Cirrhosis of the Liver

What cirrhosis is and how it develops

The liver repairs itself well after short injuries. When damage goes on for years, the repair process lays down scar tissue (fibrosis) instead of new liver cells. Over time the bands of scar join up and surround islands of regenerating cells, called nodules. This end stage of scarring is cirrhosis.

Scarring causes two separate problems:

• Liver failure: fewer working cells means less production of proteins such as albumin and clotting factors, and less clearance of bilirubin, ammonia and drugs.
• Portal hypertension: scar tissue blocks blood flowing from the gut into the liver. Pressure rises in the portal vein, and blood finds detours through fragile veins in the esophagus and stomach. This drives most of the serious complications.

Cirrhosis usually takes 10 to 30 years of ongoing injury to develop. Scarring at the fibrosis stage can partly reverse if the cause is removed. Established cirrhosis is generally permanent, but it can stay stable for many years.

Symptoms of cirrhosis

Many people have no symptoms until the liver can no longer compensate. Cirrhosis is often found by chance through abnormal blood tests or a scan done for something else.

Early symptoms

• Tiredness and weakness
• Loss of appetite, nausea and weight loss
• Itchy skin
• Small spider-shaped blood vessels on the chest and face (spider angiomas)
• Red palms (palmar erythema)
• Muscle loss in the arms, legs and temples

Later symptoms (decompensated cirrhosis)

• Jaundice: yellow skin and whites of the eyes, dark urine
• A swollen abdomen from fluid (ascites) and swollen ankles
• Easy bruising and nosebleeds, because clotting factors fall
• Confusion, poor sleep at night, a flapping tremor of the hands, and drowsiness
• Vomiting blood or passing black stools from bleeding varices
• In men, breast enlargement and shrinking testicles; in women, irregular periods

Causes and risk factors

Alcohol and fatty liver disease often act together. People who drink and also have obesity or diabetes scar faster than those with either alone.

Stages of cirrhosis

Doctors describe cirrhosis in two broad stages:

• Compensated cirrhosis: the liver still copes. You may feel well. Median survival is more than 12 years, and many people live much longer when the cause is controlled.
• Decompensated cirrhosis: at least one major complication has appeared, such as ascites, variceal bleeding, hepatic encephalopathy or jaundice. Without a transplant, median survival drops to about 2 years.

Severity scores guide treatment and transplant decisions:

• Child-Pugh score (A, B, C): based on bilirubin, albumin, clotting time (INR), ascites and confusion. Class A is mild, class C is severe.
• MELD score: based on bilirubin, INR, creatinine and sodium. It predicts short-term survival and sets priority on the US transplant waiting list.

How cirrhosis is diagnosed

1. History: alcohol intake in units or drinks, weight, diabetes, hepatitis risk factors, medicines and supplements, and family history.
2. Blood tests: liver enzymes (ALT, AST), bilirubin, albumin, platelet count (often low because the spleen enlarges) and INR. A FIB-4 score uses age, enzymes and platelets to estimate scarring risk.
3. Transient elastography (FibroScan): a painless ultrasound-based test that measures liver stiffness. A high reading strongly suggests cirrhosis.
4. Imaging: ultrasound, CT or MRI show a shrunken, lumpy liver, an enlarged spleen and ascites.
5. Liver biopsy: now needed only when the cause or degree of scarring is unclear.
6. Tests for the cause: hepatitis B and C serology, iron studies, autoimmune antibodies, copper studies in younger people, and alpha-1 antitrypsin level.

Once cirrhosis is confirmed, you should have an upper endoscopy to look for esophageal varices, unless scan results show they are very unlikely.

Treatment

Treat the cause

• Alcohol: stopping completely is the single most effective treatment. Many people see liver function improve within months. Support includes counseling, medicines that reduce cravings and supervised withdrawal.
• Hepatitis C: antiviral tablets taken for 8 to 12 weeks cure more than 95% of people.
• Hepatitis B: long-term antiviral tablets suppress the virus and lower cancer risk.
• Fatty liver disease: gradual weight loss of 7% to 10% of body weight, diabetes control and exercise. Newer medicines are approved for some people with scarring from metabolic liver disease.
• Autoimmune and genetic causes: steroids or immune-suppressing medicines, regular blood removal (venesection) for hemochromatosis, and copper-binding drugs for Wilson disease.

Manage complications

• Varices: beta-blockers lower portal pressure, and endoscopic banding ties off large varices.
• Ascites: a low-salt diet (under about 2 g of sodium a day), water tablets (diuretics), and draining fluid with a needle (paracentesis) when needed.
• Hepatic encephalopathy: lactulose to clear ammonia from the gut, often with the antibiotic rifaximin.
• Infection: preventive antibiotics for people who have had infected ascites or a variceal bleed.

Liver transplant

A transplant is considered for decompensated cirrhosis, a high MELD score or small liver cancers. Survival after transplant is about 85% to 90% at one year and about 75% at five years. Most programs require a period of proven abstinence for alcohol-related disease.

Complications

• Bleeding from varices, which can be life-threatening
• Fluid in the belly and its infection (spontaneous bacterial peritonitis)
• Hepatic encephalopathy
• Kidney failure (hepatorenal syndrome)
• Liver cancer (hepatocellular carcinoma), which develops in about 1% to 4% of people with cirrhosis each year
• Malnutrition, muscle loss and bone thinning

Living with cirrhosis

• No alcohol at all, whatever the original cause.
• Liver cancer surveillance: an ultrasound, with or without an AFP blood test, every 6 months.
• Nutrition: enough protein (about 1.2 to 1.5 g per kg of body weight a day) and a late-evening snack to limit muscle loss. Do not cut protein unless a specialist advises it.
• Medicines: acetaminophen (paracetamol) is usually the safest painkiller at lower doses (ask your doctor about your daily limit). Avoid NSAIDs such as ibuprofen and naproxen, which can trigger kidney failure and bleeding. Check every new medicine and herbal remedy with your pharmacist.
• Vaccines: hepatitis A and B, flu, pneumococcal and COVID-19 vaccines.
• Avoid raw shellfish, which can carry Vibrio bacteria that are dangerous in liver disease.

Frequently asked questions

What are the first signs of cirrhosis?

Often there are none. When early signs appear, they are vague: tiredness, poor appetite, nausea, weight loss, itching and small spider-like blood vessels on the chest. Many people learn they have cirrhosis from abnormal blood tests or a scan before they notice any symptoms.

Can cirrhosis be reversed?

Established cirrhosis is usually permanent, but it can stop progressing and sometimes partly improves once the cause is removed, for example after curing hepatitis C or stopping alcohol. Earlier stages of fibrosis are much more likely to reverse, which is why early testing matters.

What is the life expectancy with cirrhosis?

It depends on the stage and on removing the cause. People with compensated cirrhosis have a median survival of more than 12 years, and many live a normal lifespan. After decompensation, median survival without a transplant is about 2 years. Stopping alcohol improves survival at every stage.

Can you get cirrhosis without drinking alcohol?

Yes. Fatty liver disease linked to obesity and diabetes is now one of the leading causes. Chronic hepatitis B and C, autoimmune hepatitis, bile duct diseases and inherited conditions such as hemochromatosis can all cause cirrhosis in people who drink little or nothing.

Is cirrhosis painful?

The liver itself rarely hurts, but some people feel a dull ache or discomfort under the right ribs. A tense, fluid-filled belly can be uncomfortable, and fever with belly tenderness may mean infected fluid, which needs urgent care.

How is cirrhosis different from fatty liver?

Fatty liver means fat has built up in liver cells. It is common and reversible. In some people the fat causes inflammation, which leads to scarring over many years. Cirrhosis is the final, severe stage of that scarring, when the liver structure itself has changed.