinoma.

Examinations and Tests

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 find out 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 tumours 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:

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.
  • Alkaline phosphatase (ALP). An increased ALP level may indicate blockage of bile ducts.
  • 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:

Tests that provide an image of the liver

Imaging tests can check for tumours and blocked bile ducts and can be used to evaluate liver size and blood flow through the liver. These tests include:

Other tests

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 reveal 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.
  • Alpha-fetoprotein (AFP) testing, to screen for cancer of the liver (hepatocellular carcinoma). This is a blood test.
  • Ammonia testing, to look for excess ammonia in the blood, which can cause altered brain function (encephalopathy).

Treatment Overview

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 non-prescription 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:
    Click here to view an Actionset. Cirrhosis: Eating a Low-Salt Diet.
  • Get immunized (if you have not already) against hepatitis A and hepatitis B, influenza, and pneumococcus.

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 started. You may need medicines, 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 non-prescription drugs.
  • Begin or stay on a low-sodium diet if fluid retention begins or continues, to help reduce fluid buildup and its complications. For more information, see:
    Click here to view an Actionset. Cirrhosis: Eating a Low-Salt Diet.

Depending on what complications you have, 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. It 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 get rid of fluid that has built up in the belly 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 or cefotaxime, if you have a bacterial infection in your abdomen (spontaneous bacterial peritonitis, or SBP) as a result of fluid buildup.
  • Transjugular intrahepatic portosystemic shunt (TIPS). This procedure can divert fluid from the abdominal cavity and may be used to treat ascites that does not respond to other forms of treatment.

Bleeding from enlarged veins in the digestive tract (variceal bleeding) is another common and potentially life-threatening problem for people with cirrhosis. Be sure that you avoid ASA and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen 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 reduce 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 such as octreotide. 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.
  • Endoscopic variceal banding or sclerotherapy. These techniques may be used to treat and prevent variceal bleeding in the esophagus.
  • 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. A doctor inserts and inflates a balloon in the lower part of the esophagus or upper part of the stomach. The balloon presses against the enlarged veins to stop bleeding. Insertion of a balloon tamponade 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 treat you. It also may be done if nothing else has worked to stop bleeding. This treatment is rarely needed.

Changes in mental function (encephalopathy) may occur 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. This 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, anti-anxiety 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, you will also need periodic screening for enlarged veins (varices) and liver cancer (hepatocellular carcinoma).

  • The American College of Gastroenterology recommends testing for varices with endoscopy for all people who have been diagnosed with cirrhosis. This recommendation is also followed in Canada. If your initial test does not find any varices, you can be tested again in 2 to 3 years. If you already have large varices, you may need more frequent testing 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 testing and beta-blocker medicine. Or your doctor may recommend variceal banding to help prevent future bleeding.1
  • Testing to check for liver cancer should take place every 6 months. You will likely have a test for alpha-fetoprotein and a liver ultrasound.2

Cirrhosis is usually a progressive condition. Before your condition becomes severe, you may want to talk to your doctor about future treatment options. 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 good 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 think about 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 have 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.

Hospice palliative care

If your cirrhosis gets worse, you may want to think about hospice palliative care. Hospice 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. Hospice palliative care focuses on improving your quality of life—not just in your body, but also in your mind and spirit. Hospice palliative care can be combined with curative care.

Hospice 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 want to know more about hospice 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.

For more information, see the topic Hospice Palliative Care.

End-of-life issues

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 care plan while they are still able to make and communicate these decisions. You may also think about who you would choose as your substitute decision-maker 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 palliative care health professionals can provide care and comforting surroundings for someone who is preparing to die.

Home Treatment

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 new liver damage.

Giving up alcohol

In Canada and 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: Drinking and Your Health.

Changing your diet

Changes in your diet may be needed, such as restricting the amount of salt or protein you eat.

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:

Click here to view an Actionset. Cirrhosis: Eating a Low-Salt Diet.

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 you may need to avoid eating large amounts of protein at one time.

Avoiding harmful medicines

Some medicines should be used carefully or not taken by people who have cirrhosis. For example, acetaminophen (such as Tylenol) can speed up liver damage if you have cirrhosis and you are still drinking alcohol. Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and ASA, increase the risk of variceal bleeding if you have enlarged veins (varices) in the digestive tract. NSAIDs can also raise your risk for ascites. 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 (including all non-prescription medicines, vitamins, herbs, and supplements) that 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 so you don't make your gums bleed.
  • Make sure you have been vaccinated against:

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.3 Milk thistle will not reverse existing liver damage, and it will not cure infection with the hepatitis B or hepatitis C virus. Milk thistle should not be used by people who have complications from cirrhosis (such as variceal bleeding or ascites). 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 discuss 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 care plan 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 substitute decision-maker to make and carry out decisions about your care if you become unable to speak for yourself.

For more information, see the topics:

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 palliative care health professionals can provide hospice palliative care and comforting surroundings for someone who is preparing to die.

For more information, see the topic Hospice Palliative Care.

Other Places To Get Help

Organizations

Canada's Food Guide
Health Canada, Health Products and Food Branch, Office of Nutrition Policy and Promotion
Web Address: www.hc-sc.gc.ca/fn-an/food-guide-aliment/index_e.html
 

Canada's Food Guide provides resources to help guide food selection and promote the nutritional health of Canadians. Resources include outlines of the food groups, the recommended range of daily servings, background information about the food guide, and other information about healthy eating.


Canadian Association of Gastroenterology
1540 Cornwall Road
Suite 224
Oakville, ON  L6J 7W5
Phone: 1-888-780-0007
(905) 829-2504
Fax: (905) 829-0242
Email: general@cag-acg.org
Web Address: www.cag-acg.org
 

The Canadian Association of Gastroenterology (CAG) provides educational information and supports research about digestive health and disease.


Canadian Centre on Substance Abuse
75 Albert Street
Suite 500
Ottawa, ON  K1P 5E7
Phone: (613) 235-4048
Fax: (613) 235-8101
Email: info@ccsa.ca
Web Address: www.ccsa.ca
 

The Canadian Centre on Substance Abuse (CCSA) is an independent national organization working to reduce health, social, and economic harm associated with substance abuse and addictions. The centre promotes informed debate on substance abuse issues and supports organizations seeking to prevent or treat substance abuse.


Canadian Liver Foundation
2235 Sheppard Avenue East
Suite 1500
Toronto, ON  M2J 5B5
Phone: (416) 491-3353
1-800-563-5483
Fax: (416) 491-4952
Email: clf@liver.ca
Web Address: www.liver.ca
 

The Canadian Liver Foundation funds medical research and offers education and support programs for liver disease patients, their families and friends, health professionals, and the general public.


U.S. National Digestive Diseases Information Clearinghouse
2 Information Way
Bethesda, MD  20892-3570
Phone: 1-800-891-5389
Fax: (703) 738-4929
TDD: 1-866-569-1162 toll-free
Email: nddic@info.niddk.nih.gov
Web Address: www.digestive.niddk.nih.gov
 

This clearinghouse is a service of the U.S. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the U.S. National Institutes of Health. The clearinghouse answers questions; develops, reviews, and sends out publications; and coordinates information resources about digestive diseases. Publications produced by the clearinghouse are reviewed carefully for scientific accuracy, content, and readability.


References

Citations

  1. Garcia-Tsao G, et al. (2007). Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. American Journal of Gastroenterology, 102(9): 2086–2102.
  2. National Cancer Institute (2009). Liver (Hepatocellular) Cancer Screening PDQ—Health Professional Version. Available online: http://www.cancer.gov/cancertopics/pdq/screening/hepatocellular/healthprofessional.
  3. Milk thistle (2005). Review of Natural Products. St. Louis: Wolters Kluwer Health.

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.
  • 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.
  • Bacon BR (2008). Cirrhosis and its complications. In AS Fauci et al., eds., Harrison's Principles of Internal Medicine, 17th ed., vol. 2, pp. 1971–1980. New York: McGraw-Hill.
  • Bataller R (2008). Cirrhosis of the liver. In EG Nabel, ed., ACP Medicine, section 4, chap. 9. Hamilton, ON: BC Decker.
  • 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.
  • Swain MG (2007). Chronic liver diseases. In J Gray, ed., Therapeutic Choices, 5th ed., pp. 686–702. Ottawa: Canadian Pharmacists Association.

Credits

By Healthwise Staff
Primary Medical Reviewer Kathleen Romito, MD - Family Medicine
Primary Medical Reviewer Brian D. O'Brien, MD - Internal Medicine
Specialist Medical Reviewer W. Thomas London, MD - Hepatology
Last Revised November 4, 2011

Last Revised: November 4, 2011

Author: Healthwise Staff

Medical Review: Kathleen Romito, MD - Family Medicine & Brian D. O'Brien, MD - Internal Medicine & W. Thomas London, MD - Hepatology

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