What Is Cirrhosis? Symptoms, Causes, Diagnosis, Treatment, and Prevention

Chronic liver disease can lead to cirrhosis, a condition in which the healthy tissue in the liver is replaced by nonliving scar tissue. Over time, the scar tissue inhibits the flow of blood through the liver and impairs the ability of the liver to process nutrients, hormones, and medication.

Cirrhosis is always related to other liver diseases and commonly develops from chronic hepatitis, alcohol-related liver disease (ARLD), or nonalcoholic fatty liver disease (NAFLD). If cirrhosis goes untreated, the liver will not be able to function well and liver failure may result.

Scarring, or fibrosis, in the liver occurs when it is exposed to toxic substances — such as alcohol or other drugs — or to inflammation, which can be caused by any liver disease, says Christina Lindenmeyer, MD, a gastroenterologist at the Cleveland Clinic in Ohio.

“There are actually four different stages of scarring: F1 (minimal scarring), F2 (significant scarring), F3 (severe fibrosis), and F4 (advanced scarring),” says Dr. Lindenmeyer. Cirrhosis is stage 4, or the last stage of scarring of the liver, she says.

If the scarring is at an early stage, there could be no symptoms of cirrhosis, says Lindenmeyer. “You can have cirrhosis with normal liver function” — a stage referred to as “compensated cirrhosis” — she says. “It’s only once the liver decompensates, or stops doing its job, that you develop symptoms.” (1)

Many people learn they have cirrhosis because of a CT scan for another medical condition. “Until the scan, they had no idea they had liver disease,” says Lindenmeyer.

Over time, cirrhosis can begin to cause symptoms, which can include the following:

• Loss of appetite
• Fatigue
• Weight loss or sudden weight gain
• Itchy skin
• A brownish or orange color to the urine
• Light-colored stools
• Blood in the stool
• Fever

The following are among the many possible causes of cirrhosis (2):

Chronic Viral Hepatitis B, C, or D Chronic hepatitis C is the leading cause of cirrhosis in the United States. It causes the liver to swell, which can eventually lead to cirrhosis.

About 1 in 4 people with hepatitis C develop cirrhosis. Although it’s less common, hepatitis B and D can also cause cirrhosis.

Heavy Alcohol Use Alcohol is toxic to the liver, and drinking too much can lead to inflammation of the liver and changes in the liver cells themselves. This causes swelling and, eventually, cirrhosis.

Nonalcoholic Steatohepatitis (NASH) Fat buildup in the liver that is not alcohol related is called nonalcoholic fatty liver disease (NAFLD). If NAFLD worsens, it can lead to NASH, which is when inflammation appears in the liver along with the fat.

Bile Duct Diseases These diseases limit or even prevent bile from flowing to the small intestine, which can cause swelling in the liver and lead to cirrhosis.

Family History Certain genetic diseases can increase someone’s chances of developing cirrhosis. Wilson disease, hemochromatosis, glycogen storage diseases, alpha-1 antitrypsin deficiency, and autoimmune hepatitis are all genetic diseases that can cause cirrhosis.

Learn More About Alcohol-Related Liver Disease

Preliminary tests for cirrhosis include a complete medical exam and discussion of symptoms, a review of the person’s medical history and lifestyle, and blood tests. Liver function tests can measure levels of certain enzymes and proteins in the blood. If the levels are not within the normal range, it can indicate that the liver isn’t functioning properly. (2)

The gold standard for diagnosing cirrhosis is a biopsy to determine the amount of scarring, says Lindenmeyer. A biopsy involves removing a small piece of tissue from the liver for examination under a microscope.

But, according to Lindenmeyer, “a biopsy is fairly invasive and carries its own risk of potential adverse events, so we’ve actually developed a number of noninvasive ways to assess the amount of scarring.”

Among the noninvasive imaging tests available for diagnosing and monitoring liver disease are two, called shear wave elastography and transient elastography, that are based on ultrasound imaging technology. A third — magnetic resonance elastography — is based on MRI technology. All of these tests measure the stiffness of the liver tissue, which indicates the severity of fibrosis, according to research from 2020. (3)

An MRI, CT scan, or abdominal sonogram can also provide detailed images of the liver to help diagnose cirrhosis.

People with suspected cirrhosis may also have an upper endoscopy, in which a thin tube with a camera attached is inserted through the mouth into the esophagus and stomach to look for enlarged veins — called varices in the esophagus and gastropathy in the stomach — indicating portal hypertension, or high blood pressure in the vein that brings blood to the liver. (1)

Prognosis of Liver Cirrhosis

Life expectancy in cirrhosis is dependent on the severity of the disease as well as the underlying cause of it. If cirrhosis is identified and treated early, and its progression is slowed, it may have little impact on mortality.

If cirrhosis is extensive before it is diagnosed or treated, or the patient drinks alcohol or uses drugs that are toxic to the liver after diagnosis (even if substance use wasn’t the root cause of the cirrhosis), the prognosis is less favorable.

Obesity is also associated with a worse prognosis for liver cirrhosis, according to the 2016 practice guidelines of the American Association for the Study of Liver Diseases. (4)

Doctors use two scoring systems to predict mortality in people with cirrhosis: the Child-Turcotte-Pugh (CTP) score and the Model for End-Stage Liver Disease (MELD) score. Both can estimate a person’s risk of death within the next three months, and the CTP can additionally be used to estimate one- to two-year survival.

The MELD score was adopted by the United Network for Organ Sharing (UNOS) in 2002 to prioritize allocation of deceased donor organs for liver transplantation.

Whichever system is used by your doctor or hospital, if you have cirrhosis, your doctor should calculate your score at each visit to determine whether to refer you for a liver transplant evaluation. (5)

Cirrhosis is a progressive disease, which means it gets worse over time. Liver damage cannot usually be reversed, but the injury can be slowed down with treatment or lifestyle changes.

Treating the underlying type of liver disease causing your cirrhosis is the first and most important step when it comes to managing cirrhosis. Other healthy habits to prevent further liver damage include the following:

• Follow a nutritious diet and practice portion control.
• Avoid alcohol.
• Engage in regular exercise.
• Limit salt intake.
• Avoid raw shellfish, which can contain the bacteria Vibrio vulnificus and make you very ill.
• Talk to your doctor about the medication you take and whether it might be contributing to your liver damage.
• Practice safer sex.
• Don’t share needles, razors, or toothbrushes.
• Use clean needles for tattoos or piercings. (2)
• Stay up to date on vaccinations, especially those that protect against hepatitis A and B.

The first step in treating cirrhosis is avoiding whatever the insult is to the liver, says Lindenmeyer. “If autoimmune hepatitis is the root cause of the liver damage, the treatment would be treating the hepatitis. For alcohol-related liver disease, the treatment would begin with avoiding alcohol. Metabolic risk factors, such as being overweight or having diabetes, would be addressed to treat NAFLD. For hemochromatosis, the treatment would be decreasing the systemic level of iron overload,” she says.

Regardless of the primary cause of a patient’s cirrhosis, any behaviors or conditions that might further damage the liver should be avoided. For example, those with hepatitis-related cirrhosis should also avoid alcohol.

The overall goal of the therapy is to stop the progression of the disease and prevent liver failure, says Lindenmeyer.

Medication Options

In addition to any medication that might be used to treat the underlying cause of cirrhosis, certain medications may be used to treat the complications that can result from it. (1)

For example, lactulose may be prescribed for hepatic encephalopathy, or confusion that results from toxic substances entering the brain. Lactulose is a laxative that can help decrease the absorption of substances that can be harmful to the brain.

Diuretics, or water pills, may be prescribed to reduce ascites, or the accumulation of fluid in the abdomen.

Antibiotics may be prescribed to prevent or treat infections. Rifaximin (Xifaxan) is an antibiotic that can help treat hepatic encephalopathy. Rifaximin is commonly prescribed with lactulose.

Blood pressure medicine can help lower pressure in the portal vein, which brings blood to the liver. Lowering pressure in the portal vein can, in turn, decrease the risk of internal bleeding and damage to the spleen.

Drugs that may be used to relieve itching associated with cirrhosis include cholestyramine (Questran) and colesevelam (Welchol), both of which are also used to lower high blood cholesterol levels. If these drugs don’t help or cannot be tolerated, the drugs rifampin (Rifadin) or naltrexone (Vivitrol) may be tried. However, these drugs can have serious side effects affecting the liver and require close monitoring. (6)

Liver Transplantation

When medication can no longer control the complications of cirrhosis, a liver transplantation is often the only remaining option for treatment. (1)

A liver transplant is a major operation in which a diseased liver is replaced with a whole, healthy liver from a deceased person or a partial, healthy liver from a living donor. However, there are many more people who need liver transplants than there are available organs. (7)

Complementary Therapies

There are a number of supplements on the market that claim to “cleanse” or “support” liver health. Most of these supplements have no scientific evidence to back these claims, and some have been shown to contain harmful ingredients. Those products that have been studied in clinical trials generally haven’t shown efficacy in those trials.

According to the Mayo Clinic, there currently isn’t enough evidence of benefit to recommend any herbal products to treat cirrhosis. (8)

One herbal remedy frequently mentioned in discussions of liver disease is milk thistle, also known as silymarin. A particular formulation of silymarin used in research studies has been shown to have positive effects in patients with alcoholic or nonalcoholic fatty liver disease, including those with cirrhosis. And it has additionally helped those with drug-induced liver injuries. (9)

However, according to Mount Sinai, many of the studies on milk thistle and cirrhosis are small and vary widely in dosing, so it is difficult to draw any firm conclusions on milk thistle’s effectiveness. Additionally, keep in mind that the milk thistle products you find in retail stores are unlikely to be the same formulation as that used in clinical research studies.

Since some herbal remedies and other alternative or complementary therapies can be toxic to the liver, tell your doctor about any products you’re taking or are interested in taking. In addition, talk to your doctor first before trying any sort of cleanse or detox regimen.

RELATED: The Most Popular Types of Detoxes and Cleanses and What to Know Before Trying Them

Prevention of Cirrhosis/Chronic Liver Disease

There are many ways to keep your liver healthy and prevent cirrhosis, including the following: (10)

• Don’t drink alcohol to excess. If you consume alcohol, do it in moderation, which is up to one drink a day for women and up to two drinks a day for men, according to the Centers for Disease Control and Prevention (CDC). (11)
• Avoid engaging in high-risk sexual behavior such as having unprotected sex with multiple partners.
• Be cautious when using cleaning products, pesticides, and other chemicals. People who use these products routinely should wear protective clothing, including gloves, and a face mask, when handling them.
• Get vaccinated for hepatitis B.
• Follow a healthy diet.
• Have regular medical checkups, and follow your doctor’s recommendations to control your weight, blood pressure, blood cholesterol, and blood sugar if you have diabetes.

Portal hypertension is a complication of cirrhosis that can have negative effects throughout the body. It occurs when a buildup of scar tissue blocks the flow of blood through the liver, leading to abnormally high blood pressure in the portal vein, the large vein that carries blood from the intestine to the liver. This in turn causes the accumulation of fluid in the abdomen (called ascites), bleeding from veins in the esophagus or stomach, and an enlarged spleen. (12)

Additional complications from cirrhosis can include:

• Jaundice, a yellow discoloration of the skin and whites of eyes
• Bruising easily
• Edema, or fluid retention and swelling in the legs
• Hepatic encephalopathy, a buildup of toxins in the brain that causes confusion and, in advanced stages, coma
• Kidney failure
• Problems with other organs, such as heart failure
• Liver cancer

People with cirrhosis have an increased risk of liver cancer, and most people who develop liver cancer have some evidence of cirrhosis.

African Americans and Hispanic Americans have a greater risk for developing liver disease than white Americans, and they are more likely to die of liver disease. A higher prevalence of risk factors and disparities in rate and stage of diagnosis and care of liver disease all contribute to health inequity. (14)

In 2018, chronic liver disease was the ninth leading cause of death for Black Americans between ages 45 and 64, according to statistics collected by the CDC. (15)

African American men are 60 percent more likely to have liver and IBD (intrahepatic bile duct) cancer than white men. African American women are 40 percent more likely to die from liver and IBD cancer than white women. (16)

Chronic liver disease is the seventh leading cause of death for all Hispanic Americans, and the fourth leading cause of death for Hispanic men ages 55 to 64. Both Hispanic men and women have a chronic liver disease rate that is twice that of white people. (17)

Hispanic men are 60 percent more likely to die of liver and IBD cancer than white men, and Hispanic women are 80 percent more likely to die from liver and IBD cancer than white women. (17)

Research from 2015 examined the frequency of alcoholic liver disease, including alcoholic steatosis, hepatitis, and cirrhosis, in white, African American, and Hispanic individuals with alcoholic liver disease who were admitted or were followed as outpatients at University of California Davis Medical Center between 2002 and 2010.

Researchers found that Hispanic individuals developed these diseases 4 to 10 years earlier than white individuals. The proportion of people with severe alcoholic hepatitis was similar in Hispanic and white people but lower in African Americans. (18)

In this study, Hispanic patients were more likely to be obese, male, and have diabetes when compared with white patients.

A study from 2010 found that Black Americans and Hispanics with early-stage liver cancer were more likely to die from their disease than white patients. Five years after diagnosis, 18 percent of white liver cancer patients were alive, compared with 15 percent of Hispanic patients and 12 percent of Black patients. (19)

Researchers found that Black and Hispanic patients were less likely to have surgery than white patients, and white patients underwent liver transplantation more frequently than any other racial or ethnic group. Even after adjusting for cancer stage and socioeconomic factors, the authors concluded that racial and ethnic disparities in survival were evident.

Given the many important functions of the liver in the body, it’s perhaps not surprising that a broad range of dysfunctions result when the liver is damaged and is not performing its normal tasks well, including filtering the blood and managing blood glucose levels.

Chronic Parkinsonism Associated With Cirrhosis

Parkinsonism — symptoms similar to those that occur in Parkinson’s disease — can develop in people with cirrhosis of the liver. The symptoms can include rapidly progressive hypokinesia (slowed or decreased movement), dystonia (involuntary muscle contractions), and rigidity. It is thought to result from the accumulation of manganese in certain parts of the brain. (20)

Symptoms can sometimes improve with medication or a liver transplant.

Osteoporosis

Osteoporosis is commonly associated with chronic liver disease; a prevalence of as high as 55 percent has been reported in people with advanced liver cirrhosis. In a 2018 study, older age, lower body mass index (BMI), greater liver stiffness, and cirrhosis caused by alcoholic liver disease were associated with a higher risk of osteoporosis. (21)

Early diagnosis and management of both liver disease and osteoporosis are key to preventing fracture and further complications.

American Association for the Study of Liver Diseases

This is a professional organization for scientists and clinicians involved in preventing and treating liver disease. The website provides practice guidelines for diagnosing and treating various forms of liver disease, as well as information on the organization’s annual meeting, which in 2020 was virtual and open to patients and patient advocates at a discounted rate.

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

This government organization is involved in research and provides the latest information to doctors and patients. Its website includes patient education information and practice tools for the diagnosis and treatment of liver disease.

American Liver Foundation (ALF)

The American Liver Foundation is a not-for-profit organization that promotes education, advocacy, support services, and research for the prevention, treatment, and cure of liver disease. ALF has offices around the country and holds fundraising events to help fight liver disease.

Patients Like Me

This website gives patients a chance to share their insights, symptoms, treatment information, and health outcomes, in addition to learning about the experiences of other people who share their condition.