What are the causes of the inflammation that leads to cirrhosis of the liver?

* Alcohol excess: the rate of cirrhosis in a country is directly related to the average alcohol consumption in that country. Half of all cases of cirrhosis are due to alcohol excess.
* Chronic viral hepatitis: the two important viruses are hepatitis B and hepatitis C. Cirrhosis due to hepatitis B is common in Africa and Asia. Hepatitis C is increasing in importance both in Europe and the US. Hepatitis A (infectious hepatitis) does not cause cirrhosis.
* Primary biliary cirrhosis: this is an uncommon disease mainly affecting women. It is not due to alcohol. For some reason the body mounts an attack on the liver in patients with primary biliary cirrhosis.
* Autoimmune chronic active hepatitis: another uncommon condition that results in the body's immune system attacking and destroying liver cells.
* Drugs and chemicals: a number of drugs and chemicals can cause liver damage but few cause cirrhosis. Certain specialised drugs need monitoring for their effect on the liver.
* Metabolic and inherited disorders: These are a number of uncommon conditions that allow the accumulation of toxins in the liver. The commonest is haemochromatosis, which causes excess deposits of iron in the liver.

What are the symptoms of liver cirrhosis?

The symptoms will depend on how much damage has occurred to the liver.

In the early stages there may be no symptoms at all and the disease may be discovered as a result of an investigation for another illness.

As the disease progresses, tiredness, weakness, lack of energy, loss of appetite, nausea and weight loss may develop.

In the later stages the liver is struggling to perform all its functions and any or all of the following symptoms may be present.

* Jaundice: this is the yellowing of the skin (jaundice) and the eyes due to the failure of the liver to remove a substance called bilirubin from the blood.
* Nail changes: the shape and appearance of the nails may change. They may be more curved (clubbing) and they may be white rather than pink.
* Skin changes: about a quarter of patients will have darkening of the skin.
* Fluid retention: this is common at some stage in cirrhosis. An important function of the liver is to rid the body of excess fluid through the kidneys and when it fails, fluid gathers in the legs (oedema) or in the abdomen (ascites).
* Abnormal blood vessels: the commonest abnormality is a spider naevus, which is a spot surrounded by fine blood vessels. A red face is also common.
* Easy bruising: nosebleeds and easy bruising occur as a result of abnormal blood vessels and delayed clotting because the liver does not make enough clotting proteins.
* Enlargement of breasts in men: the liver destroys the female sex hormones and in cirrhosis these accumulate and cause enlargement of the breasts and shrinking of the testes in men.

In the very late stages of the disease, serious complications may occur. These include vomiting of blood, either from ulcers in the stomach or from leaking varicose veins in the lower end of the oesophagus (gullet). This is serious and requires hospital treatment.

The liver is responsible for removing poisonous substances from the blood. In cirrhosis, the blood may bypass the liver and these poisonous substances pass to the brain where they may result in alteration in brain function, causing confusion, drowsiness and finally coma. This is called hepatic encephalopathy. This is also serious and requires hospital treatment.