cirrhosis (redirected from cirrhotic)

Cirrhosis 

Definition

Cirrhosis is a chronic degenerative disease in which normal liver cells are damaged and are then replaced by scar tissue.

Description

Cirrhosis changes the structure of the liver and the blood vessels that nourish it. The disease reduces the liver's ability to manufacture proteins and process hormones, nutrients, medications, and poisons.

Cirrhosis gets worse over time and can become potentially life threatening. This disease can cause:

• excessive bleeding (hemorrhage)
• impotence
• liver cancer
• coma due to accumulated ammonia and body wastes (liver failure)
• sepsis (blood poisoning)
• death

Cirrhosis is the seventh leading cause of disease-related death in the United States. It is the third most common cause of death in adults between the ages of 45 and 65. It is twice as common in men as in women. The disease occurs in more than half of all malnourished chronic alcoholics, and kills about 25,000 people a year. In Asia and Africa, however, most deaths from cirrhosis are due to chronic hepatitis B.

Types of cirrhosis

Portal or nutritional cirrhosis is the form of the disease most common in the United States. About 30-50% of all cases of cirrhosis are this type. Nine out of every 10 people who have nutritional cirrhosis have a history of alcoholism. Portal or nutritional cirrhosis is also called Laënnec's cirrhosis.

Biliary cirrhosis is caused by intrahepatic bile-duct diseases that impede bile flow. Bile is formed in the liver and is carried by ducts to the intestines. Bile then helps digest fats in the intestines. Biliary cirrhosis can scar or block these ducts. It represents 15-20% of all cirrhosis.

Various types of chronic hepatitis, especially hepatitis B and hepatitis C, can cause postnecrotic cirrhosis. This form of the disease affects up to 40% of all patients who have cirrhosis.

Disorders like the inability to metabolize iron and similar disorders may cause pigment cirrhosis (hemochromatosis), which accounts for 5-10% of all instances of the disease.

Causes and symptoms

Long-term alcoholism is the primary cause of cirrhosis in the United States. Men and women respond differently to alcohol. Although most men can safely consume two to five drinks a day, one or two drinks a day can cause liver damage in women. Individual tolerance to alcohol varies, but people who drink more and drink more often have a higher risk of developing cirrhosis. In some people, one drink a day can cause liver scarring.

Chronic liver infections, such as hepatitis B and particularly hepatitis C, are commonly linked to cirrhosis. People at high risk of contracting hepatitis B include those exposed to the virus through contact with blood and body fluids. This includes healthcare workers and intravenous (IV) drug users. In the past, people have contracted hepatitis C through blood transfusions. As of 2003, cirrhosis resulting from chronic hepatitis has emerged as a leading cause of death among HIV-positive patients; in Europe, about 30% of HIV-positive patients are coinfected with a hepatitis virus.

Liver injury, reactions to prescription medications, exposure to toxic substances, and repeated episodes of heart failure with liver congestion can cause cirrhosis. The disorder can also be a result of diseases that run in families (inherited diseases) like:

• a lack of a specific liver enzyme (alpha₁-antitrypsin deficiency)
• the absence of a milk-digesting enzyme (galactosemia)
• an inability to convert sugars to energy (glycogen storage disease)
• an absorption deficit in which excess iron is deposited in the liver, pancreas, heart, and other organs (hemochromatosis)
• a disorder characterized by accumulations of copper in the liver, brain, kidneys, and corneas (Wilson's disease)

Obesity has recently been recognized as a risk factor in nonalcoholic hepatitis and cirrhosis. Some surgeons are recommending as of 2003 that patients scheduled for weight-reduction surgery have a liver biopsy to evaluate the possibility of liver damage.

Poor nutrition increases a person's risk of developing cirrhosis. In about 10 out of every 100 patients, the cause of cirrhosis cannot be determined. Many people who have cirrhosis do not have any symptoms (often called compensated cirrhosis). Their disease is detected during a routine physical or when tests for an unrelated medical problem are performed. This type of cirrhosis can also be detected when complications occur (decompensated cirrhosis).

Symptoms of cirrhosis are usually caused by the loss of functioning liver cells or organ swelling due to scarring. The liver enlarges during the early stages of illness. The palms of the hands turn red and patients may experience:

• constipation
• diarrhea
• dull abdominal pain
• fatigue
• indigestion
• loss of appetite
• nausea
• vomiting
• weakness
• weight loss

As the disease progresses, the spleen enlarges and fluid collects in the abdomen (ascites) and legs (edema). Spider-like blood vessels appear on the chest and shoulders, and bruising becomes common. Men sometimes lose chest hair. Their breasts may grow and their testicles may shrink. Women may have menstrual irregularities.

Cirrhosis can cause extremely dry skin and intense itching. The whites of the eyes and the skin may turn yellow (jaundice), and urine may be dark yellow or brown. Stools may be black or bloody. Sometimes the patient develops persistent high blood pressure due to the scarring (portal hypertension). This type of hypertension can be life threatening. It can cause veins to enlarge in the stomach and in the tube leading from the mouth to the stomach (esophagus). These enlarged veins are called varices, and they can rupture and bleed massively.

Other symptoms of cirrhosis include:

• anemia
• bleeding gums
• decreased interest in sex
• fever
• fluid in the lungs
• hallucinations
• lethargy
• lightheadedness
• muscle weakness
• musty breath
• painful nerve inflammation (neuritis)
• slurred speech
• tremors

If the liver loses its ability to remove toxins from the brain, the patient may have additional symptoms. The patient may become forgetful and unresponsive, neglect personal care, have trouble concentrating, and acquire new sleeping habits. These symptoms are related to ammonia intoxication and the failure of the liver to convert ammonia to urea. High protein intake in these patients can also lead to these symptoms.

Diagnosis

A patient's medical history can reveal illnesses or lifestyles likely to lead to cirrhosis. Liver changes can be seen during a physical examination. A doctor who suspects cirrhosis may order blood and urine tests to measure liver function. Because only a small number of healthy cells are needed to carry out essential liver functions, test results may be normal even when cirrhosis is present.

Computed tomography scans (CT), ultrasound, and other imaging techniques can be used during diagnosis. They can help determine the size of the liver, indicate healthy and scarred areas of the organ, and detect gallstones. Cirrhosis is sometimes diagnosed during surgery or by examining the liver with a laparoscope. This viewing device is inserted into the patient's body through a tiny incision in the abdomen.

Liver biopsy is usually needed to confirm a diagnosis of cirrhosis. In this procedure, a tissue sample is removed from the liver and is examined under a microscope in order to learn more about the organ.

A newer and less invasive test involves the measurement of hyaluronic acid in the patient's blood serum. As of 2003, however, the serum hyaluronic acid test is most useful in monitoring the progress of liver disease; it is unlikely to completely replace liver biopsy in the diagnosis of cirrhosis.

Treatment

The goal of treatment is to cure or reduce the condition causing cirrhosis, prevent or delay disease progression, and prevent or treat complications.

Salt and fluid intake are often limited, and activity is encouraged. A diet high in calories and moderately high in protein can benefit some patients. Tube feedings or vitamin supplements may be prescribed if the liver continues to deteriorate. Patients are asked not to consume alcohol.

Medication

Iron supplements, diuretics, and antibiotics may be used for anemia, fluid retention, and ammonia accumulation associated with cirrhosis. Vasoconstrictors are sometimes needed to stop internal bleeding and antiemetics may be prescribed to control nausea.

Laxatives help the body absorb toxins and accelerate their removal from the digestive tract. Beta blockers may be prescribed to control cirrhosis-induced portal hypertension. Because the diseased liver can no longer efficiently neutralize harmful substances, medications must be given with caution. Interferon medicines may be used by patients with chronic hepatitis B and hepatitis C to prevent post-hepatic cirrhosis.

Surgery

Medication that causes scarring can be injected directly into veins to control bleeding from varices in the stomach or esophagus. Varices may require a special surgical procedure called balloon tamponade ligation to stop the bleeding. Surgery may be required to repair disease-related throat damage. It is sometimes necessary to remove diseased portions of the spleen and other organs.

Liver transplants can benefit patients with advanced cirrhosis. However, the new liver will eventually become diseased unless the underlying cause of cirrhosis is removed. Patients with alcoholic cirrhosis must demonstrate a willingness to stop drinking before being considered suitable transplant candidates.

The incidence of liver cancer related to cirrhosis in the United States has increased 75% since the early 1990s. Partial surgical removal of the liver in patients with early-stage cancer of the liver appears to be as successful as transplantation, in terms of the 5-year survival rate.

Supportive measures

A balanced diet promotes regeneration of healthy liver cells. Eating five or six small meals throughout the day should prevent the sick or bloated feeling patients with cirrhosis often have after eating. Alcohol and caffeine, which destroy liver cells, should be avoided. So should any foods that upset the stomach. Patients with brain disease associated with cirrhosis should avoid excessive amounts of protein in the diet.

A patient can keep a food diary that describes what was eaten, when it was eaten, and how the patient felt afterwards. This diary can be useful in identifying foods that are hard to digest and in scheduling meals to coincide with the times the patient is most hungry.

Patients who have cirrhosis should weigh themselves every day and notify their doctor of a sudden gain of five pounds or more. A doctor should also be notified if symptoms of cirrhosis appear in anyone who has not been diagnosed with the disease. A doctor should also be notified if a patient diagnosed with cirrhosis:

• vomits blood
• passes black stools
• seems confused or unresponsive
• shows signs of infection (redness, swelling, tenderness, pain)

Alternative treatment

Alternative treatments for cirrhosis are aimed at promoting the function of healthy liver cells and relieving the symptoms associated with the disease. Several herbal remedies may be helpful to cirrhosis patients. Dandelion (Taraxacum officinale) and rock-poppy (Chelidonium majus) may help improve the efficiency of liver cells. Milk thistle extract (Silybum marianum) may slow disease progression and significantly improve survival rates in alcoholics and other cirrhosis patients. Practitioners of homeopathy and traditional Chinese medicine can also prescribe treatments that support healthy liver function.

Prognosis

Cirrhosis-related liver damage cannot be reversed, but further damage can be prevented by patients who:

• eat properly
• get enough rest
• do not consume alcohol
• remain free of infection

If the underlying cause of cirrhosis cannot be corrected or removed, scarring will continue. The liver will fail, and the patient will probably die within five years. Patients who stop drinking after being diagnosed with cirrhosis can increase their likelihood of living more than a few years from 40% to 60-70%.

Prevention

Eliminating alcohol abuse could prevent 75-80% of all cases of cirrhosis.

Other preventive measures include:

• obtaining counseling or other treatment for alcoholism
• taking precautions (practicing safe sex, avoiding dirty needles) to prevent hepatitis
• getting immunizations against hepatitis if a person is in a high-risk group
• receiving appropriate medical treatment quickly when diagnosed with hepatitis B or hepatitis C
• having blood drawn at regular intervals to rid the body of excess iron from hemochromatosis

• using medicines (chelating agents) to rid the body of excess copper from Wilson's disease
• wearing protective clothing and following product directions when using toxic chemicals at work, at home, or in the garden

In 2001, research scientists identified the protein segment and method in which excess tissue grows in diseases like cirrhosis. With further study, the discovery might one day result in an oral or inhalable peptide for those with cirrhosis.

Resources

Books

Beers, Mark H., MD, and Robert Berkow, MD. editors. "Cirrhosis." Section 4, Chapter 41 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

Pelletier, Kenneth R., MD. The Best Alternative Medicine, Part II, "CAM Therapies for Specific Conditions: Alcoholism." New York: Simon & Schuster, 2002.

Periodicals

Cha, C. H., L. Ruo, Y. Fong, et al. "Resection of Hepatocellular Carcinoma in Patients Otherwise Eligible for Transplantation." Annals of Surgery 238 (September 2003): 315-321.

Foreman, M. G., D. M. Mannino, and M. Moss. "Cirrhosis as a Risk Factor for Sepsis and Death: Analysis of the National Hospital Discharge Survey." Chest 124 (September 2003): 1016-1020.

Higuchi, H., and G. J. Gores. "Mechanisms of Liver Injury: An Overview." Current Molecular Medicine 3 (September 2003): 483-490.

Kamath, B. M., and D. A. Piccoli. "Heritable Disorders of the Bile Ducts." Gastroenterology Clinics of North America 32 (September 2003): 857-875.

"Management of Alcoholic Hepatitis." Drug Therapy Bulletin 41 (July 2003): 49-52.

Moretto, M., C. Kupski, C. C. Mottin, et al. "Hepatic Steatosis in Patients Undergoing Bariatric Surgery and Its Relationship to Body Mass Index and Co-Morbidities." Obesity Surgery 13 (August 2003): 622-624.

"Peptides: Peptide Critical to Cirrhosis Development." Drug Discovery and Technology News 4, no. 11 (November 2001).

Phillips, M. G., V. R. Preedy, and R. D. Hughes. "Assessment of Prognosis in Alcoholic Liver Disease: Can Serum Hyaluronate Replace Liver Biopsy?" European Journal of Gastroenterology and Hepatology 15 (September 2003): 941-944.

Ristig, M., H. Drechsler, J. Crippin, et al. "Management of Chronic Hepatitis B in an HIV-Positive Patient with 3TC-Resistant Hepatitis B Virus." AIDS Patient Care and STDs 17 (September 2003): 439-442.

Organizations

American Liver Foundation. 1425 Pompton Ave., Cedar Grove, NJ 07009. (800) 223-0179. http://www.liverfoundation.org.

United Network for Organ Sharing. 1100 Boulders Parkway, Suite 500, P.O. Box 13770, Richmond, VA 23225-8770. (804) 330-8500. http://www.unos.org.

Other

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Cirrhosis of the Liver. April 200 [cited October 2002]. http://www.niddk.nih.gov/health/digest/pubs/cirrhosi/cirrhosi.htm.

---

cirrhosis /cir·rho·sis/ (sĭ-ro´sis) a group of liver diseases marked by interstitial inflammation of the liver, loss of normal hepatic architecture, fibrosis, and nodular regenerationcirrhot´ic

---

alcoholic cirrhosis  a type in alcoholics, due to associated nutritional deficiency or chronic excessive exposure to alcohol as a hepatotoxin.

atrophic cirrhosis  a type in which the liver is decreased in size, seen in posthepatic or postnecrotic cirrhosis and in some alcoholics.

biliary cirrhosis  a type due to chronic bile retention after obstruction or infection of the major extra- or intrahepatic bile ducts (secondary biliary c.), or of unknown etiology (primary biliary c.), and sometimes occurring after administration of certain drugs.

cardiac cirrhosis  fibrosis of the liver, probably following central hemorrhagic necrosis, in association with congestive heart disease.

fatty cirrhosis  a form in which liver cells become infiltrated with fat.

Laënnec's cirrhosis  a type associated with alcohol abuse.

macronodular cirrhosis  a type that follows subacute hepatic necrosis due to toxic or viral hepatitis.

metabolic cirrhosis  a type associated with metabolic diseases, such as hemochromatosis, Wilson's disease, glycogen storage disease, galactosemia, and disorders of amino acid metabolism.

portal cirrhosis  Laënnec's c.

posthepatitic cirrhosis  a type (usually macronodular) that is a sequel to acute hepatitis.

postnecrotic cirrhosis  macronodular c.

---

cir·rho·sis (s-rss)

n.

1. A chronic disease of the liver characterized by the replacement of normal tissue with fibrous tissue and the loss of functional liver cells. It can result from alcohol abuse, nutritional deprivation, or infection, especially by the hepatitis virus.

2. Chronic interstitial inflammation of any tissue or organ. Also called fibroid induration.

---

cir·rhotic (-rtk) adj.

---

cirrhosis

[sirō′sis]

Etymology: Gk, kirrhos, yellow-orange, osis, condition

a chronic degenerative disease of the liver in which the lobes are covered with fibrous tissue, the parenchyma degenerates, and the lobules are infiltrated with fat. Gluconeogenesis, detoxification of drugs and alcohol, bilirubin metabolism, vitamin absorption, GI function, hormonal metabolism, and other functions of the liver deteriorate. Blood flow through the liver is obstructed, causing back pressure and leading to portal hypertension and esophageal varices. Unless the cause of the disease is removed, hepatic coma, GI hemorrhage, and kidney failure may occur. Cirrhosis is most commonly the result of chronic alcohol abuse; other causes include nutritional deprivation, hepatitis, and cardiac problems. The symptoms of cirrhosis are the same regardless of the cause: nausea, fatigue, anorexia, weight loss, ascites, varicosities, and spider angiomas. Diagnosis is made definitively by biopsy, but radiographic and physical examinations and several blood tests of liver function are serially performed to monitor the course of the disease. Treatment depends on the cause. The liver has remarkable ability to regenerate, but recovery may be very slow.

observations Cirrhosis is often asymptomatic in early disease or may manifest as abdominal pain, diarrhea, nausea, vomiting, fatigue, and fever. As the disease progresses, manifestations such as chronic dyspepsia, constipation, anorexia, weight loss, pruritus, easy bruising, bleeding gums, nosebleeds, upper gastrointestinal bleeding, and enlarged liver are seen. Late disease is accompanied by telangiectasis, spider angiomas, enlarged breasts, testicular atrophy, jaundice, impotence, enlarged spleen, depression, abdominal vein distention, ascites, encephalopathy, and peripheral neuropathy. Diagnostic tests include abnormal liver function studies, including elevations in alkaline phosphatase, aminotransferase, and alanine aminotransferase. A CBC may show evidence of anemia, leukopenia, or thrombocytopenia. Protein metabolism tests show decreased total protein, decreased albumin, and increased globulin. Cholesterol levels are decreased as a result of abnormalities in fat metabolism. Prothrombin time is prolonged, and bilirubin metabolism is abnormal. Blood glucose may be reduced. Ultrasonography is used to reveal hepatosplenomegaly and enlarged portal veins. Liver scans show reduced liver uptake. Liver biopsy will show definitive histologic changes in the liver cells and reveal altered structure in the lobes. Ascitic fluid may be tapped and drawn for differential analysis. Complications include bleeding esophageal varices, which can lead to massive hemorrhage; hepatorenal syndrome, which leads to renal failure; and hepatic encephalopathy, which leads to coma and death.

interventions The first step is elimination of toxic agents, such as alcohol or drugs. Therapy is aimed at liver cell regeneration and the prevention or treatment of symptoms. This includes rest to reduce metabolic demands on the liver; a high-calorie, high-protein (unless hepatic encephalopathy is present), high-carbohydrate, and low-fat, low-sodium diet; diuretics to reduce edema; digestants to promote fat digestion; supplemental vitamins; and stool softeners. Ascites may be treated with abdominal paracentesis or peritoneovenous shunt. Esophageal varices may be treated by using blood and blood products, gastric lavage, or esophageal balloon to stem bleeding. Variceal sclerosis may be performed via endoscopy to eliminate the varicosities. A portal systemic shunt may be surgically placed to treat resistant esophageal varices. A transjugular intrahepatic portosystemic shunt may be used to divert portal blood from the liver to relieve portal hypertension. Renal dialysis is used to treat renal failure. Hepatic encephalopathy is managed by reducing ammonia formation through reduced protein intake, administering lactulose to decrease pH in the intestines, and administering antibiotics to reduce bacterial flora in the colon. Liver transplantation may be the only hope for those with advanced disease.

nursing considerations Nursing care for individuals with acute disease is multifaceted, complex, and dictated by the stage of the disease and presenting symptomatology. The focus is on strength conservation. This includes balancing rest and activity and correcting nutritional imbalances. Edema and ascites produce itching and impaired skin integrity. Skin care requires careful diligence to prevent excoriation and breakdown. Ascites can also produce shortness of breath from pressure placed on the diaphragm. This requires careful positioning and monitoring of respiratory rate and rhythm. Sensory perception may be decreased secondary to peripheral neuropathy. This places the individual at increased risk for injury and requires the implementation of injury prevention protocols. Infection control measures should also be in effect to reduce the possibility of infection from environmental pathogens in these susceptible individuals. Careful monitoring is needed to spot early signs of life-threatening complications, such as hepatic encephalopathy or esophageal bleeding. In the individual with hepatic encephalopathy, the focus is on monitoring systems affected by increased ammonia levels and assessing whether levels are effectively being reduced. Assessment of alertness (orientation, reflexes, and pupil reaction), and sensory and motor abnormalities (incoordination or hyperreflexia) is necessary. Adequate hydration must be maintained with careful monitoring for fluid and electrolyte and acid base imbalances, reduction of protein, prevention of constipation, and strict bed rest. Signs of esophageal bleeding, such as hematemesis or bloody stools, should be treated as an emergency because bleeding must be stopped quickly. Chronic care focuses on education. Individuals need to understand that this disease is chronic in nature and requires continuous care to reduce or prevent serious complications. Prompt treatment needs to be sought at any sign of complication. Instruction is needed about diet, medication use and restrictions, skin care, infection protection, and importance of complete alcohol abstinence. Referrals may be made to substance abuse programs and community or home health care agencies.

---

cirrhosis (s·rōˑ·sis),

n chronic liver condition where the lobules are filled with fat, the parenchyma deteriorates, and the lobes become fibrous. Most commonly caused by alcohol abuse.

Cirrhosis.

---

cirrhosis (sirō´sis),

n a chronic degenerative disease of the liver in which blood flow is restricted and metabolic and detoxification functions are impaired or destroyed. Cirrhosis is most commonly the result of chronic alcohol abuse.

---

cirrhosis

a liver disease characterized pathologically by the loss of the normal microscopic lobular architecture and regenerative replacement of necrotic parenchymal tissue with fibrous bands of connective tissue which eventually constrict and partition the organ into irregular nodules. The term is sometimes used to refer to chronic interstitial inflammation of any organ.

---

cardiac cirrhosis

fibrosis or scarring of the liver resulting from the anoxia and centrilobular necrosis associated with the passive congestion of congestive heart failure.

---

cirrhosis

Greek, orange-yellow 1. A term rarely used for chronic interstitial inflammation of non-liver organs–eg, cardiac cirrhosis Hepatology The final irreversible stage of chronic inflammation and/or cell injury of the liver, which results in a scarred, contracted, and functionally effete organ Etiology Alcohol, viral hepatitis–HAV, HBV, HCV, HDV, PBC, hemochromatosis, Wilson's disease, alpha-1-antitrypsin deficiency, intestinal bypass, venous outflow obstruction Clinical Jaundice, itching, fatigue and, with failure, end-stage liver disease Diagnosis Physical exam, labs, liver Bx Lab ↑ Transaminases–ALT, AST, ↓ albumin Complications Confusion, coma–due to hepatic encephalopathy, fluid accumulation–ascites, internal bleeding, kidney failure Management Conservative–eg, diuretics, alcohol detoxification–'drying out'; liver transplantation may be an option for Pts with advanced cirrhosis. See Alcoholic cirrhosis, Cardiac cirrhosis, Indian childhood cirrhosis, Micro-micronodular cirrhosis, Primary biliary cirrhosis.

---

Patient discussion about cirrhotic.

Q. I would like to know what it takes to get on a liver transplant list.. I have been diagnosed with cirrhosis of the liver. I have been clean and sober now over 2 years... I have also been hospitalized more times than i don't like talking about but I have been admitted for high amounts of ammonia levels, low blood pressure, and dehydration

A. Your cirrhosis is an indication for a liver transplantation, and your doctor should be aware of when you are suitable for transplant and put you on the transplant list. Patients are categorized according to the Child's Criteria method based on their developing of ascites, low albumiin level, encephalopathy (high amonia levels that affect the brain), and blood clotting problems.

Q. What are the risks of cirrhosis of liver? My dad has cirrhosis and I would like to know what are the risks and how does it get treated.

A. there is a long list of risks in cirrhosis. Osteoporosis, varices in esophagus(bleeding), Jaundice and Liver failure are just some of them. How it’s treated- first of all if they found out what is the cause- they stop it (like drinking alcohol). Then what happen depends on how young and strong is the patient, in what stage the cirrhosis is. And the treatment is mostly for the symptoms in hope that the liver will hill itself. In really bad cases- transplant.

Q. Is alcoholism very much related to cirrhosis? I have heard that people who drink a lot get cirrhosis….is alcoholism very much related to cirrhosis?

A. HELLO ROHAN,YES alcoholism is related to CIRRHOSIS OF THE LIVER.liver cancer developes in about one in five sufferers of cirrhosis.HIGH alcohol consumption increases the risk of cancers of the mouth,tongue,pharynx(back of the throat),larynx(voice box),and esophagus,---liver disease caused by a high alcohol consumption include (fatty liver)-(alcoholic hepatitis)(cirrhosis)and liver cancer.ALCOHOLISM causes nervous system disorders,(confusion)(disturbance of speech)(weakness in the legs)(psychosis).the heart is affected by reducing pumping efficiency,usually combined with edema(fluid collection in the tissues.---mrfoot56