This article was last reviewed on
This article waslast modified on
21 September 2017.
What is cirrhosis?

Cirrhosis is severe scarring of the liver caused by chronic liver disease. As healthy liver tissue is damaged over a long period of time, it is replaced by scar tissue, affecting the structure of the liver and decreasing its ability to function. Cirrhosis is seen with a variety of chronic liver diseases and may take years or even decades to develop. Unlike scars in other parts of the body, some of the scarring that occurs in the liver is reversible, even in people with cirrhosis; it is difficult to tell which scars can be removed and which will be permanent.

The liver is a vital organ located in the upper right-hand side of the abdomen. Among other functions, it helps convert nutrients from food into essential blood components, produces many of the factors necessary for normal blood clotting, metabolises and detoxifies substances that would otherwise be harmful to the body, and produces bile – a fluid necessary for the digestion of fats.

Liver diseases can affect any of these critical functions. These diseases may be the result of infection, injury, exposure to a toxin, an autoimmune process, or due to a genetic defect that leads to the build-up of substances such as copper or iron. The damage that liver diseases cause can lead to inflammation, obstruction,and clotting abnormalities. Prolonged and persistent damage can lead to the accumulation of excess connective tissue, or fibrosis of the liver. Fibrosis can lead to cirrhosis.

With cirrhosis, the structure of the liver changes, forming nodules of cells surrounded by fibrous tissue. This tissue does not function like healthy liver tissue and can interfere with the flow of blood and (rarely) bile through the liver. As cirrhosis progresses, it can begin to affect other organs and tissues throughout the body. Some examples of these effects and complications include:

  • An increase in pressure in the vein that carries blood to the liver; this is called portal hypertension.
  • Swelling and bleeding of the veins in the oesophagus and/or stomach (oesophageal and/or gastric varices) due to the increased pressure from portal hypertension and the redirection of blood into these smaller veins
  • An increase in toxins in the blood, which can cause confusion and other mental changes (hepatic encephalopathy)
  • Ascites – a build-up of fluid in the abdomen (peritoneal cavity)
  • Kidney dysfunction (hepatorenal syndrome)
  • Decline in clotting factor production, which can cause easy bleeding and bruising

Individuals with cirrhosis are also at increased risk of developing liver cancer (hepatocellular carcinoma). This is estimated to occur in 3-5% of patients with cirrhosis each year, and multiple cancers can form over time.

 

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About Cirrhosis
  • Causes

    When injury to the liver is acute or liver damage is limited, the liver can usually repair itself. It is usually not short-term damage that causes cirrhosis, but repeated injury or damage occurring over many years that can lead to the development of cirrhosis. Causes are wide-ranging but generally fall into one of several categories:

    • Alcoholic—excessive alcohol use over time can lead to alcoholic liver disease and cirrhosis.
    • Associated with hepatitis, such as viral hepatitis, autoimmune hepatitis and non-alcoholic fatty liver disease (NAFLD)
    • Biliary—obstruction and/or damage to bile ducts
    • Cardiac—congestive heart failure over time can cause liver damage and cirrhosis
    • Metabolic or inherited—these include diseases such as cystic fibrosis, haemochromatosis, Wilson’s disease, alpha-1 antitrypsin deficiency and Fanconi syndrome
    • Drug-related (other than alcohol)
    • Unknown—in about 10% of cases of cirrhosis, the cause is not known.

    The frequency of these causes varies by population and geographic region. In the United States, about half of the cases of cirrhosis are caused by chronic hepatitis C infection and/or by chronic alcohol abuse (alcoholism). Chronic hepatitis B infection (sometimes with hepatitis D co-infection) causes a significant number of cases – and is one of the major causes in many parts of the world. Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are significant non-infectious causes of cirrhosis, and the frequency of this cause is increasing while cases due to most other causes are remaining the same or decreasing.

     

  • Symptoms

    Many of those who have cirrhosis have few to no symptoms. The liver compensates for some damage, and symptoms may not emerge until significant scarring is present. Symptoms may be nonspecific and include:

    • Fatigue
    • Weakness
    • Confusion and difficulty concentrating
    • Abdominal discomfort
    • Itching
    • Abdominal swelling (from fluid build-up, ascites)
    • Jaundice
    • Easy bleeding and bruising

     

  • Tests

    It is important to detect cirrhosis as soon as possible since significant liver damage may occur with few or no symptoms. If the cause of liver damage can be eliminated or controlled, further scarring will stop and some existing scars may actually resolve. While blood tests can detect liver injury, there is no single test that can be used to diagnose cirrhosis. A liver biopsy is considered the "gold standard" for diagnosing cirrhosis, but the procedure is invasive and will not detect every case.

    Routine laboratory tests may be done to detect liver damage and/or scarring and to evaluate its severity, particularly if the individual has some risk factor for developing cirrhosis. Additional tests may be performed to help diagnose the underlying cause and to monitor the affected individual's health over time. This can include monitoring for the possible development of hepatocellular carcinoma.

    Routine Tests

    • Liver injury may be first detected in those who do not have symptoms during general health screening using a metabolic screen.
    • Liver function tests (LFTs) may be performed when someone has symptoms that may be due to liver injury.

    These panels include several liver tests: Other routine testing may include:

    If any of these tests are abnormal, then they will be further investigated. Typically, the pattern of results is more significant than the result from one or a few of these tests. A doctor may repeat them over a few days or weeks to determine if a pattern is present and to help gain clues to the underlying cause.

    Other routine testing may include:

    • Full blood count (FBC) – may be requested to evaluate a person's red and white blood cells and platelets; anaemia may be present if bleeding has occurred and the number of platelets is often decreased in cirrhosis.
    • Prothrombin time (PT/INR) – most clotting factors are produced by the liver. This tests evaluates clotting function and results may be prolonged with cirrhosis.

    Many ot the tests listed above may be used to monitor the progression of cirrhosis. As the condition worsens, results may become increasingly abnormal.

    Follow-up Testing

    • Hepatitis B and hepatitis C testing may be requested to help diagnose the underlying cause of chronic liver disease.
    • If ascites is present, peritoneal fluid analysis may be performed.
    • Liver biopsy involves taking a sample of liver tissue to evaluate the structure and cells of the liver. It can clearly indicate the presence of cirrhosis, but since the sample is tiny, a negative result may not rule cirrhosis out.

    Depending on the suspected cause, one or more specialised tests may be performed:

    Some tests may be requested to monitor for the development of complications:

    • Alpha-fetoprotein (AFP) – often mildly elevated with cirrhosis; may be markedly elevated in liver cancer
    • Des-gamma-carboxy prothrombin (DCP) – may be elevated in liver cancer
    • Ammonia – occasionally requested – may be elevated in encephalopathy

    Sometimes Requested

    Calculations based upon panels of specific tests may be used to evaluate prognosis or likely cirrhosis:

    • Child-Turcotte-Pugh (CTP) scoring system for cirrhosis - may be used to help evaluate life expectancy in those with advanced cirrhosis
    • MELD (model of end-stage liver disease) - used to help determine those who are at a high risk of mortality, to consider for liver transplant
    • Several commercially developed calculations (algorithms) are available to help recognise the presence and severity of scarring in the liver.

    Non-Laboratory Tests

    Other procedures and imaging tests may be useful:

    • Ultrasound scan – sometimes requested to help diagnose non-alcoholic fatty liver disease (NAFLD)
    • Once diagnosed with cirrhosis, periodic ultrasound scans to monitor for development of hepatocellular carcinoma (liver cancer)
    • Magnetic or transient elastography – to evaluate degree of liver fibrosis by measuring liver stiffness

    For more on these, visit Radiologyinfo.org tests for the abdomen.

     

  • Prevention and Treatment

    Prevention

    Steps can be taken to avoid and/or minimise the risk of certain forms of liver disease, thus preventing cirrhosis from developing. Some examples include preventing:

    • Alcoholic liver disease – through alcohol moderation
    • Hepatitis C infection through blood precautions, such as not sharing needles or personal items such as razors
    • Hepatitis B infection through vaccination and taking precautions to avoid exposure
    • Some cases of non-alcoholic fatty liver disease (NAFLD) by maintaining a healthy weight

    Treatment

    In individuals diagnosed with cirrhosis, treatment involves:

    • Addressing and treating the underlying cause of the liver disease where possible
    • Maintaining remaining liver function
    • Treating complications

    Those affected should avoid alcohol and should avoid substances that can harm the liver. They may need to modify or supplement their diet to ensure adequate nutrition and work with their doctor on medication doses as their liver may not be able to process drugs at a normal rate.

    Endoscopy is sometimes needed to look for varices (dilated veins) and to address bleeding varices. In advanced cases of cirrhosis, a liver transplantation may be indicated.