• The clinical manifestations may be generalised and non-specific, such as malaise, and loss of appetite. More specific symptoms include symptoms suggestive of decompensation such as jaundice, ascites, and upper gastrointestinal bleeds (variceal) and confusion (hepatic encephalopathy). 
• Patients with compensated disease may be asymptomatic or may have the above stated non-specific symptoms. 
• Man may experience symptoms of hypogonadism, such as loss of libido, infertility and atrophy of the gonads (testicles), this is due to hormonal imbalances. 
• Cirrhosis signs, include jaundice, gynecomastia (up to one third of men), loss of axillary and pubic hair, ascites, and splenomegaly (due to portal hypertension), finger clubbing, asterixis and spider angiomata. Bilateral parotid enlargement usually seen in alcoholic patients. Caput medusae is a very sensitive sign of portal hypertension with liver cirrhosis.
• On auscultation there may be Cruveilhier-Baumgarten murmur due to portal hypertension [5].

• Splenomegaly

  The SBLS is more feasible and effective than ALS in patients with massive splenomegaly (≥30 cm) secondary to portal hypertension and liver cirrhosis. [ncbi.nlm.nih.gov]

• Weight Loss

  As such, weight loss may be beneficial in these patients. Copyright © 2017. Published by Elsevier B.V. [ncbi.nlm.nih.gov]

  Weight loss. Fluid retention. Black stools and bloody vomit. Causes There are a number of causes that can lead to cirrhosis of the liver. These causes include: Excessive alcohol intake. Autoimmune liver disease such as hepatitis. [medanta.org]

  A loss of 4% to 10% body weight is recommended, with 10% to 40% weight loss completely reversing NASH without cirrhosis. [en.wikipedia.org]

  Maintain a healthy weight. An excess amount of body fat can damage your liver. Talk to your doctor about a weight-loss plan if you are obese or overweight. Reduce your risk of hepatitis. [mayoclinic.org]

• Fatigue

  In the presented case, the authors describe an obese middle-aged man that presented to the emergency department for persistent oedema, scleral icterus and fatigue. [ncbi.nlm.nih.gov]

  Symptoms & Causes Cirrhosis has many signs and symptoms, such as fatigue and severe itchy skin. They may not appear until the liver is badly damaged. [niddk.nih.gov]

  Early stage liver cirrhosis is identified by symptoms such as: Fatigue. Fever. Jaundice. Weight loss. Fluid retention. Black stools and bloody vomit. Causes There are a number of causes that can lead to cirrhosis of the liver. [medanta.org]

• Anemia

  Glycated hemoglobin (HbA1c) is a widely used marker of glycemic control but can be affected by hemolytic anemia. Glycated albumin (GA) is also affected in patients with liver cirrhosis. [ncbi.nlm.nih.gov]

• Leg Edema

  A 65-year-old male with liver cirrhosis of alcoholic etiology was admitted to hospital with bilateral leg edema, ascites, and marked weakness. At admission, his blood pressure was 82/52 mmHg and he had sinus tachycardia of 130/min. [ncbi.nlm.nih.gov]

  Early symptoms include: Fatigue and loss of energy Poor appetite and weight loss Nausea or belly pain Small, red spider-like blood vessels on the skin As liver function worsens, symptoms may include: Fluid buildup of the legs (edema) and in the abdomen [nlm.nih.gov]

  As liver function decreases, fewer proteins such as albumin are produced resulting in fluid accumulation in the legs (edema) or abdomen (ascites). [liver.ca]

  Swelling in the legs and abdomen. The increased pressure in the portal vein can cause fluid to accumulate in the legs (edema) and in the abdomen (ascites). [mayoclinic.org]

  (edema) impotence gynecomastia (when males start to develop breast tissue) A diagnosis of cirrhosis begins with a detailed history and physical exam. [healthline.com]

• Weight Gain

  As the disease gets worse, symptoms may include: Loss of appetite Lack of energy (fatigue) Weight loss or sudden weight gain Bruises Yellowing of skin or the whites of eyes ( jaundice ) Itchy skin Fluid retention ( edema ) and swelling in the ankles, [my.clevelandclinic.org]

  Although people in their 40s and 50s have a higher risk of developing NAFLD, researchers have also seen it in obese adolescents. 3 of 10 Suparat Malipoom/Getty Images Soda Sugar-laden sodas are a notorious cause of weight gain, so it’s not surprising [health.com]

  Fever Vomiting Diarrhea Itching - From deposition in the skin of products of the breakdown of bile Abdominal pain - From enlargement of the liver or formation of gallstones Abdominal swelling or bloating - From fluid retention Weight gain - From fluid [emedicinehealth.com]

  Diabetes promotes abdominal weight gain, and this is the most dangerous body part to store excess fat. [liverdoctor.com]

  A loss of 4% to 10% body weight is recommended, with 10% to 40% weight loss completely reversing NASH without cirrhosis. [en.wikipedia.org]

• Easy Bruising

  Easy bruising and severe bleeding. This happens when the liver stops making proteins that are needed for your blood to clot. Type 2 diabetes. When you have cirrhosis, your body does not use insulin properly (insulin resistance). [urmc.rochester.edu]

  Cirrhosis can lead to Easy bruising or bleeding, or nosebleeds Swelling of the abdomen or legs Extra sensitivity to medicines High blood pressure in the vein entering the liver Enlarged veins called varices in the esophagus and stomach. [medlineplus.gov]

  Kidney disease or failure Easy bruising and severe bleeding. This happens when the liver stops making proteins that are needed for your blood to clot. Type 2 diabetes. [hopkinsmedicine.org]

  […] symptoms may include: Fluid buildup of the legs (edema) and in the abdomen (ascites) Yellow color in the skin, mucous membranes, or eyes (jaundice) Redness on the palms of the hands In men, impotence, shrinking of the testicles, and breast swelling Easy [nlm.nih.gov]

  There may be also easy bruising. There also may be heavy internal bleeding from the food pipe which may be fatal. [symptoma.com]

• Clubbed Finger

  […] become wider/thicker (clubbed fingers) hair loss swelling of the legs, ankles, feet (oedema) swelling of the abdomen (ascites) dark urine pale-coloured stools or very dark/black tarry stools frequent nosebleeds and bleeding gums easy bruising and diffi [britishlivertrust.org.uk]

• Abdominal Pain

  The patient was admitted with acute and severe abdominal pain during weight-bearing physical labor. He had a history of alcoholic liver cirrhosis but no chronic abdominal pain or gallstones. [ncbi.nlm.nih.gov]

  Around 2-5% of children with pneumonia have associated abdominal pains, far more diffuse, than localized. [posterng.netkey.at]

• Nausea

  On the basis of the Edmonton Symptom Assessment System, 65% of patients had evidence of pain, 58% had evidence of nausea, 10% had depression, 36% had anxiety, 48% had dyspnea, and 49% had symptoms of anorexia. [ncbi.nlm.nih.gov]

  However occasionally it may be so violent and especially when associated with paralytic ileus, nausea, vomiting and diarrhea, as to overshadow the thoracic symptoms. leading to superfluous US and CT examinations. [posterng.netkey.at]

  Symptoms may include fever, jaundice, nausea, vomiting, abdominal pain and tenderness. [liverfoundation.org]

  Symptoms may include loss of appetite, nausea, vomiting, abdominal pain, fever and jaundice. Up to 35 percent of heavy drinkers develop alcoholic hepatitis. Alcoholic hepatitis can be mild or severe. If it is mild, liver damage may be reversed. [web.archive.org]

• Loss of Appetite

  Symptoms may include loss of appetite, nausea, vomiting, abdominal pain, fever and jaundice. Up to 35 percent of heavy drinkers develop alcoholic hepatitis. Alcoholic hepatitis can be mild or severe. If it is mild, liver damage may be reversed. [web.archive.org]

  As the disease gets worse, symptoms may include: Loss of appetite Lack of energy (fatigue) Weight loss or sudden weight gain Bruises Yellowing of skin or the whites of eyes ( jaundice ) Itchy skin Fluid retention ( edema ) and swelling in the ankles, [my.clevelandclinic.org]

  The clinical manifestations may be generalised and non-specific, such as malaise, and loss of appetite. [symptoma.com]

  However, as time goes by and more healthy tissue is replaced with scar tissue, the liver begins to fail and a person may experience: Nausea and vomiting Weakness and exhaustion Loss of appetite and weight loss Red, spidery blood vessels on the skin Mental [cedars-sinai.edu]

• Abdominal Distension

  We report a case of diabetic myonecrosis in a 33-year-old man with hepatitis B-induced liver cirrhosis and type 2 diabetes who presented with abdominal distension and pain in the left thigh. [ncbi.nlm.nih.gov]

  It is common to withdraw large amounts (liters) of fluid from the abdomen when the ascites is causing painful abdominal distension and/or difficulty breathing because it limits the movement of the diaphragms. [rxlist.com]

• Hematemesis

  The child presented with complaints of malena, hematemesis and variceal bleed. The examination revealed a child with respiratory distress, irritability, tachycardia, clubbing and abdominal distention. [ncbi.nlm.nih.gov]

  We are of the opinion that airway protection at emergency endoscopy is extremely important in patients with suspected variceal bleeding, who present with hematemesis, and particularly in hemodynamically unstable patients and those with hepatic encephalopathy [wjgnet.com]

  Review of Symptoms : In patients with cirrhosis it is critical to inquire about symptoms that would suggest complications of advanced liver disease, including abdominal girth swelling or tightness, lower extremity edema, jaundice, hematemesis or melena [hepatitisc.uw.edu]

  Gastrointestinal hemorrhaging can result in hematemesis (vomiting of blood), melena (tarry stools), or hematochezia (bloody stools). [ssa.gov]

• Cyanosis

  CONCLUSIONS We reported a case of peripheral cyanosis following terlipressin administration, which resolved after discontinuation of terlipressin administration. [ncbi.nlm.nih.gov]

  The following may also occur: Dyspnoea Sharp chest pain Worsening cough Fever/chills Tachycardia Pleuritic chest pain Headaches Malaise Muscle pains Cyanosis due to poorly oxygenated blood Loss of appetite Rapid breathing Wheezing or grunting during breathing [physio-pedia.com]

  Clinical manifestations usually include dyspnea, orthodeoxia (increasing hypoxemia with erect position), platypnea (improvement of dyspnea with flat position), cyanosis, and clubbing. [ssa.gov]

• Jaundice

  Differential diagnosis from obstructive jaundice and a severe prognosis without alcohol abstinence make early diagnosis mandatory. Its evolution in cirrhosis can be astonishingly rapid. [ncbi.nlm.nih.gov]

  Complications at this stage include coma, kidney failure, jaundice, infection, and hemorrhages. In the advanced stage of the disease, the liver shrinks and the surface usually has a roughened appearance. [britannica.com]

  Abstract A heavily T2-weighted gradient-echo sequence was used for magnetic resonance (MR) imaging of the biliary system in five healthy volunteers and 13 patients with obstructive jaundice. [dx.doi.org]

• Hepatomegaly

  Cardinal symptoms include fasting hypoglycemia, lactic acidosis and hepatomegaly as well as neutropenia. [ncbi.nlm.nih.gov]

  In our study, the fibroscan showed a positive correlation with the hepatic size (liver span) as 60% of F3 patients had hepatomegaly and 40% of F3 patients had normal liver, whereas75% of F4 patients had hepatomegaly. [mmj.eg.net]

  For lowering the likelihood of cirrhosis, the most useful findings are a Lok index 3 /μL (LR, 0.29; 95% CI, 0.20-0.39); or the absence of hepatomegaly (LR, 0.37; 95% CI, 0.24-0.51). [dx.doi.org]

• Scleral Icterus

  In the presented case, the authors describe an obese middle-aged man that presented to the emergency department for persistent oedema, scleral icterus and fatigue. [ncbi.nlm.nih.gov]

  A compelling clinical picture required, in the absence of other explanations, the presence of at least 4 of the following: spider nevi, scleral icterus, palmar erythema, ascites, flapping tremor, hepatosplenomegaly, a platelet count of less than 140 000 [archinte.ama-assn.org]

  Scleral icterus can usually be detected if the serum bilirubin level is greater than 3.0 mg/dL. Identifying jaundice is an important factor in determining if a patient has decompensated liver disease. [hepatitisc.uw.edu]

• Liver Firm

  These investigators found good agreement beyond chance for liver firmness (κ = 0.72), spleen size (κ = 0.66), and stated that agreement for liver enlargement was similar (κ not stated). [ncbi.nlm.nih.gov]

• Muscle Cramp

  Some other symptoms you might get are: Vomiting blood Severe muscle cramps Brownish urine Fever Enlarged spleen Bone disease, causing bones to break more easily Keep in mind that you may not get all these symptoms, and some of these problems are also [webmd.com]

  Is taurine effective for treatment of painful muscle cramps in liver cirrhosis? [letter]. Am J Gastroenterol. 1993;88:1466 - 1467. Okita M, Watanabe A, Nagashima H. A vegetable protein-rich diet for the treatment of liver cirrhosis. [cancercarewny.com]

  cramps nosebleeds pain in the right shoulder breathlessness stools become black and tarry, or very pale. urine becomes darker. vomiting blood problems with walking and mobility The liver tissue is replaced by fibrous scar tissue. [medicalnewstoday.com]

  This means that your body has to use its own muscle tissue to provide energy between meals and this can lead to muscle wasting and weakness. If you are affected in this way, snacking between meals is a way you can top up on calories and protein. [britishlivertrust.org.uk]

  Cirrhosis can lead to a hyperdynamic circulation, reduction in lean muscle mass, muscle cramps, and umbilical herniation. [ncbi.nlm.nih.gov]

• Palmar Erythema

  Patients cannot reproduce simple designs (e.g. a star of David) Drowsiness and confusion Parotid gland enlargement Spider angiomas Icterus Bilateral parotid swelling ( Credit ) Diminished axillary hair Spider angioma Gynecomastia in a male Asterixis Palmar [stanfordmedicine25.stanford.edu]

  erythema) itchy skin hair loss dark coloured urine fluid retention in the abdomen and legs internal bleeding presenting as dark-coloured stools or vomiting blood hormone disruptions that could cause a range of problems, including testicular atrophy [betterhealth.vic.gov.au]

  Palmar erythema. Bruising. Petechiae or purpura. Hair loss. White nails (horizontal white bands or a proximal white nail plate; sign of hypoalbuminaemia). Finger clubbing. Dupuytren's contracture. [patient.info]

  There was significant heterogeneity in the reported diagnostic accuracy of palmar erythema, precluding meta-analysis. [ncbi.nlm.nih.gov]

• Pruritus

  Colestyramine is the mainstay of therapy for the pruritus of liver disease. Rifampicin has helped some patients unresponsive to colestyramine. Severe pruritus may require treatment with ultraviolet light or plasmapheresis. [patient.info]

  Symptoms include: jaundice portal hypertension, which increases blood pressure in the vein that travels through the liver skin itching (pruritus) Damage from repeated and excessive alcohol abuse leads to alcoholic liver cirrhosis. [healthline.com]

  The most common side effects of Ocaliva are severe itching of the skin (pruritus), fatigue, abdominal pain and discomfort, joint pain (arthralgia), pain in the middle part of the throat (oropharyngeal), dizziness and constipation. [fda.gov]

  Pruritus Pruritus is a common complaint in cholestatic liver diseases (eg, primary biliary cirrhosis) and in noncholestatic chronic liver diseases (eg, hepatitis C). [emedicine.com]

• Yellow Discoloration of the Skin

  Jaundice is a yellow discoloration of the skin and whites of the eyes due to abnormally high levels of bilirubin (bile pigment) in the bloodstream. Urine is usually dark because of the bilirubin excreted through the kidneys. [stanfordchildrens.org]

  When signs and symptoms do occur, they may include: Fatigue Easily bleeding or bruising Loss of appetite Nausea Swelling in your legs, feet or ankles (edema) Weight loss Itchy skin Yellow discoloration in the skin and eyes (jaundice) Fluid accumulation [mayoclinic.org]

  This may be visible as an increase in abdominal girth.[13] Fetor hepaticus is a musty breath odor resulting from increased dimethyl sulfide.[14] Jaundice, or icterus is yellow discoloration of the skin and mucous membranes, (with the white of the eye [en.wikipedia.org]

• Alopecia

  8·9 to 10·1) * −1·1 (−1·4 to −0·7) * 4133·9 (2628·4–6153·4) 9·4 (8·8 to 10·1) * −1·0 (−1·5 to −0·6) * Acne vulgaris 632 741·0 (595 241·9 to 671 248·9) 4·6 (3·5 to 5·6) * 0·8 (−0·1 to 1·7) 6854·0 (3275·1–12 713·9) 4·6 (3·5 to 5·6) * 0·8 (−0·1 to 1·8) Alopecia [ncbi.nlm.nih.gov]

• Multiple Spider Angiomata

  Blanching is replaced by rapid refill from the central arteriole when pressure is released.[5] Multiple spider angiomata Spider angiomas are found only in the distribution of the superior vena cava, and are thus commonly found on the face, neck, upper [en.wikipedia.org]

• Kidney Failure

  Complications at this stage include coma, kidney failure, jaundice, infection, and hemorrhages. In the advanced stage of the disease, the liver shrinks and the surface usually has a roughened appearance. [britannica.com]

  Risks The main risk factors for this disease include: Kidney failure. Bleeding by portal hypertension. Diabetes. Breast enlargement in men. Reduction of oxygen in the body. [medanta.org]

  Kidney failure Jaundice Severe itching Gallstones A small number of people with cirrhosis get liver cancer. Your doctor will diagnose cirrhosis with blood tests, imaging tests, or a biopsy. Cirrhosis has many causes. [medlineplus.gov]

  If left untreated, cirrhosis can lead to serious complications such as: kidney failure malnutrition diabetes liver cancer Children with cirrhosis bruise and bleed easily and are more susceptible to infection than other children. [childrenshospital.org]

• Amenorrhea

  The following year, in June 1802, he published his first paper and while still a student, published a number of papers on such notable topics as peritonitis, amenorrhea and liver disease. 1 He also served as editor of the Journal de Médecine. [ncbi.nlm.nih.gov]

  Diagnosis The risk factors for osteoporosis should be evaluated in patients with chronic liver disease, including the following: chronic alcohol intake, smoking, body mass index lower than 19 Kg/m 2, male hypogonadism, early menopause, secondary amenorrhea [em-consulte.com]

• Confusion

  MEDICINES FROM YOUR DOCTOR Water pills (diuretics) to get rid of fluid build-up Vitamin K or blood products to prevent excess bleeding Medicines for mental confusion Antibiotics for infections OTHER TREATMENTS Endoscopic treatments for enlarged veins [nlm.nih.gov]

  More specific symptoms include symptoms suggestive of decompensation such as jaundice, ascites, and upper gastrointestinal bleeds (variceal) and confusion (hepatic encephalopathy). [symptoma.com]

  (pronounced "a-sigh-tees") Encephalopathy Confusion from the buildup of toxins in the blood. [surgery.ucsf.edu]

  You’re experiencing confusion iStock/elenaleonova Confusion can also be added to the list of fatty liver symptoms. [rd.com]

• Tremor

  Liver cirrhosis in the index patient was complicated by hyperamonemia, hepatic encephalopathy and flapping tremor. [ncbi.nlm.nih.gov]

  […] liver Enlarged spleen Appearance of thin, purplish-red, spidery looking blood vessels on the skin, especially around the navel Water retention and swelling in the legs and abdomen Vomiting blood Itching Abdominal infections Forgetfulness or confusion Tremors [chp.edu]

  […] may include: Impaired consciousness Changes in logical thinking, personality, and behavior Mood changes Impaired judgment Drowsiness Confusion Sluggish speech and movement Disorientation Loss of consciousness Coma Seizures (rare) Muscle stiffness or tremors [stanfordchildrens.org]

  It can also feature problems in movement (called ataxia) and speech, slurring of words, tremor and a particular symptom of fl apping hands when you extend your arms (called asterixis). [britishlivertrust.org.uk]

  The physical exam can show signs such as: pale skin yellow eyes (jaundice) reddened palms hand tremors an enlarged liver or spleen small testicles excess breast tissue (in men) decreased alertness Tests can reveal how damaged the liver has become. [healthline.com]

• Personality Change

  changes Blood in the stool Fever An early sign of cirrhosis is retaining (holding onto) fluid and salt. [my.clevelandclinic.org]

  A cirrhotic liver no longer removes toxins effectively leading to toxin accumulation in the blood, which in turn can impair mental function and lead to personality changes and possibly coma. [liver.ca]

  These toxins can dull mental functioning and cause personality changes, coma and even death. [health24.com]

  Outlook The survival rate of a person with liver cirrhosis depends on the severity of the scarring. [medicalnewstoday.com]

  Hepatic encephalopathy Hepatic encephalopathy is defined as a complex neuropsychiatric syndrome marked by personality changes, intellectual impairment, and an altered level of consciousness. [cfp.ca]

• Insomnia

  The following signs and symptoms may occur: blood capillaries become visible on the skin on the upper abdomen. fatigue insomnia itchy skin loss of appetite loss of bodyweight nausea pain or tenderness in the area where the liver is located red or blotchy [medicalnewstoday.com]

  […] variceal bleed, the combination of nonselective beta-blockers and endoscopic variceal ligation are recommended to decrease the risk of another bleed Hepatic Encephalopathy Overview: Variable abnormalities of neurological and psychiatric function, including insomnia [hiv.va.gov]

  Adverse effects may include: Anemia (ribavirin‑induced hemolysis), neutropenia, thrombocytopenia, fever, cough, fatigue, myalgia, arthralgia, nausea, loss of appetite, pruritis, and insomnia. Behavioral side effects may also occur. [ssa.gov]

  This class of drugs is commonly prescribed to alcoholics for insomnia or anxiety management.[147] Initiating prescriptions of benzodiazepines or sedative-hypnotics in individuals in recovery has a high rate of relapse with one author reporting more than [en.wikipedia.org]

• Slurred Speech

  speech (hepatic encephalopathy) When to see a doctor Make an appointment with your doctor if you have any of the signs or symptoms listed above. [mayoclinic.org]

  Symptoms Asterixis EEG abnormal Grade 1 Mild confusion, disordered sleep, slurred speech, shortened attention span, euphoria or depression Yes/No No Grade 2 Lethargy, inappropriate behavior, moderate confusion Yes Yes Grade 3 Sever confusion, incoherent [dx.doi.org]

  A BAC of 0.18% to 0.30% causes profound confusion, impaired speech (e.g. slurred speech), staggering, dizziness and vomiting. [en.wikipedia.org]

The gold standard for diagnosis is to view the liver architecture, this can only be done on autopsy or on a removed liver during transplantation. The next best test would be a biopsy. The sample may be obtained percutaneous, transjugular, or by a laparoscopic approach. The sensitivity is usually very good if done appropriately.

Other tests that may be asked for to access the liver function include, INR (international normalized ratio), protein, albumin levels and liver enzyme levels. The INR increases with advance disease, while albumin and protein level decrease with advancing disease. Other examinations include tests to look for infective causes as listed above and autoimmune diseases [6].

Imaging 

Ultrasonography is a reliable tool that can be used to access the liver non-invasively. It can also access the nodularity and size of the liver and suspicious nodules (malignant), may be seen. It can also be used to access the portal pressures [7] [8]. Computed tomography may be used to diagnose hepatocellular carcinoma with specialized sequences.

• Transaminases Increased

  It is also associated with hormonal disorders (panhypopituitarism, hypothyroidism, hypogonadism, polycystic ovary syndrome), persistently elevated transaminases, increasing age and BMI and hypoxia caused by obstructive sleep apnea, with some of them predicting [en.wikipedia.org]

The treatment is to find the underlying cause and remove or treat it. As cirrhosis is the end stage, most of the injury is non-reversible and transplantation is the only option left. Some modalities which are mostly supportive may help slow the symptomology, for example laxatives [9].

Many patients with liver cirrhosis will eventually decompensate and the treatment is liver transplantation. Without transplantation the options for decompensated liver cirrhosis are only supportive. Despite the dramatic improvements in survival in liver transplant patients, donor organs are rare and difficult to come by. Overall without transplantation, outlook is poor [4].

Alcohol is considered to be one of the major causes of cirrhosis, but other diseases such as hepatitis B and C are also common causes. The etiology may be divided into the following categories:

Infective

• Viral hepatitis
• Brucellosis
• Schistosomiasis

Ingestion

• Alcohol
• Methotrexate

Genetic

• Hemochromatosis
• Celiac disease
• Wilson disease
• Polycystic liver disease
• Alpha-1 antitrypsin deficiency
• Cystic fibrosis

Autoimmune

• Autoimmune hepatitis
• Biliary cirrhosis [2]

Many causes of chronic injury to the liver can lead to cirrhosis. In most cases of cirrhosis the cause may be found (80-90%). Previously alcohol was thought to be the commonest cause of liver cirrhosis, but infective causes are immerging, particularly hepatitis C has become the leading cause in the United States of America. It is in the top cause of cirrhosis currently.

The occurrence of fibrosis is due to an imbalance between the laying down of collagen within the extracellular matrix and it degradation with subsequent distortion of the normal architecture. The extracellular matrix is produced by stellate cells of the liver. These cells get activated and produce collagen. The activation is via cytokines released by Kupffer cells, and sinusoidal endothelium as a response to injury. The injury is usually chronic as in alcoholism.

The collagen is deposited in the space of Disse with subsequent reduction in the size of the sinusoids leading to their capillarization. The fibrosis continues with area of regeneration which eventually leads to the end stage of cirrhosis [3].

Vaccination against the infective causes is necessary. With those treatable diseases such as hepatitis B, early identification and appropriate treatment is paramount in halting the fibrosis before it becomes irreversible [10].

Liver cirrhosis is the end stage of progressive liver fibrosis with the characteristic regeneration nodules and fibrosis. This process may take weeks to years and is caused by a number of diseases and environmental factors. Cirrhosis is defined histologically as a diffuse hepatic process with fibrosis and areas of regeneration. The fibrosis is caused by the laying down of excess extracellular matrix. Initially it is reversible, but by the time it progresses to cirrhosis which is considered irreversible [1]. 

• Definition: Liver cirrhosis is a disease where the liver is irreversibly scared. The reasons for the scarring are multiple. The inciting cause usually causes the scarring over a prolonged time, of up to 40 years. Damage to the liver can cause bleeding, body swelling and a big belly full of fluid. 
• Cause: Causes are multiple and include infections such as hepatitis B and C. Another common cause is excessive alcohol intake. Other causes may be familial.
• Symptoms: Some people may have no symptoms while others may be very sick with yellowing of the eyes, swelling of the legs and body, fatigue and decreased appetite. There may be also easy bruising. There also may be heavy internal bleeding from the food pipe which may be fatal. The worse the patient gets the more confused they get, till they eventually fall into a coma 
• Diagnosis: The test that give the best results is a biopsy. The doctor gets a piece of the liver and sends it for diagnosis. Blood test may be done to find out the causes of the cirrhosis. 
• Treatment: There is no treatment as the cirrhosis is permanent. The only option is to have a liver transplant. Usually people get a liver when they become symptomatic and the cause cannot be reversed. The outcomes after surgery are improving with time.

1. Harrison’s principals of Internal medicine 18th edition McGraw hill chapter 308.
2. Heidelbaugh JJ, Bruderly M. Cirrhosis and chronic liver failure: part I. Diagnosis and evaluation. Am Fam Physician 2006; 74:756.
3. Friedman SL. Hepatic fibrosis. In: Schiff ER, Sorrell MF, Maddrey WC, eds. Schiff's Diseases of the Liver. 8th ed. Philadelphia, Pa: Lippincott-Raven; 1999:371-85
4. Freeman RB. Overview of the MELD/PELD system of liver allocation indications for liver transplantation in the MELD era: evidence-based patient selection. Liver Transpl. Oct 2004;10(10 Suppl 2):S2-3
5. Burra P, Germani G, Masier A, et al. Sexual dysfunction in chronic liver disease: is liver transplantation an effective cure? Transplantation 2010; 89:1425.
6. Simonovský V. The diagnosis of cirrhosis by high resolution ultrasound of the liver surface. Br J Radiol 1999; 72:29.
7. Di Lelio A, Cestari C, Lomazzi A, Beretta L. Cirrhosis: diagnosis with sonographic study of the liver surface. Radiology 1989; 172:389.
8. Sanford NL, Walsh P, Matis C, et al. Is ultrasonography useful in the assessment of diffuse parenchymal liver disease? Gastroenterology 1985; 89:186.
9. Abt PL, Desai NM, Crawford MD, et al. Survival following liver transplantation from non-heart-beating donors. Ann Surg. Jan 2004;239(1):87-92
10. Bonis PA, Friedman SL, Kaplan MM. Is liver fibrosis reversible? N Engl J Med 2001; 344:452.