Cirrhosis
A late-stage liver disease characterized by extensive scarring that permanently damages liver function
Quick Facts
- Type: Chronic Liver Disease
- ICD-10: K74
- Prevalence: ~4.5 million in US
- Mortality: 12th leading cause of death
Overview
Cirrhosis is the late stage of scarring (fibrosis) of the liver caused by many forms of liver diseases and conditions. Each time your liver is injured — whether by disease, excessive alcohol consumption, or other causes — it tries to repair itself. In the process, scar tissue forms. As cirrhosis progresses, more and more scar tissue forms, making it difficult for the liver to function.
The liver is a vital organ that performs many essential functions, including detoxifying harmful substances, producing bile for digestion, storing vitamins and minerals, and manufacturing proteins necessary for blood clotting. When cirrhosis develops, these functions become impaired, leading to serious complications throughout the body.
Cirrhosis is generally considered irreversible, though early-stage cirrhosis may be partially reversible with treatment of the underlying cause. Advanced cirrhosis is life-threatening, and liver transplantation is often the only treatment option. Approximately 4.5 million adults in the United States have liver disease, with cirrhosis being responsible for more than 40,000 deaths annually.
Symptoms
Cirrhosis often has no signs or symptoms until liver damage is extensive. When symptoms do occur, they may be nonspecific and develop gradually. As the disease progresses, symptoms become more severe and numerous.
Early Symptoms
Advanced Symptoms
- Abdominal distention (ascites - fluid accumulation)
- Swelling in legs and ankles (edema)
- Jaundice (yellowing of skin and eyes)
- Dark urine and pale stools
- Easy bruising and bleeding
- Spider-like blood vessels on skin (spider angiomas)
- Redness in palms (palmar erythema)
- Itchy skin (pruritus)
Serious Complications Symptoms
- Vomiting blood (from esophageal varices)
- Blood in stool or black, tarry stools
- Confusion or difficulty thinking (hepatic encephalopathy)
- Shortness of breath
- Severe abdominal pain and tenderness
- Fever (may indicate infection)
- Kidney problems
Gender-Specific Symptoms
In men:
- Breast enlargement (gynecomastia)
- Testicular atrophy
- Decreased libido
- Erectile dysfunction
In women:
- Irregular or absent menstrual periods
- Premature menopause
- Difficulty becoming pregnant
Causes
Cirrhosis develops when the liver is repeatedly or continuously damaged. The liver attempts to repair itself by forming scar tissue, but excessive scarring impairs liver function. Multiple conditions can lead to cirrhosis.
Most Common Causes
Chronic Alcohol Abuse
- Long-term heavy drinking (10-15+ years)
- Women more susceptible than men
- Risk increases with amount and duration
- Genetic factors affect susceptibility
Chronic Viral Hepatitis
- Hepatitis C: Most common viral cause in developed countries
- Hepatitis B: More common in Asia and Africa
- Co-infection with HIV accelerates progression
- May take 20-30 years to develop cirrhosis
Nonalcoholic Fatty Liver Disease (NAFLD)
- Associated with obesity and metabolic syndrome
- Nonalcoholic steatohepatitis (NASH) can progress to cirrhosis
- Increasing cause due to obesity epidemic
- Often associated with diabetes
Other Causes
- Autoimmune hepatitis: Immune system attacks liver cells
- Primary biliary cholangitis: Bile duct destruction
- Primary sclerosing cholangitis: Bile duct inflammation and scarring
- Hemochromatosis: Iron accumulation in liver
- Wilson's disease: Copper accumulation
- Alpha-1 antitrypsin deficiency: Genetic disorder
- Cystic fibrosis: Affects bile ducts
- Medications: Methotrexate, isoniazid, others
- Biliary atresia: Bile duct malformation in infants
Cryptogenic Cirrhosis
In some cases, the cause remains unknown (cryptogenic cirrhosis), though many are likely due to:
- Unrecognized NAFLD/NASH
- Prior resolved hepatitis B
- Autoimmune conditions
- Genetic factors
Risk Factors
Various factors increase the risk of developing cirrhosis. Some are modifiable through lifestyle changes, while others cannot be controlled.
Lifestyle Risk Factors
- Alcohol consumption: Heavy, long-term drinking
- Obesity: Increases risk of fatty liver disease
- Poor diet: High in processed foods, low in nutrients
- Sedentary lifestyle: Lack of physical activity
- Injection drug use: Risk of hepatitis B and C
- Unprotected sex: Risk of viral hepatitis
- Tattoos/piercings: If done with unsterile equipment
Medical Risk Factors
- Type 2 diabetes: Especially with NAFLD
- Metabolic syndrome: Cluster of conditions including obesity
- High cholesterol and triglycerides:
- Autoimmune diseases: Various types affecting liver
- Chronic hepatitis B or C infection:
- Previous liver damage: From any cause
Demographic Risk Factors
- Age: Risk increases with age
- Gender: Men more likely to develop alcohol-related cirrhosis
- Ethnicity: Higher rates in Hispanic populations
- Family history: Genetic liver diseases
- Geographic location: Areas with high hepatitis prevalence
Environmental/Occupational Factors
- Exposure to certain chemicals and toxins
- Aflatoxin exposure (contaminated foods)
- Healthcare workers (hepatitis exposure)
- Travel to high-risk areas without vaccination
Diagnosis
Diagnosing cirrhosis involves a combination of medical history, physical examination, laboratory tests, and imaging studies. Early cirrhosis may be detected incidentally during routine testing.
Medical History and Physical Exam
- Review of symptoms and duration
- Alcohol use history
- Risk factors for viral hepatitis
- Family history of liver disease
- Medication history
- Physical signs: jaundice, ascites, spider angiomas
Blood Tests
Liver Function Tests
- ALT and AST: Liver enzymes, may be elevated
- Alkaline phosphatase: May indicate bile duct problems
- Bilirubin: Elevated in advanced disease
- Albumin: Low levels indicate poor liver function
- Prothrombin time/INR: Prolonged with liver dysfunction
Other Blood Tests
- Complete blood count (low platelets common)
- Hepatitis B and C testing
- Autoimmune markers
- Iron studies (hemochromatosis)
- Copper studies (Wilson's disease)
- Alpha-1 antitrypsin levels
Imaging Studies
- Ultrasound: First-line imaging, shows liver texture
- CT scan: Detailed liver structure, complications
- MRI: Best for detecting early cirrhosis
- Elastography: Measures liver stiffness (FibroScan)
- Endoscopy: Checks for esophageal varices
Liver Biopsy
- Gold standard for diagnosis and staging
- Not always necessary with clear clinical picture
- Percutaneous, transjugular, or laparoscopic approach
- Provides information on cause and severity
Staging Systems
- Child-Pugh Score: Classifies severity (A, B, C)
- MELD Score: Predicts 3-month mortality
- Used for treatment decisions and transplant listing
Treatment Options
While cirrhosis damage is generally irreversible, treatment can slow progression, manage complications, and improve quality of life. The approach depends on the cause, stage, and complications present.
Treating Underlying Causes
Alcohol-Related Cirrhosis
- Complete alcohol abstinence is essential
- Alcohol rehabilitation programs
- Nutritional support and vitamins
- Counseling and support groups
Viral Hepatitis
- Hepatitis C: Direct-acting antivirals (cure rate >95%)
- Hepatitis B: Antiviral medications (tenofovir, entecavir)
- Regular monitoring of viral load
- Screening for liver cancer
NAFLD/NASH
- Weight loss (7-10% of body weight)
- Exercise and dietary changes
- Control diabetes and cholesterol
- Vitamin E in some cases
Managing Complications
Portal Hypertension and Varices
- Beta-blockers to reduce portal pressure
- Endoscopic band ligation for varices
- TIPS procedure for refractory cases
- Avoid NSAIDs and blood thinners
Ascites and Edema
- Low-sodium diet (<2g/day)
- Diuretics (spironolactone, furosemide)
- Paracentesis for large volume ascites
- Albumin infusions
- TIPS for refractory ascites
Hepatic Encephalopathy
- Lactulose to reduce ammonia absorption
- Rifaximin antibiotic
- Protein restriction in acute episodes
- Treat precipitating factors
Liver Transplantation
- Only definitive treatment for end-stage cirrhosis
- Evaluation includes MELD score
- Must meet strict criteria
- 6 months abstinence for alcohol-related cirrhosis
- 5-year survival rate approximately 75%
Supportive Care
- Regular monitoring and blood tests
- Vaccinations (hepatitis A/B, flu, pneumonia)
- Nutritional counseling
- Avoid alcohol and hepatotoxic medications
- Screen for liver cancer every 6 months
- Manage related conditions
Prevention
Many cases of cirrhosis can be prevented by addressing risk factors and maintaining liver health. Prevention strategies vary based on the underlying causes.
Alcohol-Related Prevention
- Limit alcohol intake or abstain completely
- Men: No more than 2 drinks per day
- Women: No more than 1 drink per day
- Seek help for alcohol dependency
- Never mix alcohol with medications
Preventing Viral Hepatitis
- Get vaccinated against hepatitis A and B
- Practice safe sex
- Don't share needles or personal items
- Ensure tattoos/piercings use sterile equipment
- Healthcare workers: follow safety protocols
- Get tested if at risk
Lifestyle Modifications
- Maintain healthy weight: Prevents fatty liver disease
- Exercise regularly: At least 150 minutes weekly
- Healthy diet: Low in saturated fats, high in fruits/vegetables
- Control diabetes: Keep blood sugar well-managed
- Manage cholesterol: Through diet and medications if needed
- Avoid toxins: Chemicals, certain medications
Medical Prevention
- Regular check-ups if at risk
- Monitor liver function with chronic conditions
- Treat hepatitis infections promptly
- Careful use of medications
- Genetic counseling for hereditary conditions
Dietary Recommendations
- Coffee may have protective effects (3-4 cups daily)
- Limit processed foods and added sugars
- Choose whole grains over refined
- Adequate protein from lean sources
- Stay hydrated
- Consider Mediterranean diet pattern
When to See a Doctor
Early detection and treatment of liver disease can prevent progression to cirrhosis. Seek medical attention for concerning symptoms or if you have risk factors.
Seek Immediate Emergency Care
- Vomiting blood or coffee-ground material
- Black, tarry stools
- Severe abdominal pain and swelling
- High fever with abdominal pain
- Sudden confusion or disorientation
- Difficulty breathing
- Severe weakness or fainting
- Rapid heart rate with other symptoms
Schedule an Appointment
- Persistent fatigue and weakness
- Unexplained weight loss
- Abdominal swelling or pain
- Yellowing of skin or eyes
- Dark urine or pale stools
- Persistent nausea or loss of appetite
- Easy bruising or bleeding
- Swelling in legs or ankles
- Chronic itching
Regular Screening Needed If:
- History of heavy alcohol use
- Chronic hepatitis B or C
- Family history of liver disease
- Obesity with metabolic syndrome
- Type 2 diabetes
- Autoimmune conditions
- Taking medications that affect the liver
For Those with Cirrhosis
Regular follow-up is essential:
- Every 3-6 months for stable cirrhosis
- More frequently with decompensation
- Immediate care for new symptoms
- Regular screening for liver cancer
- Monitor for varices
Frequently Asked Questions
Cirrhosis itself is generally not reversible, as scar tissue cannot become healthy liver tissue again. However, early-stage cirrhosis may show some improvement with treatment of the underlying cause. The progression can be slowed or stopped with proper management, and the liver has remarkable ability to function even with significant scarring.
Life expectancy varies greatly depending on the stage, cause, and whether complications develop. With compensated cirrhosis (no complications), many people live for more than 10-15 years. Decompensated cirrhosis has a poorer prognosis, with average survival of 2-4 years without transplant, though this varies significantly among individuals.
No, complete alcohol abstinence is essential for anyone with cirrhosis, regardless of the cause. Even small amounts of alcohol can accelerate liver damage and increase the risk of complications. This includes alcohol in medications, mouthwash, and cooking.
Avoid high-sodium foods (processed foods, canned soups, deli meats), raw or undercooked shellfish (infection risk), and excessive protein during encephalopathy episodes. Limit saturated fats and simple sugars. Your doctor may recommend specific dietary restrictions based on your complications.
Yes, cirrhosis can be detected before symptoms appear through blood tests, imaging studies, and elastography. Regular screening is important for those at risk. Early detection allows for intervention to prevent progression and complications. Many people have cirrhosis for years before developing symptoms.
No, not everyone with cirrhosis develops liver cancer, but the risk is significantly increased. About 3-5% of people with cirrhosis develop hepatocellular carcinoma each year. Regular screening with ultrasound and blood tests every 6 months helps detect cancer early when it's most treatable.
References
- American Association for the Study of Liver Diseases. AASLD Practice Guidelines. 2024.
- European Association for the Study of the Liver. EASL Clinical Practice Guidelines on Cirrhosis. J Hepatol. 2023.
- National Institute of Diabetes and Digestive and Kidney Diseases. Cirrhosis. NIDDK. 2024.
- Tsochatzis EA, et al. Liver cirrhosis. Lancet. 2014;383(9930):1749-61.
- Centers for Disease Control and Prevention. Chronic Liver Disease and Cirrhosis. CDC. 2024.
- World Health Organization. Global Health Estimates: Liver Disease. WHO. 2023.