Cirrhosis of the Liver
What is cirrhosis of the liver?
Cirrhosis is a late-stage liver disease in which healthy liver tissue is replaced with scar tissue and the liver is permanently damaged. Scar tissue keeps your liver from working properly.
Many types of liver diseases and conditions injure healthy liver cells, causing cell death and inflammation. This is followed by cell repair and finally tissue scarring as a result of the repair process.
The scar tissue blocks the flow of blood through the liver and slows the liver’s ability to process nutrients, hormones, drugs and natural toxins (poisons). It also reduces the production of proteins and other substances made by the liver. Cirrhosis eventually keeps the liver from working properly. Late-stage cirrhosis is life-threatening.
How common is cirrhosis?
Scientists estimate that cirrhosis of the liver affects about one in 400 adults in the U.S. It affects about 1 in 200 adults age 45 to 54, the age group most commonly affected by cirrhosis. Cirrhosis causes about 26,000 deaths each year in the U.S. and is the seventh leading cause of death in the U.S. among adults 25 to 64 years of age.
Who gets cirrhosis, who is most at risk?
You are more likely to get cirrhosis of the liver if you:
- Abuse alcohol for many years.
- Have viral hepatitis.
- Have diabetes.
- Are obese.
- Inject drugs using shared needles.
- Have a history of liver disease.
- Have unprotected sex.
Is cirrhosis cancer?
No, cirrhosis of the liver isn’t cancer. However, most people who have liver cancer have cirrhosis. If you have cirrhosis, you have an increased risk of liver cancer. If you have hepatitis B or hepatitis C, you have an increased risk of liver cancer because these diseases often lead to cirrhosis. Any cause of liver disease can lead to cirrhosis, which increases your chance of liver cancer. (Even if you have hepatitis B or fatty liver disease without cirrhosis, you are at increased risk of liver cancer.)
Is cirrhosis a hereditary disease?
Cirrhosis itself is not an inherited (passed from parent to child) disease. However, some of the diseases that can cause liver damage that lead to cirrhosis are inherited diseases.
Can cirrhosis be reversed?
Generally no. If you have been told you have cirrhosis, you have a late-stage liver disease and the damage that is already done is permanent. There are many liver diseases and complications of liver diseases that can lead to cirrhosis. If your liver disease or complication is caught early and successfully managed, it may be possible to slow or stop the progression of disease.
Is cirrhosis fatal?
Having a diagnosis of cirrhosis of the liver doesn’t mean you have an immediately fatal condition. However, as cirrhosis continues, more scarring occurs and liver function continues to decline. Eventually, your failing liver may become a life-threatening condition. Yet there’s still hope. You and your medical team will discuss if you are a candidate for a liver transplant. If so, you will begin the process of being placed on a national liver transplant recipient list.
Symptoms and Causes
What are the symptoms of cirrhosis?
The symptoms of cirrhosis depend on the stage of your disease. In the beginning stages, you may not have any symptoms. If you do have symptoms, some are general and could easily be mistaken for symptoms of many other diseases and illnesses.
Early symptoms and signs of cirrhosis include:
As liver function gets worse, other more commonly recognized symptoms of cirrhosis appear including:
- Easy bruising and bleeding.
- Yellow tint to your skin or the whites of your eyes (jaundice).
- Itchy skin.
- Swelling (edema) in your legs, feet and ankles.
- Fluid buildup in your belly/abdomen (ascites).
- Brownish or orange color to your urine.
- Light-colored stools.
- Confusion, difficulty thinking, memory loss, personality changes.
- Blood in your stool.
- Redness in the palms of your hands.
- Spider-like blood vessels that surround small, red spots on your skin (telangiectasias).
- In men: loss of sex drive, enlarged breasts (gynecomastia), shrunken testicles.
- In women: premature menopause (no longer having your menstrual period).
Is cirrhosis painful?
Yes, cirrhosis can be painful, especially as the disease worsens. Pain is reported by up to 82% of people who have cirrhosis and more than half of these individuals say their pain is long-lasting (chronic).
Most people with liver disease report abdominal pain. Pain in your liver itself can feel like a dull throbbing pain or a stabbing sensation in your right upper abdomen just under your ribs. General abdominal pain and discomfort can also be related to swelling from fluid retention and enlargement of your spleen and liver caused by cirrhosis.
Pain can come both from the diseases that lead to cirrhosis and/or cirrhosis can make the pain from existing diseases worse. For instance, if you have non-alcoholic fatty liver disease and are obese, you may also have osteoarthritis and cirrhosis makes your bone and joint pain worse. Cirrhosis also causes an inflammatory state in your entire body. Inflammation and your body’s reaction to inflammation can cause general pain.
What causes cirrhosis?
The most common causes of cirrhosis of the liver are:
- Alcohol abuse (alcohol-related liver disease caused by long-term [chronic] use of alcohol).
- Chronic viral infections of the liver (hepatitis B and hepatitis C).
- Fatty liver associated with obesity and diabetes and not alcohol. This condition is called non-alcoholic steatohepatitis.
Anything that damages the liver can lead to cirrhosis. Other causes include:
- Inherited diseases:
- Alpha-1 antitrypsin deficiency (build-up of an abnormal protein in the liver)
- Hemochromatosis (excess iron stored in the liver).
- Wilson disease (excess copper stored in the liver).
- Cystic fibrosis (sticky, thick mucus builds up in the liver).
- Glycogen storage diseases (liver can’t store or break down glycogen, a form of sugar).
- Alagille syndrome (born with fewer than normal number of bile ducts; affects bile flow and causes jaundice).
- Autoimmune hepatitis (your body’s own immune system attacks healthy liver tissue causing damage).
- Diseases that damage or block bile ducts in the liver (tubes that carry bile from the liver to other parts of digestive system; bile helps digest fats):
- Primary biliary cholangitis (bile ducts become injured, then inflamed, then permanently damaged).
- Primary sclerosing cholangitis (inflammation of the bile ducts leads to scarring and narrowing of the ducts and buildup of bile in the liver).
- Blocked bile duct (can cause infections, backup of products in the liver).
- Biliary atresia (infants are born with poorly formed or blocked bile ducts, causing damage, scarring, loss of liver tissue and cirrhosis).
- Chronic heart failure (causes fluid to back up in your liver, swelling in other areas of your body and other symptoms).
- Rare diseases, such as amyloidosis, in which abnormal deposits in the liver of an abnormal protein called amyloid disrupts normal liver function.
Changes from liver diseases that lead to cirrhosis are gradual. Liver cells are injured and if injury – from whatever cause – continues, liver cells start to die. Over time, scar tissue replaces the damaged liver cells and the liver can’t function properly.
What are the complications of cirrhosis?
There are many complications of cirrhosis of the liver. Because cirrhosis develops over many years, some of these complications may be your first noticeable signs and symptoms of the disease.
Portal hypertension: This is the most common serious complication. Portal hypertension is an increase in the pressure in your portal vein (the large blood vessel that carries blood from the digestive organs to the liver). This increase in pressure is caused by a blockage of blood flow through your liver as a result of cirrhosis. When blood flow through veins is partially blocked, veins in your esophagus, stomach or intestines can become enlarged (a condition called varices). As the pressure in these veins builds, the veins can bleed or even burst, causing severe internal bleeding.
Additional complications of portal hypertension include:
- Swelling (edema) in your legs, ankles or feet.
- Buildup of fluids in your abdomen (called ascites).
- Swelling/enlargement of your spleen (splenomegaly).
- Formation and dilation (expansion) of blood vessels in the lungs (hepatopulmonary syndrome), leading to low levels of oxygen in the blood and body and shortness of breath.
- Failure of kidney function as a result of having portal hypertension as a complication of cirrhosis (hepatorenal syndrome). This is a type of kidney failure.
- Confusion, difficulty thinking, changes in your behavior, even coma. This occur when toxins from your intestines aren’t removed by your damaged liver and circulate in the bloodstream and buildup in your brain (a condition called hepatic encephalopathy).
Hypersplenism: Hypersplenism is an overactive spleen. This condition causes quick and premature destruction of blood cells.
Infections: Cirrhosis increases your risk of getting and fighting serious infections, such as bacterial peritonitis (infection of the tissue that lines the inner wall of your abdomen).
Malnutrition: Your liver processes nutrients. A damaged liver makes this more difficult and leads to weight loss and general weakness.
Liver cancer: Most people who develop liver cancer have cirrhosis of the liver.
Liver failure: Many diseases and conditions cause liver failure including cirrhosis of the liver. As its name implies, liver failure occurs when your liver isn’t working well enough to perform its many functions.
Diagnosis and Tests
How is cirrhosis of the liver diagnosed?
Your healthcare provider will first ask about your medical history and over-the-counter and prescription drug use. They will also ask about any supplements or herbal products you may take. Your provider may suspect you have cirrhosis if you have a long history of alcohol abuse, injectable drug abuse or have had hepatitis B or C and have the symptoms listed in this article.
To diagnosis cirrhosis, your provider will perform a physical exam and may order one or more of the following tests:
- Physical exam: Your doctor will examine you, looking for the signs and symptoms of cirrhosis including: the red, spider-like blood vessels on your skin; yellowing of your skin or whites of your eyes; bruises on your skin; redness on your palms; swelling, tenderness or pain in your abdomen; enlarged firmer-feeling, bumpy texture to the lower edge of your liver (the part of your liver below the rib cage that can be felt).
- Blood tests: If your doctor suspects cirrhosis, your blood will be checked for signs of liver disease. Signs of liver damage include:
- Lower than normal levels of albumin and blood clotting factors (lower levels means your liver has lost its ability to make these proteins).
- Raised levels of liver enzymes (suggests inflammation).
- Higher level of iron (may indicate hemochromatosis).
- Presence of autoantibodies (may indicate autoimmune hepatitis or primary biliary cirrhosis).
- Raised bilirubin level (suggests liver isn’t working properly to remove bilirubin from the blood).
- High white blood cell count (indicates an infection).
- High creatinine level (a sign of kidney disease that suggests late-stage cirrhosis).
- Lower levels of sodium (is an indicator of cirrhosis).
- Raised level of alpha-fetoprotein (indicates presence of liver cancer).
In addition, other blood work will include a complete blood count to look for signs of infection and anemia caused by internal bleeding and a viral hepatitis test to check for hepatitis B or C.
- Imaging tests: Imaging test show the size, shape and texture of the liver. These tests can also determine the amount of scarring, the amount of fat you have in your liver and fluid in your abdomen. Imaging tests of your liver that could be ordered include computerized tomography (CT) scan, abdominal ultrasound and magnetic resonance imaging (MRI). A special ultrasound, called a transient elastography, measures the fat content and amount of stiffness in your liver. Two different types of endoscopies might be ordered: an endoscopic retrograde cholangiopancreatography to detect bile duct problems, and/or upper endoscopy to detect enlarged veins (varices) or bleeding in your esophagus, stomach or intestines.
- Biopsy: A sample of liver tissue (biopsy) is removed from your liver and examined under the microscope. A liver biopsy can confirm a diagnosis of cirrhosis, determine other causes or extent of liver damage or enlargement or diagnosis liver cancer.
Are there stages of cirrhosis?
If you have been diagnosed with cirrhosis of the liver, you are already beyond the early stages of liver disease. Having cirrhosis means your liver has scar tissue in it because it has been damaged.
Liver specialists and researchers have developed many different scoring systems to predict outcome and to guide treatment for chronic liver disease. Some specific liver diseases also have their own scoring systems. However, not every liver disease has a scoring system and there’s no scoring system if you happen to have more than one liver disease at the same time.
For these reasons, perhaps it’s easier to talk about cirrhosis according to a classification system you are more likely to hear from your healthcare provider. He or she may refer to you having either compensated cirrhosis or decompensated cirrhosis.
Compensated cirrhosis means you have cirrhosis but you don’t yet have noticeable symptoms (you are asymptomatic). Your lab work and imaging findings may not be abnormal. A liver biopsy may be the only way to confirm a diagnosis of cirrhosis. Median survival in patients with compensated cirrhosis is approximately nine to 12 years. (Median is the middle point in set of numbers, so an equal number of individuals survived less than 9 to 12 years as the number of individuals who survived over this time range.)
Decompensated cirrhosis means your cirrhosis has worsened to the point that you have noticeable symptoms. Your healthcare provider recognizes your condition based on your history, physical and lab findings. You have at least one complication, which includes jaundice, ascites, hepatic encephalopathy, hepatorenal syndrome, variceal bleeding or liver cancer. You are usually admitted to the hospital for care. Median survival in patients with decompensated cirrhosis is approximately two years.
Management and Treatment
Is there a cure for cirrhosis of the liver?
No, there is no cure for cirrhosis. The damage already done to your liver is permanent. However, depending on the underlying cause of your cirrhosis, there may be actions you can take to keep your cirrhosis from getting worse. These actions include:
- Stop drinking alcohol.
- Treat chronic hepatitis (if you have it).
- Avoid medications that stress the liver.
- Eat a healthy, well-balanced, low-fat diet, such as the Mediterranean diet.
Follow other tips listed under the Prevention section in this article.
What are the goals of cirrhosis treatment?
The goals of treatment for cirrhosis of the liver are to:
- Slow further damage to your liver.
- Prevent and treat symptoms.
- Prevent and treat complications.
How is cirrhosis of the liver treated?
Treatment depends on what’s causing your cirrhosis and how much damage exists.
Although there is no cure for cirrhosis, treatments can delay or stop its progress and reduce complications.
Treatments for the causes of cirrhosis are as follows:
- Alcohol-related liver disease: If you’ve developed cirrhosis from alcohol abuse, stop drinking alcohol. If you need help, ask your healthcare provider for recommendations for alcohol addiction treatment programs.
- Hepatitis B or C: Several approved antiviral medications are available to treat hepatitis types B and C.
- Nonalcoholic fatty liver disease: Management of nonalcoholic fatty liver disease includes losing weight, following a healthy diet, getting physical exercise and following your provider’s instructions for managing your diabetes.
- Inherited liver diseases: Treatment depends on the specific inherited disease. Treatments are aimed at treating symptoms and managing complications. Treatment of alpha-1 antitrypsin deficiency may include medicine to reduce swelling in your abdomen and legs, antibiotics to treat infections and other medicines for complications. For hemochromatosis, treatment is to remove blood to reduce the level of iron in your blood. For Wilson disease, treatment is medicines to remove copper from your body and zinc to prevent absorption of cooper. For cystic fibrosis, medications are prescribed to improve lung function, methods to clear mucous and treatment of complications. Treatment for glycogen storage diseases that involve the liver is to keep glucose at the right level.
- Autoimmune hepatitis: Treatment includes medications to suppress your immune system.
- Diseases that damage or block bile ducts in the liver: Treatments include medications such as ursodiol (Actigall®) or surgery to open narrowed or blocked bile ducts.
- Heart failure: Treatment depends on the cause and stage of your heart failure. Medications include drugs to treat high blood pressure, reduce cholesterol, remove excess fluids (edema) from your body and improve heart pumping function. Other treatments include implantation of devices to help pump blood or monitor heart rhythm, surgeries to unblock arteries or replace or repair heart valves and transplant surgery to replace your heart.
- Medications that may be contributing to cirrhosis: Your provider will review all of your medications to determine if any are causing problems for your liver and if so, stop the drug, lower the dosage or change to a different drug if possible.
How are the complications of cirrhosis treated?
Portal hypertension: Portal hypertension is mainly the result of chronic end-stage liver disease. Treatment consists of treating its many complications. Treatments of portal hypertension include:
- Giving beta blockers or nitrates to lower blood pressure in your veins.
- Cutting off blood flow through the varices to stop or reduce further bleeding with procedure using tiny elastic bands (band ligation) or with sclerotherapy.
- Redirecting blood from the portal vein to reduce pressure in the portal vein and to control variceal bleeding. This is achieved using either one of two techniques – distal splenorenal shunt or transjugular intrahepatic portosystemic shunt.
- Prescribing lactulose to absorb toxins in the blood that result from hepatic encephalopathy, which cause symptoms including confusion and other mental changes.
- Draining excess fluid in your abdomen (ascites) in a procedure called paracentesis or taking a diuretic medication to decrease extra fluids (edema) in your legs and other areas of your body.
Bacterial peritonitis: Antibiotics and infusion of a protein (albumin) will be prescribed. Typically patients are admitted to the hospital for treatment and monitoring. Following a diagnosis of bacterial peritonitis, an oral antibiotic will be prescribed for daily use to prevent recurrence of infection.
Liver cancer: Treatment depends on the stage of your cancer and other factors. One or more treatments may be tried. Options include surgery to remove part of your liver or your whole liver (to be replaced with a new liver as part of a liver transplantation) and nonsurgical tumor-destroying methods including ablation, chemotherapy, targeted therapy (drugs zero in on cancer genes or tissue), immunotherapy and radiation bead therapy (inject bead that give off radiation into the blood vessels that feed the tumor).
Kidney failure: Treatment may include medication, dialysis and kidney transplant, depending on the cause and extent of failure.
Liver failure: Treatment depends on if you have acute or chronic failure. For chronic liver failure, diet and lifestyle changes include stopping alcohol and medications that harm the liver; eating less red meat, cheese and eggs; losing weight; controlling high blood pressure and diabetes and cutting down on salt.
Acute treatments for liver failure include intravenous fluids to maintain blood pressure, laxatives to help flush toxins from the body and blood glucose monitoring.
If you have either acute or chronic liver failure, your liver specialist may recommend a liver transplant. Liver transplants can come from a living or deceased donor. Only a portion of the donor liver needs to be transplanted. The liver is the only human organ capable of growing back.
Many tests are required of both you (the liver transplant recipient) and the person donating a portion of their liver or the cadaver liver (liver from a deceased person). If your doctors determine that you need a liver transplant, you will be placed on a national liver transplant waiting list, which lists patients by blood type, body size and severity of end-stage liver disease.
How can I prevent cirrhosis of the liver?
Food and drink issues:
- Don't abuse alcohol. If you do drink alcohol, limit how much you drink and how often. If you drink more than two drinks a day if you are a man or more than one if you are a woman, you are increasing your risk. A drink is a glass of wine or a 12-ounce can of beer or a 1.5 ounce serving of hard liquor. If you have liver disease, you should not drink alcohol at all.
- Eat a well-balanced, low-fat diet, such as the Mediterranean diet. A well-balanced healthy diet consists of fruits, vegetables, lean proteins and whole grains.
- Don’t eat raw seafood, especially oysters and clams. These foods can contain a bacteria that can cause serious illness.
- Cut back on the amount of salt in your diet. Use other seasonings to flavor your foods.
Healthy body habits:
- Maintain a healthy weight. Excess body fat can damage your liver. Ask your healthcare provider for a weight loss plan if you are overweight.
- Exercise regularly.
- See your healthcare provider regularly for check-ups. Follow medical recommendations to control obesity, diabetes, hypertension (high blood pressure) and cholesterol (high bad cholesterol [LDL] and/or low good cholesterol [HDL]) and high triglycerides.
- Quit smoking if you smoke.
Healthy liver practices:
- Avoid high-risk behaviors that can lead to infection with hepatitis B or C, such as sharing needles for illegal drug use or having unprotected sex.
- Get vaccinated against hepatitis B. If you already have hepatitis, ask your provider if drug treatment is appropriate for you.
- Get your annual flu shot and ask if a pneumonia vaccine makes sense for you (people with cirrhosis are more likely to get infections).
- Avoid nonsteroidal anti-inflammatory drugs (such as ibuprofen [Advil®, Motrin®] indomethacin [Indocin®] celecoxib [Celebrex®] and aspirin) and high doses of acetaminophen (Tylenol®). Acetaminophen can be taken safely at a dose up to 2,000 mg daily. These drugs can cause or worsen liver function.
- Take all medications and keep all appointments as recommended by your healthcare provider.
Outlook / Prognosis
What can I expect if I have cirrhosis?
Damage already done to your liver is permanent. But your liver is a large organ. If part of your liver is still working, you might be able to slow the progression of disease, depending on its cause. For instance, if your cirrhosis is caused by alcohol abuse, you need to stop drinking immediately. If you are obese or have diabetes, you will need to lose weight and manage your blood sugar so you can lower the damage caused by fatty liver disease.
You and your healthcare provider or team will work together to determine what’s causing your cirrhosis and what complications may have resulted from your cirrhosis and treat them accordingly.
What’s the life expectancy for people with cirrhosis?
Life expectancy depends on several factors including the cause and severity of your cirrhosis, your response to treatments, presence of cirrhosis complications, your age and any other existing general health problems. Ask your liver specialist about your life expectancy since every person is unique, with unique overall health issues and specific liver health issues.
If your cirrhosis is advanced, liver transplantation may be an option. You and your doctors will discuss if this is an option for you.
What’s a Child-Turcotte-Pugh score and MELD score?
A Child-Turcotte-Pugh (CTP) score, also known simply as the Child-Pugh score, is a clinical score that tells your doctors how severe your liver disease is and forecasts your expected survival rate. The scoring system provides a score on the presence of five clinical measures (the lab values of bilirubin, serum albumin and prothrombin time; presence of ascites and hepatic encephalopathy) and the degree of severity of each of these measures.
|Class Status||Severity of Liver Disease||Two-Year Survival Rate|
The Model for End-stage Liver Disease (MELD) score is a score that is used to rank the urgency for a liver transplant. The worse your liver function is, the higher your MELD score and the higher your position is on the transplant list. The Pediatric End-stage Liver Disease (PELD) score is similar to MELD but is a scoring system for children under the age of 12.
When should I call 911 or go to the emergency room?
If you have cirrhosis and experience the following, call 911:
- Your poop (stools) are black and tarry or contain blood (may be maroon or bright red in color).
- You are vomiting blood.
- The whites of your eyes are turning yellow.
- You have difficulty breathing.
- You have abdominal swelling.
- You have muscle tremors or shakiness.
- You are confused, irritable, disoriented, sleepy, forgetful or “foggy.”
- You have a change in your level of consciousness or alertness; you pass out.
What type of healthcare providers will treat my cirrhosis?
Depending on the stage of your cirrhosis, different healthcare providers may be involved in your care. Healthcare professionals likely to be part of your care team include:
- Your primary care provider.
- Gastroenterologist (doctor who specializes in conditions of your digestive tract).
- Hepatologist (doctor who specializes in conditions of your liver).
- Nephrologist (doctor who specializes in conditions of your kidney).
- Members of a liver transplant team include: hepatologist, transplant surgeon, anesthesiologist, infectious disease specialist, nephrologist, dietitian, transplant pharmacist, physical and occupational therapist, case manager/social worker and nurses.
A note from Cleveland Clinic
Cirrhosis of the liver is a late-stage result of liver disease and its complications. Cirrhosis causes your liver to not function properly. Your liver plays a vital role in many of the processes and functions that keep you alive.
Although scarring from liver disease causes permanent damage, it’s still possible to live a long life. Depending on the underlying cause, it’s possible to slow or stop cirrhosis from worsening. Many of the causes and complications that lead to cirrhosis are treatable or manageable. If you drink alcohol, stop. If you have nonalcoholic fatty liver disease, lose weight and control your metabolic risk factors. If you have diabetes, make sure you are following your healthcare provider’s management recommendations. Take all medications for all your medical conditions as directed by your healthcare team. Get vaccinated for hepatitis A and B.
If you have end-stage cirrhosis, don’t lose hope. You and your healthcare team will work together to closely manage your condition and put you on a wait list for a donor liver.