1. PATHOPHYSIOLOGY
   1. scarring or fibrosis
      1. hepato cellular disease
         1. post necrotic cirrhosis due to hepatitis A,B,C,D viral hepatitis or toxic exposures
         2. Laennec's cirrhosis-hep C and alcoholism-malnutrition
         3. autoimmune-sarcoidosis or chronic inflammatory bowel disease
      2. cholestatic disease
         1. diseases of the biliary tree & sclerosing cholangitis
      3. metabolic disease
         1. include Wilson's disease & hemochromatosis
      4. other type of cirrhosis
         1. include Budd-Chiari syndroome, cardiac cirrhosis & cryptogenetic cirrhosis
   2. hepatocyte function is impaired
   3. fat storing cells become new matrix components
   4. CNS alteration-hepatic encephalopathy with lethargy, mental changes, paranoia, hallucinations, obtundation & coma due to toxic ammonia in the brain
   5. CVS alteration-portal hypertension-due to increased resistance or Budd-Chiari syndroome
      1. causes splenomegaly with thrombocytopenia, ascites, jaundice, coagulopathy, hepatic encephalopathy, bleeding- esophageal varices, GI bleed, or even renal failure
2. CLINICAL PRESENTATION
   1. Early Stage
      1. anorexia
      2. nausea and vomiting
      3. diarrhea
      4. dull abdominal ache
   2. Late Stage
      1. Respiratory-pleural effusion
      2. CNS-hepatic encephalopathy
      3. Hematology-bleeding tendencies
      4. Endocrine-testicular atrophy, menstrual irregularities, gynecomastia, & loss of chest & axillary hair
      5. Skin-abnormal pigmentation, spider angiomas, palmar erythema, & jaundice with severe pruritus, dryness & poor tissue turgor
      6. musty breath & RUQ abdominal pain
3. DIAGNOSIS
   1. liver biopsy
   2. abdominal x-ray
   3. ct scan including liver scan
   4. esophagogastroduodenoscopy (EGD)
   5. blood studies
   6. urine studies
   7. fecal studies
   8. history and physical examination
4. EPIDEMIOLOGY
   1. 0.27% corresponding to 633,323 adults are affected in the United States
   2. 69%reports being unaware of having liver disease
   3. higher in non-Hispanic black & Mexican Americans, those living below poverty level, & with <12th grade education
   4. diabetes, alcohol abuse, hep C & B, male sex, & older age
   5. 53.5% from viral hepatitis, mostly hep C, diabetes, & alcohol
   6. mortality was 26.4%
5. TREATMENT
   1. rest and alcohol abstinence
   2. vitamin & nutritional supplement
   3. antacids
   4. potassium sparing diuretics
   5. vasopressin
   6. paracentesis
   7. surgical shunt placement
   8. gastirc lavage to control the bleeding
   9. liver transplant