Cirrhosis

Cirrhosis is advanced scarring (fibrosis) of the liver that disrupts its normal structure and function. Healthy liver tissue is progressively replaced by scar tissue, which impairs blood flow through the liver and reduces the organ’s ability to process nutrients, hormones, drugs, and toxins, and to produce proteins and clotting factors.

Common causes include chronic alcohol use, chronic viral hepatitis (B and C), and metabolic dysfunction–associated steatotic liver disease (MASLD/MASH, formerly NAFLD/NASH). Early cirrhosis may have no symptoms. As it advances, complications such as fluid accumulation, bleeding varices, confusion (hepatic encephalopathy), and liver cancer can develop. Treatment focuses on addressing the underlying cause, preventing complications, and, in end-stage disease, evaluating for liver transplantation.

Early cirrhosis is often asymptomatic. As disease progresses, symptoms and signs may include:

• Fatigue and weakness
• Easy bruising and bleeding
• Swelling in the legs (edema) and abdomen (ascites)
• Itchy skin
• Yellowing of the skin and eyes (jaundice)
• Spider-like blood vessels on the skin
• Redness in the palms
• Loss of appetite, nausea, and weight loss
• Confusion, drowsiness, or slurred speech (hepatic encephalopathy)
• Breast enlargement in men and loss of sex drive
• Dark urine and pale stools

Acute worsening can be triggered by infection, bleeding, alcohol, or medications.

Major causes of cirrhosis include:

• Chronic alcohol-related liver disease
• Chronic hepatitis B or C
• Metabolic dysfunction–associated steatotic liver disease (MASLD) and steatohepatitis (MASH)
• Autoimmune hepatitis
• Primary biliary cholangitis and primary sclerosing cholangitis
• Inherited conditions (hemochromatosis, Wilson disease, alpha-1 antitrypsin deficiency)
• Medications and toxins
• Repeated bouts of heart failure (cardiac cirrhosis)
• Cryptogenic (no clear cause identified after evaluation)

Risk factors include heavy long-term alcohol use, chronic viral hepatitis, obesity, type 2 diabetes, metabolic syndrome, injecting drug use (hepatitis risk), unprotected sex (hepatitis B), and certain genetic conditions. Coexistence of multiple risk factors (e.g., alcohol plus viral hepatitis or obesity) accelerates progression.

Complications of cirrhosis include:

• Portal hypertension
• Ascites and spontaneous bacterial peritonitis
• Esophageal and gastric varices with life-threatening bleeding
• Hepatic encephalopathy
• Hepatorenal syndrome
• Hepatocellular carcinoma
• Coagulopathy and thrombocytopenia
• Malnutrition and sarcopenia
• Increased susceptibility to infection
• Pulmonary complications (hepatopulmonary syndrome, portopulmonary hypertension)

Prevention strategies:

• Limit or avoid alcohol
• Vaccinate against hepatitis A and B
• Treat chronic hepatitis B or C
• Maintain a healthy weight and manage diabetes and metabolic syndrome
• Use medications safely; avoid unnecessary hepatotoxic drugs and high-dose acetaminophen
• Practice safe sex and do not share needles
• Screen high-risk people for viral hepatitis and advanced fibrosis when indicated

Evaluation includes:

• History of alcohol, metabolic risk, viral exposures, and family history
• Blood tests — liver enzymes, bilirubin, albumin, INR, complete blood count, viral hepatitis serologies, iron studies, autoantibodies, and others as indicated
• Noninvasive fibrosis assessment — transient elastography (FibroScan), serum fibrosis scores (FIB-4, APRI)
• Imaging — ultrasound, CT, or MRI to assess liver morphology, portal hypertension, and screen for cancer
• Upper endoscopy to evaluate for varices in patients with portal hypertension
• Liver biopsy when the diagnosis or cause remains uncertain

Staging distinguishes compensated from decompensated cirrhosis and guides prognosis and transplant referral.

See a clinician for persistent fatigue, unexplained swelling, jaundice, easy bruising, or risk factors for liver disease (heavy alcohol use, viral hepatitis, obesity with metabolic syndrome). Seek emergency care for vomiting blood, black stools, severe confusion, high fever, or rapidly increasing abdominal swelling.

Management has several pillars:

• Treat the cause — alcohol cessation programs, antiviral therapy for hepatitis B or C, weight loss and metabolic control for MASH, specific therapies for autoimmune and cholestatic diseases, chelation or phlebotomy for selected inherited disorders
• Prevent and treat complications — nonselective beta-blockers or endoscopic therapy for varices; diuretics and salt restriction for ascites; lactulose and rifaximin for encephalopathy; antibiotics for spontaneous bacterial peritonitis; screening for hepatocellular carcinoma every 6 months
• Nutrition — adequate protein and calories; address deficiencies
• Avoid hepatotoxins — alcohol, unnecessary NSAIDs, unneeded herbal supplements
• Liver transplantation — for decompensated cirrhosis or selected patients with liver cancer who meet criteria

A multidisciplinary team (hepatology, nutrition, addiction medicine, transplant) improves outcomes.

Essential self-management:

• Stop alcohol completely; seek support if needed
• Take prescribed medicines for complications as directed
• Follow a low-sodium diet if ascites or edema is present
• Maintain adequate protein intake unless specifically restricted
• Attend surveillance appointments for varices and liver cancer screening
• Stay current with recommended vaccines (including hepatitis A/B, influenza, pneumococcal, COVID-19)
• Report fever, increasing confusion, black stools, or rapid weight gain promptly

Bring:

• Alcohol and medication history (including supplements)
• Prior liver test results and imaging
• List of symptoms (swelling, confusion, bleeding, jaundice)
• Family history of liver disease
• Questions about cause, stage, cancer screening, and transplant evaluation if relevant