against the progression of liver disease. these effects are more noticeable in liver disease that is associated with alcohol use disorder. coffee has antioxidant and antifibrotic effects. caffeine may not be the important component; polyphenols may be more important. drinking two or more cups of coffee a day is associated with improvements in the liver enzymes alt, ast, and ggt. even in those with liver disease, coffee consumption can lower fibrosis and cirrhosis. treatment generally, liver damage from cirrhosis cannot be reversed, but treatment can stop or delay further progression and reduce complications. a healthy diet is encouraged, as cirrhosis may be an energy-consuming process. a recommended diet consists of high-protein, high-fiber diet plus supplementation with branched-chain amino acids. close follow-up is often necessary. antibiotics are prescribed for infections, and various medications can help with itching. laxatives, such as lactulose, decrease the risk of constipation. carvedilol increases survival benefit for patients with cirrhosis and portal hypertension. alcoholic cirrhosis caused by alcohol use disorder 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 is treated by removing the copper which builds up in organs. this is carried out using chelation therapy such as penicillamine. when the cause is an iron overload, iron is removed using a chelation agent such as deferoxamine or by bloodletting. as of 2021, there are recent studies studying drugs to prevent cirrhosis caused by non-alcoholic fatty liver disease (nafld or nash). a drug called semaglutide was shown to provide greater nash resolution versus placebo. no improvement in fibrosis was observed. a combination of cilofexor/firsocostat was studied in patients with bridging fibrosis and cirrhosis. it was observed to have led to improvements in nash activity with a potential antifibrotic effect. lanifibranor is also shown to prevent worsening fibrosis. preventing further liver damage regardless of the underlying cause of cirrhosis, consumption of alcohol and other potentially damaging substances are discouraged. there is no evidence that supports the avoidance or dose reduction of paracetamol in people with compensated cirrhosis; it is thus considered a safe analgesic for said individuals. vaccination of susceptible patients should be considered for hepatitis a and hepatitis b. treating the cause of cirrhosis prevents further damage; for example, giving oral antivirals such as entecavir and tenofovir where cirrhosis is due to hepatitis b prevents progression of cirrhosis. similarly, control of weight and diabetes prevents deterioration in cirrhosis due to non-alcoholic fatty liver disease. avoid drugs that could further harm the liver. these include several drugs such as anti-depressants, certain antibiotics, and nsaids (like ibuprofen). these agents are hepatotoxic as they are metabolized by the liver. if medication that harms the liver is still recommended by your doctor, the dosage can be adjusted. lifestyle according to a 2018 systematic review based on studies that implemented 8 to 14 week-long exercise programs, there is currently insufficient scientific evidence regarding either the beneficial or harmful effects of physical exercise in people with cirrhosis on all-cause mortality, morbidity (including both serious and non-serious adverse events), health-related quality of life, exercise capacity and anthropomorphic measures. these conclusions were based on low to very low quality research, which imposes the need to develop further research with higher quality, especially to evaluate its effects on clinical outcomes. 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%. the survival rate depends largely on the severity of disease and other medical risk factors in the recipient. in the united states, the meld score is used to prioritize patients for transplantation. transplantation necessitates the use of immune suppressants (ciclosporin or tacrolimus). decompensated cirrhosis manifestations of decompensation in cirrhosis include gastrointestinal bleeding, hepatic encephalopathy, jaundice or ascites. 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 below. people with decompensated cirrhosis generally require admission to a hospital, with close monitoring of the fluid balance, mental status, and emphasis on adequate nutrition and medical treatment – often with diuretics, antibiotics, laxatives or enemas, thiamine and occasionally steroids, acetylcysteine and pentoxifylline. administration of saline is avoided, as it would add to the already high total body sodium content that typically occurs in cirrhosis. life expectancy without liver transplant is low, at most 3 years. palliative care palliative care is specialized medical care that focuses on providing patients with relief from the symptoms, pain, and stress of a serious illness, such as cirrhosis. the goal of palliative care is to improve quality of life for both the patient and the patient's family and it is appropriate at any stage and for any type of cirrhosis. especially in the later stages, people with cirrhosis experience significant symptoms such as abdominal swelling, itching, leg edema, and chronic abdominal pain which would be amenable for treatment through palliative care. because the disease is not curable without a transplant, palliative care can also help with discussions regarding the person's wishes concerning health care power of attorney, do not resuscitate decisions and life support, and potentially hospice. despite proven benefit, people with cirrhosis are rarely referred to palliative care. immunity cirrhosis is known to cause immune dysfunction in numerous ways. it impedes the immune system from working normally. bleeding and blood clot risk cirrhosis can increase the risk of bleeding. the liver produces various proteins in the coagulation cascade (coagulation factors ii, vii, ix, x, v, and vi). when damaged, the liver is impaired in its production of these proteins. this will ultimately increase bleeding as clotting factors are diminished. clotting function is estimated by lab values, mainly platelet count, prothrombin time (pt), and international normalized ratio (inr). the american gastroenterological association (aga) provided recommendations in 2021 in regards to coagulopathy management of cirrhotic patients in certain scenarios. the aga does not recommend for extensive pre-procedural testing, including repeated measurements of pt/inr or platelet count before patients with stable cirrhosis undergo common gastrointestinal procedures. nor do they suggest the routine use of blood products, such as platelets, for bleeding prevention. cirrhosis is stable when there are no changes in baseline abnormalities of coagulation lab values. for patients with stable cirrhosis and low platelet count undergoing common low-risk procedures, the aga does not recommend the routine use of thrombopoietin receptor agonists for bleeding prevention. in hospitalized patients who meet standard guidelines for clot prevention, the aga suggests standard prevention. the aga does not recommend in routine screening for portal vein thrombosis. if there is a portal vein thrombosis, the aga suggests treatment by anticoagulation. in the case of cirrhosis with atrial fibrillation, the aga recommends using anticoagulation over no anticoagulation. complications ascites salt restriction is often necessary, as cirrhosis leads to accumulation of salt (sodium retention). diuretics may be necessary to suppress ascites. diuretic options for inpatient treatment include aldosterone antagonists (spironolactone) and loop diuretics. aldosterone antagonists are preferred for people who can take oral medications and are not in need of an urgent volume reduction. loop diuretics can be added as additional therapy. where salt restriction and the use of diuretics are ineffective then paracentesis may be the preferred option. this procedure requires the insertion of a plastic tube into the peritoneal cavity. human serum albumin solution is usually given to prevent complications from the rapid volume reduction. in addition to being more rapid than diuretics, 4–5 liters of paracentesis is more successful in comparison to diuretic therapy. esophageal and gastric variceal bleeding for portal hypertension, nonselective beta blockers such as propranolol or nadolol are commonly used to lower blood pressure over the portal system. in severe complications from portal hypertension, transjugular intrahepatic portosystemic shunting (tips) is occasionally indicated to relieve pressure on the portal vein. as this shunting can worsen hepatic encephalopathy, it is reserved for those patients at low risk of encephalopathy. tips is generally regarded only as a bridge to liver transplantation or as a palliative measure. balloon-occluded retrograde transvenous obliteration can be used to treat gastric variceal bleeding. gastroscopy (endoscopic examination of the esophagus, stomach, and duodenum) is performed in cases of established cirrhosis. if esophageal varices are found, prophylactic local therapy may be applied such as sclerotherapy or banding, and beta blockers may be used. hepatic encephalopathy hepatic encephalopathy is a potential complication of cirrhosis. it may lead to functional neurological impairment ranging from mild confusion to coma. goal of treatment is reducing ammonia. this can be achieved by administering lactulose or lactitol to increase potassium. hydration and nutritional support is also provided. protein uptake is encouraged. the underlying cause may also need to be identified and treated. causes include alcohol use, excess protein, gastrointestinal bleeding, infection, constipation, and vomiting/diarrhea. drugs like benzodiazepines, diuretics, or narcotics can also precipitate hepatic encephalopathy. a low protein diet is recommended with gastrointestinal bleeding. rifaximin is administered if mental state does not improve in 48 hours. antibiotic treatment may need to be continued for at least 3 months. the grading or severity of hepatic encephalopathy is determined by mental status. grading of hepatic encephalopathy grade mental status grade 1: mild changes in behavior mild confusion slurred speech disordered sleep grade 2: moderate lethargy moderate confusion grade 3: severe stupor incoherent sleeping but arousable grade 4: coma coma/unresponsive hepatorenal syndrome hepatorenal syndrome is a serious complication of end-stage cirrhosis when kidney damage is also involved. spontaneous bacterial peritonitis people with ascites due to cirrhosis are at risk of spontaneous bacterial peritonitis. portal hypertensive gastropathy portal hypertensive gastropathy refers to changes in the mucosa of the stomach in people with portal hypertension, and is associated with cirrhosis severity. infection cirrhosis can cause immune system dysfunction, leading to infection. signs and symptoms of infection may be nonspecific and are more difficult to recognize (for example, worsening encephalopathy but no fever). moreover, infections in cirrhosis are major triggers for other complications (ascites, variceal bleading, hepatic enecphalopathy, organ failures, death). hepatocellular carcinoma hepatocellular carcinoma is the most common primary liver cancer, and the most common cause of death in people with cirrhosis. screening using an mri scan can detect this cancer and is often carried out for early signs which has been shown to improve outcomes. epidemiology cirrhosis deaths per million persons in 2012 9-44 45-68 69–88 89–104 105–122 123–152 153–169 170–204 205–282 283–867 disability-adjusted life year for cirrhosis of the liver per 100,000 inhabitants in 2004. no data <50 50-100 100-200 200-300 300-400 400-500 500-600 600-700 700-800 800-900 900–1000 >1000 each year, approximately one million deaths are due to complications of cirrhosis, making cirrhosis the 11th most common cause of death globally. cirrhosis and chronic liver disease were the tenth leading cause of death for men and the twelfth for women in the united states in 2001, killing about 27,000 people each year. the cause of cirrhosis can vary; alcohol and non-alcoholic fatty liver disease are main causes in western and industrialized countries, whereas viral hepatitis is the predominant cause in low and middle-income countries. cirrhosis is more common in men than in women. the cost of cirrhosis in terms of human suffering, hospital costs, and lost productivity is high. globally, age-standardized disability-adjusted life year (daly) rates have decreased from 1990 to 2017, with the values going from 656.4 years per 100,000 people to 510.7 years per 100,000 people. in males daly rates have decreased from 903.1 years per 100,000 population in 1990, to 719.3 years per 100,000 population in 2017; in females the daly rates have decreased from 415.5 years per 100,000 population in 1990, to 307.6 years per 100,000 population in 2017. however, globally the total number of dalys have increased by 10.9 million from 1990 to 2017, reaching the value of 41.4 million dalys. etymology the word "cirrhosis" is a neologism derived from greek: κίρρωσις; kirrhos κιρρός, meaning "yellowish, tawny" (the orange-yellow colour of the diseased liver) and the suffix -osis, i.e. "condition" in medical terminology. while the clinical entity was known before, rené laennec gave it this name in an 1819