Cirrhosis of the Liver

What is cirrhosis of the liver?

Cirrhosis is long-term scarring of the liver. When the liver is hurt again and again, by alcohol, a virus, fat buildup or an immune attack, it tries to repair itself. Each repair leaves a little scar tissue behind. Over many years, that scar tissue replaces healthy liver tissue, and the liver slowly loses its ability to do its jobs.

The U.S. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) describes cirrhosis as a condition in which the liver is scarred and permanently damaged. Researchers estimate that about 1 in 400 adults in the United States has cirrhosis, and the true number may be higher because many people do not know they have it.

Cirrhosis is not one single moment. It is a stage along a longer road. To see where it fits, read our guide to the stages of liver disease, which runs from early inflammation and fibrosis to cirrhosis and then end-stage liver disease.

Scarring also makes it harder for blood to flow through the liver. Pressure builds up in the portal vein, the large vein that carries blood from the gut to the liver. Doctors call this portal hypertension. It is behind many of the serious problems of later cirrhosis, such as fluid in the belly and swollen veins that can bleed.

What causes cirrhosis?

Anything that injures the liver for a long time can lead to cirrhosis. According to the NIDDK, the most common causes in the United States are:

• Alcohol-associated liver disease: liver damage from drinking heavily over many years.
• Fatty liver disease: now called MASLD (metabolic dysfunction-associated steatotic liver disease), and its more serious, inflamed form MASH. These were formerly called NAFLD and NASH. They are linked to overweight, type 2 diabetes and related conditions.
• Chronic hepatitis C: a long-lasting viral infection of the liver.
• Chronic hepatitis B: another long-lasting viral infection.

Less common causes include:

• Autoimmune hepatitis, where the body's immune system attacks the liver.
• Bile duct diseases such as primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC).
• Inherited (genetic) diseases such as hemochromatosis (too much iron), Wilson disease (too much copper) and alpha-1 antitrypsin deficiency.
• Long-term use of certain medicines, and long-term heart failure that backs blood up into the liver.

Many people have more than one cause, for example fatty liver disease plus alcohol. Knowing the cause matters, because treating it is the best way to slow the damage.

The stages of cirrhosis: compensated vs. decompensated

Liver doctors split cirrhosis into two main phases. The difference between them is the single most important thing to understand about your outlook.

Compensated cirrhosis

In compensated cirrhosis, the liver is scarred but still doing enough of its work. Many people feel fine or have only mild symptoms, such as tiredness. Some people live in this phase for many years.

Decompensated cirrhosis

Cirrhosis becomes decompensated when the liver can no longer keep up and a major complication appears. International experts (the Baveno VII consensus) define decompensation by events such as ascites (fluid in the belly), bleeding from swollen veins (varices) and hepatic encephalopathy (confusion caused by toxins the liver can't clear). Jaundice, yellow skin or eyes, is also a warning sign of a failing liver. Our page on decompensated cirrhosis walks through each one.

Four clinical stages

A large review of 118 studies by D'Amico and colleagues described four clinical stages. The table shows the share of people who died within one year at each stage in the original research cohort.

These figures come from patients followed decades ago, before many of today's treatments. Later studies have found different numbers, so treat the table as a picture of how risk rises from stage to stage, not as a prediction for any one person.

Symptoms of cirrhosis

Early cirrhosis often causes no symptoms at all. Many people find out from a routine blood test, a scan done for another reason, or only after a complication. When early symptoms do appear, the NIDDK lists:

• Feeling tired or weak
• Poor appetite and losing weight without trying
• Nausea
• Itchy skin
• Mild discomfort in the upper right belly, muscle cramps and muscle loss

As the liver gets worse, later symptoms can include:

• Bruising and bleeding easily
• Swelling in the legs, ankles or feet, and a swollen belly from fluid (ascites)
• Yellow skin or whites of the eyes (jaundice) and dark urine
• Confusion, memory problems, personality changes or trouble sleeping
• Bleeding inside the body from enlarged veins (varices)

The later symptoms are signs that cirrhosis may be turning decompensated. Some, like vomiting blood or sudden confusion, are medical emergencies.

How is cirrhosis diagnosed?

Doctors usually combine several kinds of tests:

• Blood tests help show how well the liver is working and how serious the disease is. A complete blood count can point to infection or to anemia from internal bleeding.
• Imaging such as ultrasound, CT or MRI shows the size, shape and texture of the liver.
• Elastography is a special scan that measures how stiff the liver is. More stiffness can be a sign of more scarring (fibrosis). It is painless and done from outside the body.
• Liver biopsy, where a doctor takes a tiny piece of liver with a needle, is used when other tests leave the answer unclear.

Once cirrhosis is found, your team will also use blood tests to track how sick the liver is over time. One of these measures is the MELD score, which matters a great deal later if a transplant is needed.

Treatment: slowing cirrhosis down

There is no medicine that cures cirrhosis or erases scarring. But treating the cause can slow or stop further damage, and that can make a real difference. The NIDDK lists these steps:

• Stop drinking alcohol completely if alcohol is a cause. Your doctor can connect you with treatment and support. Ask your team whether any alcohol is safe for you.
• Treat hepatitis C. Modern antiviral pills cure more than 95% of cases, usually in 8 to 12 weeks.
• Treat hepatitis B. Antiviral medicines can slow or stop the damage the virus causes.
• Lose weight if advised. For people with fatty liver disease and overweight, weight loss may help.
• Check every medicine with your doctor, including over-the-counter pain relievers and supplements. A damaged liver handles many drugs differently.
• Get vaccinated against hepatitis A, hepatitis B, flu, pneumonia and shingles.

Your team will also treat or prevent complications. For example, medicines can lower the pressure in swollen veins to cut the risk of bleeding. Treating complications early may keep them from getting worse.

Screening for liver cancer every 6 months

Cirrhosis raises the risk of the most common type of liver cancer, hepatocellular carcinoma (HCC). Most people who develop this cancer already have cirrhosis. Cancer found early is much easier to treat, and in some cases a liver transplant is part of that treatment.

The American Association for the Study of Liver Diseases (AASLD) recommends surveillance for most people with cirrhosis using a liver ultrasound plus an AFP blood test about every 6 months. Ask your doctor whether you are on this schedule, and put the dates on your calendar.

Cirrhosis life expectancy

This is often the first question people ask, and there is no single answer. Outlook depends most on whether cirrhosis is compensated or decompensated, on the cause and whether it can be treated, and on overall health.

What large studies have found:

• People with compensated cirrhosis had a median survival of more than 12 years. "Median" means half of people lived longer than that.
• People with decompensated cirrhosis had a median survival of about 2 years without a transplant.
• Risk rises with each complication, as the staging table above shows.

These numbers describe large groups, not you. They also come from older research, before today's hepatitis C cures and other advances. Some people live many years with compensated cirrhosis, and a liver transplant can greatly improve the outlook for people whose disease progresses. Your hepatologist can tell you what your own test results suggest.

When a liver transplant enters the picture

A liver transplant replaces the scarred liver with a healthy one from a donor. Doctors consider it when cirrhosis leads to liver failure and other treatments are no longer enough.

Timing matters. The AASLD and the American Society of Transplantation advise that evaluation for a transplant should be considered once a person with cirrhosis has had a first major complication (ascites, hepatic encephalopathy or variceal bleeding) or once the MELD score reaches 15 or higher. You can estimate your number with our MELD calculator, then bring it to your next appointment.

Referral is not the same as being listed. A transplant center will run its own evaluation of your liver, heart, kidneys, support system and more. Learn more about who qualifies for a liver transplant and how the liver transplant waiting list works.

Centers differ in how many transplants they do and how long people wait. It is worth comparing liver transplant centers early. Some patients also register at more than one center; our dual-listing guide explains how that works.

You do not have to wait for your doctor to bring it up. It is reasonable to ask, "Should I be referred to a transplant center?" at any visit after a cirrhosis diagnosis.