What is cirrhosis?
Cirrhosis (say "suh-ROH-sus") is a very serious condition in which scarring damages the liver. The liver is a large organ that is part of the digestive system. It does a wide range of complex jobs that are vital for life. For example, the liver:
- Makes many important substances, including bile to help digest food and clotting factors to help stop bleeding.
- Filters poisons from the blood.
- Breaks down (metabolizes) alcohol and many drugs.
- Controls the amounts of sugar, protein, and fat in the bloodstream.
- Stores important vitamins and minerals, including iron.
When a person has cirrhosis, scar tissue (fibrosis) replaces healthy tissue. This scar tissue prevents the liver from working as it should. For example, the liver may stop producing enough clotting factors, which can lead to bleeding and bruising. Bile and poisons may build up in the blood. Scarring can also cause high blood pressure in the vein that carries blood from the intestines through the liver (portal hypertension). This can lead to severe bleeding in the digestive tract and other serious problems.
Cirrhosis can be deadly. But early treatment can help stop damage to the liver.
What causes cirrhosis?
Cirrhosis can have many causes. Some of the main ones include:
- Long-term, heavy use of alcohol.
- Chronic viral hepatitis.
- Autoimmune diseases, such as autoimmune hepatitis or primary sclerosing cholangitis (PSC).
- Non-alcoholic steatohepatitis (NASH).
- Blocked bile ducts. A disease called primary biliary cirrhosis develops when the ducts that carry bile out of the liver become inflamed and blocked.
- Inherited diseases, such as Wilson's disease, cystic fibrosis, or hemochromatosis.
Less common causes of cirrhosis include severe reactions to medicines or long-term exposure to poisons, such as arsenic. Some people have cirrhosis without an obvious cause.
What are the symptoms?
You may not have symptoms in the early stages of cirrhosis. As it gets worse, it can cause a number of symptoms, including:
- Small red spots and tiny lines on the skin called spider angiomas.
- Bruising easily.
- Heavy nosebleeds.
- Weight loss.
- Yellowing of the skin (jaundice).
- Swelling from fluid buildup in the legs (edema) and the abdomen (ascites).
- Bleeding from enlarged veins in the digestive tract.
How is cirrhosis diagnosed?
The doctor will start with a physical examination and questions about your symptoms and past health. If the doctor suspects cirrhosis, you may have blood tests and imaging tests, such as an ultrasound or CT scan. These tests can help your doctor find out what is causing the liver damage and how severe it is.
To confirm that you have cirrhosis, the doctor may do a liver biopsy. This means that he or she will use a needle to take a sample of liver tissue for testing.
How is it treated?
Treatment may include medicines, surgery, or other options, depending on the cause of your cirrhosis and what problems it is causing. It is important to get treated for cirrhosis as soon as possible. Treatment cannot cure cirrhosis. But it can sometimes prevent or delay further liver damage.
There are things you can do to help limit the damage to your liver and control the symptoms:
- Do not drink any alcohol. If you don't stop completely, liver damage may quickly get worse.
- Talk to your doctor before you take any medicines. This includes both prescription and over-the-counter drugs, vitamins, supplements, and herbs. Medicines that can hurt your liver include acetaminophen (such as Tylenol) and other pain medicines such as aspirin, ibuprofen (such as Advil or Motrin), and naproxen (Aleve).
- Make sure that your immunizations are up-to-date. You are at higher risk for infections.
- Follow a low-sodium diet. This can help prevent fluid buildup, a common problem in cirrhosis that can become life-threatening.
Symptoms may not appear until a problem is severe. So it's important to see your doctor for regular checkups and lab tests. You may also need testing to check for possible problems such as enlarged veins in your digestive tract or liver cancer.
If cirrhosis becomes life-threatening, then a liver transplant may be an option. But a organs are hard to find, and it doesn't always work. And the cost of travel and the medicines needed after a transplant can be expensive.
Hospice palliative care is a kind of care for people who have serious illnesses. It's different from care to cure your illness. Its goal is to improve your quality of life—not just in your body but also in your mind and spirit.
If your cirrhosis is getting worse, you may choose to get care that focuses on your comfort and dignity. You may also want to make important end-of-life decisions, such as writing an advance care plan. It can be comforting to know that you will get the type of care you want.
It can be hard to face having cirrhosis. If you feel very sad or hopeless, be sure to tell your doctor. You may be able to get counselling or other types of help. Think about joining a support group. Talking with other people who have cirrhosis can be a big help.
Health Tools help you make wise health decisions or take action to improve your health.
People who have cirrhosis sometimes don't have symptoms until liver damage is extensive. Symptoms of cirrhosis and its complications may include:
- Yellowing of the skin (jaundice).
- Swelling from fluid buildup in the legs (edema).
- Bruising easily and having heavy nosebleeds.
- Redness of the palms.
- Small red spots and tiny lines on the skin called spider angiomas.
- Weight loss and muscle wasting.
- Belly pain or discomfort.
- Frequent infections.
Complications of cirrhosis
Scar tissue from cirrhosis may block the proper flow of blood from the intestines through the liver. The scarring can lead to increased pressure in the veins that supply this area. This is called portal hypertension. It can lead to other complications, which may include:
- Fluid buildup in the belly (ascites).
- Bleeding from enlarged veins (varices) in the digestive tract. This is called variceal bleeding.
- Increased spleen size. This can lead to a low blood platelet count.
- Infection of the fluid in the belly (spontaneous bacterial peritonitis, or SBP).
- Altered brain function (encephalopathy). This usually only occurs in people who have advanced portal hypertension.
- Hepatorenal syndrome. Kidney (renal) failure can occur in cases of advanced liver disease.
- Hepatopulmonary syndrome. Portal hypertension can cause lung problems, such as widening of the blood vessels in the lungs. This causes the blood to move too swiftly through the lungs to pick up enough oxygen.
- Hepatic hydrothorax. Fluid can build up between the lungs and the chest (pleural effusion) and press on the lungs.
People who have cirrhosis also are at increased risk of getting liver cancer, mainly hepatocellular carcinoma.
Examinations and Tests
Your doctor will do a physical examination and ask about your medical history to see if you have symptoms of liver disease and to help find out possible causes of liver damage.
If your doctor thinks you may have cirrhosis, you may have blood and imaging tests. You also may have a liver biopsy. This test can show for sure if you have cirrhosis.
Blood tests to check liver function
Measuring the levels of certain chemicals produced by the liver can show how well your liver is working. Blood tests may be used to measure:
- Albumin and total serum protein. Albumin is a type of protein. Liver disease can cause a decrease in protein levels in the blood.
- Partial thromboplastin time or prothrombin time/INR. These tests measure blood-clotting factors that are produced in the liver.
- Bilirubin. This is produced when the liver breaks down hemoglobin, the oxygen-carrying substance in red blood cells. Cirrhosis may cause high bilirubin levels, which causes jaundice.
Blood tests to check for inflammation of the liver
You may have blood tests to check your liver enzymes. These can help show whether you have had liver inflammation for a long time. These blood tests include:
- Aspartate aminotransferase (AST), alanine aminotransferase (ALT), and lactate dehydrogenase (LDH). An increased level of these enzymes may mean injury to the liver and the death of liver cells.
- Alkaline phosphatase (ALP). An increased ALP level may mean blockage of bile ducts.
- Gamma-glutamyl transpeptidase (GGT). An increased level can happen because of alcohol use or diseases of the bile ducts.
Some people with cirrhosis have normal liver enzymes.
Blood tests to diagnose a cause of cirrhosis
Tests to check for conditions that may cause cirrhosis include:
- Antinuclear antibodies (ANA). ANA testing and anti-smooth-muscle antibody (ASMA) testing may help find autoimmune chronic hepatitis.
- Antimitochondrial antibody test (AMA), which may help find primary biliary cirrhosis.
- Ferritin and iron tests. These may help diagnose iron overload, or hemochromatosis.
- Tests for hepatitis B and hepatitis C or tests for infection with hepatitis viruses. These tests may help diagnose infection with certain hepatitis viruses.
- Blood alcohol level (BAL) tests. These tests may show alcohol use, which can cause alcoholic cirrhosis.
- Serum ceruloplasmin testing, which may help diagnose Wilson's disease.
- Alpha1-antitrypsin level. This may diagnose a condition in which people lack this protein (alpha1-antitrypsin deficiency).
Tests that show an image of the liver
Imaging tests can check for tumours and blocked bile ducts. They also can be used to look at liver size and blood flow through the liver. These tests include:
- Abdominal ultrasound.
- CT scan of the abdomen (including the liver, gallbladder, and spleen).
- MRI scan of the abdomen.
- Liver and spleen scan (rarely done).
Other tests also may be done to confirm cirrhosis or to look for possible complications. These include:
- Liver biopsy. This is the only test that can confirm cirrhosis. Looking at liver tissue also may reveal signs of inflammation.
- Paracentesis. This test can help diagnose the cause of fluid buildup in the belly or to look for infection in the fluid (spontaneous bacterial peritonitis).
- Endoscopy. It looks for enlarged veins (varices) and bleeding (variceal bleeding) in the digestive tract.
- Endoscopic retrograde cholangiopancreatogram (ERCP), to look inside the tubes (bile ducts) that drain the liver, pancreas, and gallbladder. ERCP may be done if your doctor thinks that a condition called primary sclerosing cholangitis (PSC) might be leading to your liver problems.
- Alpha-fetoprotein (AFP) testing, to screen for cancer of the liver. This is a blood test.
- Ammonia testing. This test looks for excess ammonia in the blood, which can cause altered brain function (encephalopathy).
No treatment will cure cirrhosis or repair scarring in the liver that has already occurred. But treatment can sometimes prevent or delay further liver damage. Treatment involves lifestyle changes, medicines, and regular doctor visits. In some cases, you may need surgery for treatment of complications from cirrhosis.
Your doctor will recommend some lifestyle changes to help prevent further liver damage.
- Stop drinking alcohol. You need to quit completely.
- Talk to your doctor about all of the medicines you take, including non-prescription drugs such as acetaminophen (for example, Tylenol), aspirin, ibuprofen (for example, Advil or Motrin), and naproxen (Aleve). These could increase the risk of liver damage and bleeding.
- Get immunized (if you have not already) against hepatitis A and hepatitis B, influenza, and pneumococcus.
- Begin following a low-sodium diet if you have fluid buildup (ascites). Reducing your sodium intake can help prevent fluid buildup in your belly and chest.
Treatment for complications of cirrhosis
Cirrhosis can cause other problems (complications) that need treatment with medicines or procedures. Complications include:
Fluid buildup in the belly (ascites). It can be deadly if it is not controlled. Treatment can include:
- Following a low-sodium diet.
- Medicines such as diuretics and antibiotics.
- Removing fluid with a needle (paracentesis).
- Transjugular intrahepatic portosystemic shunt (TIPS). This procedure diverts fluid from the belly.
Bleeding from enlarged veins.
Variceal bleeding in the digestive tract can be treated with:
- Beta-blocker and vasoconstrictor medicines.
- Shunts to move blood or other fluid away from the belly.
- Endoscopic variceal banding or sclerotherapy to stop bleeding.
- Balloon tamponade. A doctor inserts and inflates a balloon in the lower part of the esophagus or upper part of the stomach. This stops bleeding by pressing against the veins.
Changes in mental function.
Encephalopathy may occur when the liver cannot filter poisons from the bloodstream. As these toxins build up in your blood, they can affect your brain function. You may need to:
- Eat a limited amount of protein. Too much protein can cause toxins to build up.
- Take lactulose or antibiotics. These medicines help prevent the buildup of ammonia and other toxins in the large intestine.
- Avoid sedative medicines, such as sleeping pills, antianxiety medicines, and opioids. These can make symptoms of encephalopathy worse.
It's important to work with your doctor to watch your condition, especially because symptoms may not start until a problem has become severe. In addition to regular checkups and lab tests, you will also need periodic screening for enlarged veins (varices) and liver cancer (hepatocellular carcinoma).
- The American College of Gastroenterology recommends testing for varices with endoscopy for all people who have been diagnosed with cirrhosis. This recommendation is also followed in Canada. If your initial test does not find any varices, you can be tested again in 2 to 3 years. If you already have large varices, you may need more frequent testing and treatment with beta-blocker medicines to try to prevent future bleeding episodes.footnote 1
- Testing to check for liver cancer usually takes place every 6 months. You will likely have a test for alpha-fetoprotein and a liver ultrasound or a magnetic resonance imaging test (MRI).
Receiving a liver from an organ donor (liver transplant) is the only treatment that will restore normal liver function and cure portal hypertension. A liver transplant is usually considered only when liver damage is severe and threatening your life.
Before your condition becomes severe, you may want to talk to your doctor about whether you will be a good candidate for a liver transplant if your disease becomes advanced.
Liver transplant surgery is very expensive. You may have to wait a long time for a transplant, because so few organs are available. Even if a transplant occurs, it may not work. With these things in mind, doctors must decide who will benefit most from receiving a liver. Good candidates include those who have not abused alcohol or illegal drugs for the previous 6 months and those who have a good support system of family and friends.
Talk to your doctor about what steps you can take now to improve your overall health so that you can increase your chances of being considered a good candidate.
Hospice palliative care
If your cirrhosis gets worse, you may want to think about hospice palliative care. This is a kind of care for people who have illnesses that do not go away and often get worse over time. It's different from care to cure your illness. Its goal is to improve your quality of life—not just in your body but also in your mind and spirit. You can have this care along with treatment to cure your illness.
Hospice palliative care providers will work to help manage pain and other symptoms or side effects. They may help you decide what treatment you want or don't want. And they can help your loved ones understand how to support you.
If you're interested in hospice palliative care, talk to your doctor.
If you have not already made decisions about the issues that may arise at the end of life, consider doing so now. Many people find it helpful and comforting to state their health care choices in writing (with an advance directive such as a living will) while they are still able to make and communicate these decisions. You may also think about who you would choose as your health care agent to make and carry out decisions about your care if you were unable to speak for yourself.
A time may come when your goals change from treating or curing an illness to maintaining comfort and dignity. Hospice palliative care health professionals can provide hospice palliative care and comforting surroundings for someone who is preparing to die.
Lifestyle changes may reduce symptoms caused by complications of the disease and may slow new liver damage.
Giving up alcohol
If you are diagnosed with cirrhosis, it is extremely important that you stop drinking alcohol completely, even if alcohol was not the cause of your cirrhosis. If you don't stop, liver damage may quickly become worse. For information about how to quit drinking, see Alcohol: Drinking and Your Health.
Changing your diet
You may need to limit the amount of salt or protein you eat.
If your body is retaining fluid, the most important dietary change you need to make is to reduce your sodium intake. You do this by reducing the amount of salt in your diet. People with liver damage tend to retain sodium. This can make fluid build up in your belly (ascites).
- Healthy Eating: Eating Less Sodium
- Low-Salt Diets: Eating Out
If you are at risk for altered mental function (encephalopathy) because of advanced liver disease, your doctor may want you to limit the amount of protein you eat for a while. You will still need protein in your diet to be well nourished. But you may need to get most of your protein from vegetable sources (rather than animal sources). And you may need to avoid eating large amounts of protein at one time.
Avoiding harmful medicines
Some medicines should be used carefully or not taken by people who have cirrhosis. For example, acetaminophen (such as Tylenol) can speed up liver damage. Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs)—for example, ibuprofen (such as Motrin or Advil) and naproxen (Aleve)—increase the risk of variceal bleeding if you have enlarged veins (varices) in the digestive tract. NSAIDs can also raise your risk for ascites. Talk to your doctor or pharmacist about what medicines are safe for you.
Certain prescription medicines used to treat other conditions may be harmful if you have cirrhosis. Make sure your doctor knows all the medicines (including all non-prescription medicines, vitamins, herbs, and supplements) that you are taking.
Improving your general health
Taking other steps to improve your overall health may help you cope with the symptoms of cirrhosis.
- Stop smoking. Quitting tobacco use will improve your overall health, which may help make you a better candidate for a liver transplant if you need one.
- Your doctor may encourage you to take a multivitamin. Don't take one containing extra iron unless your doctor tells you to. And don't take an iron supplement unless your doctor recommends it.
- Brush and floss your teeth daily to avoid dental problems that could lead to infection (abscess). Be gentle when you floss so you don't make your gums bleed.
- Make sure you have been vaccinated against:
Using complementary and alternative medicines wisely
In general, you should avoid most herbal and other supplements, which may make liver disease worse. Kava is particularly bad for people who have liver problems.
Limited research has shown that the herbal supplement milk thistle may help protect the liver, but other research has not shown a benefit.footnote 2 Milk thistle will not reverse existing liver damage, and it will not cure infection with the hepatitis B or hepatitis C virus. Milk thistle should not be used by people who have complications from cirrhosis (such as variceal bleeding or ascites). Talk to your doctor about whether you should try milk thistle (or any other alternative treatment).
- Garcia-Tsao G, et al. (2007). Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. American Journal of Gastroenterology, 102(9): 2086–2102.
- Milk thistle (2005). Review of Natural Products. St. Louis: Wolters Kluwer Health.
Other Works Consulted
- Angulo P, Lindor KD (2010). Primary biliary cirrhosis. In M Feldman et al., eds., Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 9th ed., vol. 2, pp. 1477–1488. Philadelphia: Saunders.
- Bacon BR (2015). Cirrhosis and its complications. In DL Kasper et al., eds., Harrison's Principles of Internal Medicine, 19th ed., vol. 2, pp. 2058–2067. New York: McGraw-Hill Education.
- Carithers RL, McClain CJ (2010). Alcoholic liver disease. In M Feldman et al., eds., Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 9th ed., vol. 2, pp. 1383–1400. Philadelphia: Saunders.
Primary Medical Reviewer Adam Husney, MD - Family Medicine
Brian O'Brien, MD, FRCPC - Internal Medicine
E. Gregory Thompson, MD - Internal Medicine
Kathleen Romito, MD - Family Medicine
W. Thomas London, MD - Internal Medicine, Hepatology
Current as ofMarch 28, 2018
Current as of: March 28, 2018