Liver disease usually moves through four stages: inflammation, fibrosis (scarring), cirrhosis, and end-stage liver disease. Early stages are often silent and can improve with treatment. This guide explains each stage, its common causes, the tests that find it, and when a liver specialist or a transplant team should be involved.
Most long-term liver disease moves through the same broad steps, no matter what started it. Doctors often describe them as four stages: inflammation (often with fat buildup), fibrosis (scarring), cirrhosis (severe scarring), and end-stage liver disease (liver failure). Many people never get past the first stage, and the earlier a problem is found, the more can be done.
Doctors may also grade scarring from F0 (none) to F4 (cirrhosis). Ask which stage your results match.
| Stage | What happens in the liver | Common symptoms | Can it reverse? | What to do |
|---|---|---|---|---|
| 1. Inflammation (fat buildup or hepatitis) | Fat, alcohol, a virus, or the immune system irritates liver cells. The liver may swell. | Usually none. Some people feel tired or have mild discomfort in the upper right belly. | Often yes, if the cause is treated or removed. | Find the cause. Treat it. Get a scarring test such as FIB-4. |
| 2. Fibrosis (scarring) | Long-lasting inflammation leaves scar tissue. The liver still works. | Usually none. | Scarring can improve when the cause is controlled. | See a liver specialist. Ask about elastography and treatment for the cause. |
| 3. Cirrhosis (severe scarring) | Scar tissue replaces healthy tissue and slows blood flow through the liver. | May be none at first. Later: fatigue, itching, poor appetite, weight loss, muscle cramps. | The damage is usually permanent, but treating the cause can keep it from getting worse. | Regular care with a hepatologist, liver cancer checks, vaccines, no alcohol. |
| 4. End-stage liver disease (liver failure) | The liver can no longer do its main jobs. | Yellow skin or eyes, belly swelling, confusion, easy bleeding or bruising. | No. A liver transplant is the only treatment for liver failure. | Ask for a referral to a transplant center for evaluation. |
Everyone's path is different; your care team can tell you which stage you are in.
When something keeps hurting the liver for months or years, it becomes inflamed. That "something" might be extra fat stored in the liver, alcohol, a hepatitis virus, or the body's own immune system.
Fat buildup in the liver is called steatosis. It is very common. Experts estimate that about 24% of U.S. adults have fatty liver disease linked to weight, blood sugar, or other metabolic factors. Most people with fatty liver never develop serious damage. A smaller group develops inflammation and liver cell injury on top of the fat, and that group has a higher chance of moving on to scarring.
The good news: this is the stage where change helps most. When the cause is treated, inflammation often settles down and fat can leave the liver.
When inflammation lasts a long time, the liver tries to heal itself by laying down scar tissue. This is called fibrosis. In this stage the liver still does its work, so most people feel fine. That is exactly why fibrosis is easy to miss.
Fibrosis is a turning point. Scarring can stay the same, get better, or get worse. For people with metabolic fatty liver disease, losing 7% to 10% of body weight can reduce liver inflammation and scarring. Curing hepatitis C or stopping alcohol removes the main source of injury. Finding fibrosis early gives you the best chance to stop it here.
Cirrhosis means the liver is badly scarred and permanently damaged. Scar tissue replaces healthy tissue and partly blocks blood flow through the liver. About 1 in 400 U.S. adults has cirrhosis.
Doctors split cirrhosis into two phases:
Doctors cannot cure cirrhosis or reverse the scarring. But treating the cause, avoiding alcohol, getting vaccines, and checking for liver cancer with imaging about every 6 months can help people stay in the compensated phase longer.
We explain both phases in depth in our guide to cirrhosis of the liver. If you or someone you care for has had a complication like ascites or bleeding, read our page on decompensated cirrhosis.
End-stage liver disease, also called liver failure, happens when the liver stops doing its main jobs: cleaning the blood, making proteins that help blood clot, and helping the body use food for energy. Symptoms can include jaundice, a swollen belly, swollen legs, easy bruising, and confusion or sleep changes.
Medicines and procedures can manage many of these problems for a time. But the only treatment for liver failure is a liver transplant. Learn what this stage means day to day, and what families can expect, in our guide to end-stage liver disease.
Many different conditions can start the path from inflammation to scarring. Some people have more than one cause. The most common causes of cirrhosis in the U.S. are fatty liver disease, alcohol-associated liver disease, and long-term hepatitis B or C.
In June 2023, liver doctors from around the world agreed on new names for fatty liver disease. The old names, "nonalcoholic fatty liver disease" (NAFLD) and "nonalcoholic steatohepatitis" (NASH), described the disease by what it was not and could feel stigmatizing. The new names describe what it is:
MASLD is the most common chronic liver disease worldwide, affecting more than 30% of people. It is linked to overweight, type 2 diabetes, high blood pressure, and high cholesterol or triglycerides. One-third to two-thirds of people with type 2 diabetes have it. It is most common among Hispanic adults in the U.S., which is why we encourage Hispanic families with diabetes or obesity to ask their doctor about a liver check, even if nobody feels sick.
Heavy drinking over time can cause fat buildup, inflammation (alcohol-associated hepatitis), fibrosis, and cirrhosis. The most important treatment at every stage is to stop drinking. The liver has a strong ability to recover once alcohol is removed, and much of its function can come back in early stages. If drinking is hard to stop, that is a medical problem with real treatments, not a personal failure. Alcohol use disorder can be treated with counseling, support groups, and medicines, and your liver doctor can help you find care.
Long-term infection with hepatitis B or C can quietly scar the liver for decades. Hepatitis C can now be cured: antiviral pills cure more than 95% of people in 8 to 12 weeks. Hepatitis B can be prevented with a vaccine, and antiviral medicines can slow or stop the virus from damaging the liver. What matters most is getting tested and treated.
In autoimmune hepatitis, the immune system attacks liver cells. In primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC), the bile ducts are slowly damaged, and bile backs up into the liver. Medicines can control autoimmune hepatitis and slow PBC. PSC has no cure or proven treatment yet, and doctors may consider a transplant if it leads to liver failure.
These conditions run in families. If a parent or sibling has one, ask your doctor whether you should be tested.
The liver can keep doing its work even while it is being damaged. So early liver disease usually causes no symptoms at all. Fatty liver disease is often called a "silent" disease, and some people do not have symptoms even after cirrhosis develops. Many people first learn about their liver from a routine blood test or an imaging scan done for another reason.
When symptoms do appear, early ones can include:
Signs that the liver is failing include yellow skin or eyes, dark urine, a swollen belly or legs, easy bruising or bleeding, vomiting blood or black stools, and confusion or personality changes. Vomiting blood, black stools, or new confusion are medical emergencies.
Because symptoms show up late, testing matters. Your doctor may use:
A good question to ask at your next visit: "What is my FIB-4 score, and do I need elastography?"
Treatment depends on what is hurting the liver. Your care team will tailor it to you.
For nearly everyone with liver disease: avoid alcohol, ask your doctor before taking supplements or herbal remedies, and get vaccinated against hepatitis A and B.
A hepatologist is a doctor who focuses on the liver. Consider asking for a referral if:
For caregivers: if you are helping a parent or spouse, ask the care team to explain the stage in plain words and to include you in visits. Our caregiver guide has checklists and questions to bring.
Transplant usually enters the conversation when cirrhosis becomes decompensated or the liver begins to fail. Widely used guidance says to refer a person with cirrhosis for transplant evaluation after a first major complication (such as ascites, variceal bleeding, or hepatic encephalopathy) or when the MELD score reaches 15. Studies show that delayed referral is common and is linked to worse outcomes, so it is reasonable to ask about evaluation early.
Before a transplant, a person is referred to a transplant center, evaluated by a transplant team, and, if approved, placed on the national liver transplant waiting list. To learn about the medical and personal factors teams consider, read who qualifies for a liver transplant. Wait times and transplant rates differ between programs, so it helps to compare liver transplant centers near you.
Some centers require a period without alcohol before evaluation for people with alcohol-associated liver disease; rules vary by program, and some centers evaluate people sooner. Ask each center directly.
La enfermedad del hígado suele avanzar en cuatro etapas. Primero aparece la inflamación, muchas veces por grasa acumulada en el hígado (hígado graso), el alcohol o un virus como la hepatitis B o C. Si la causa no se trata, se forman cicatrices: eso es la fibrosis. Cuando las cicatrices son muchas y permanentes, se llama cirrosis. La última etapa es la enfermedad hepática terminal, cuando el hígado deja de funcionar y el trasplante es el único tratamiento.
Las dos primeras etapas casi nunca causan síntomas, pero son las que mejor responden al tratamiento. El hígado graso (MASLD) es muy común en familias hispanas, sobre todo cuando hay diabetes, sobrepeso o colesterol alto. Bajar de peso poco a poco, moverse más y evitar el alcohol pueden reducir la grasa y hasta las cicatrices.
Pida a su médico un análisis llamado FIB-4 o una elastografía (FibroScan) si tiene diabetes, hígado graso, hepatitis o si toma alcohol con frecuencia. Consulte con un especialista del hígado (hepatólogo) si le dicen que tiene fibrosis avanzada o cirrosis, o si nota piel u ojos amarillos, hinchazón del abdomen o confusión. Si vomita sangre o tiene heces negras, vaya a emergencias de inmediato.
The four stages are inflammation (often with fat buildup in the liver), fibrosis (scarring), cirrhosis (severe, permanent scarring), and end-stage liver disease (liver failure). Not everyone moves through every stage, and many people with early disease never develop serious scarring.
Often, in the early stages. Fat and inflammation can improve when the cause is treated, and scarring (fibrosis) can lessen with weight loss in fatty liver disease, curing hepatitis C, or stopping alcohol. Cirrhosis is usually permanent, but treating the cause can keep it from getting worse.
Early liver disease usually has no symptoms. When early signs appear, they can include tiredness, weakness, poor appetite, nausea, itchy skin, and mild discomfort in the upper right belly. Yellow skin or eyes, belly swelling, and confusion are later signs that need prompt medical care.
Most people with fatty liver disease (MASLD) do not develop serious liver damage, but a smaller group develops inflammation (MASH) that can lead to scarring, cirrhosis, and liver cancer. People with MASLD also have a higher risk of heart disease. A FIB-4 blood score or elastography can show whether scarring is present.
They describe the same condition. In June 2023, international liver societies renamed nonalcoholic fatty liver disease (NAFLD) to metabolic dysfunction-associated steatotic liver disease (MASLD), and NASH to MASH, to describe the disease by its cause and avoid stigmatizing language.
A transplant is considered when cirrhosis leads to liver failure. Guidance commonly recommends referral for transplant evaluation after a first major complication such as ascites, variceal bleeding, or confusion, or when the MELD score reaches 15. Talk with your hepatologist about whether evaluation is right for you.
Doctors often start with a FIB-4 score calculated from routine blood tests. If the score is not low, the next step is usually elastography, such as vibration-controlled transient elastography (FibroScan), which measures liver stiffness. A liver biopsy is used when other tests are unclear.
Medically reviewed by James F. Trotter, MD and Joseph S. Redman, MD, PhD of the National Friends Medical Advisory Board on . Reviewers check clinical statements against the cited sources; data tables come from the public SRTR program-specific reports and OPTN policy.
Published by Friends of the National Liver Waiting List, a 501(c)(3) patient advocacy charity. Updated . Not medical advice: talk with your hepatologist or transplant team about your own care.