Cirrhosis
Cirrhosis is a chronic, progressive scarring of the liver in which healthy liver tissue is gradually replaced by fibrous tissue and abnormal nodules of regenerating cells. It is the end stage of many forms of chronic liver disease, including fatty liver disease, alcohol-related liver disease, viral hepatitis, autoimmune liver disease, and metabolic and biliary conditions. Cirrhosis can range from compensated disease with few or no symptoms to decompensated disease with major complications such as ascites, variceal bleeding, hepatic encephalopathy, and liver cancer. Imaging—particularly ultrasound, CT, MRI, and elastography—plays a central role in diagnosis and monitoring.
What is it?
Cirrhosis is the end stage of many forms of chronic liver disease, in which long-standing injury and inflammation cause healthy liver tissue to be replaced by fibrous (scar) tissue and clusters of abnormally regenerating liver cells called nodules. As scarring progresses, the architecture of the liver becomes distorted, blood flow through the liver is disrupted, and many of its functions are gradually impaired. Cirrhosis is generally considered a chronic, progressive condition; however, in some causes (such as viral hepatitis or alcohol-related disease), treatment of the underlying condition can stabilize, partially reverse, or significantly slow disease progression—particularly when started before advanced complications develop.
Cirrhosis is often classified as compensated or decompensated. In compensated cirrhosis, the liver has scarring but is still able to perform its essential functions and the patient may have few or no symptoms. Decompensated cirrhosis is marked by the development of complications such as ascites (fluid accumulation in the abdomen), variceal bleeding (from enlarged veins in the esophagus or stomach), hepatic encephalopathy (brain dysfunction related to liver failure), and severe jaundice. Cirrhosis also significantly increases the risk of hepatocellular carcinoma, a primary liver cancer.
Many different conditions can lead to cirrhosis. Metabolic dysfunction–associated steatotic liver disease (MASLD) and steatohepatitis (MASH)—formerly called nonalcoholic fatty liver disease and steatohepatitis—are now among the most common causes worldwide, driven by obesity, diabetes, metabolic syndrome, and lipid abnormalities. Alcohol-related liver disease is another major cause and can develop with long-term heavy alcohol use, often interacting with metabolic factors. Chronic viral hepatitis (hepatitis B, C, and D) remains a leading cause globally, although effective antiviral therapy—particularly cures for hepatitis C—has changed the trajectory of disease for many patients. Autoimmune liver diseases include autoimmune hepatitis, primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC). Genetic and metabolic causes include hemochromatosis (iron overload), Wilson disease (copper accumulation), and alpha-1 antitrypsin deficiency. Other contributors include chronic biliary obstruction, cardiac causes (such as long-standing right-sided heart failure or constrictive pericarditis producing congestive hepatopathy), certain medications and toxins, vascular conditions (such as Budd-Chiari syndrome), and rare diseases.
Symptoms vary widely and depend on the underlying cause and stage of disease. Many patients with compensated cirrhosis feel well and are diagnosed because of abnormal blood tests, imaging findings, or routine evaluation. As disease progresses, fatigue, loss of appetite, weight loss, nausea, vague upper abdominal discomfort, and itching can develop. Decompensation may bring jaundice (yellow eyes and skin), dark urine, pale stools, easy bruising or bleeding, swelling of the legs and abdomen (ascites), confusion or sleep-pattern changes (hepatic encephalopathy), gastrointestinal bleeding from varices, and increased susceptibility to infections such as spontaneous bacterial peritonitis. Hormonal and metabolic changes may occur, including muscle wasting, sexual dysfunction, and effects on blood sugar.
Diagnosis combines clinical evaluation, blood tests, and imaging. Routine liver function tests (ALT, AST, alkaline phosphatase, GGT, bilirubin), markers of synthetic function (albumin, prothrombin time/INR), platelet count, and complete blood count are essential. Additional blood tests are tailored to the suspected cause (viral hepatitis testing, iron and copper studies, autoimmune antibodies, alpha-1 antitrypsin level, and more). Ultrasound of the abdomen is often the first imaging study and can show characteristic changes such as nodular liver contour, surface irregularity, alterations in liver size and shape, enlargement of the spleen, ascites, and signs of portal hypertension. CT and MRI provide detailed information and are particularly useful for evaluating focal lesions and detecting hepatocellular carcinoma. Elastography—using ultrasound (FibroScan) or MR elastography—measures liver stiffness as a marker of fibrosis. Upper endoscopy is used to screen for varices in patients with established or advanced cirrhosis. Liver biopsy is sometimes used to confirm the diagnosis, characterize the cause, or assess severity in selected cases.
Important to Know
Management of cirrhosis is individualized and combines treatment of the underlying cause, prevention and management of complications, supportive care, and—when appropriate—consideration of liver transplantation. Care is typically coordinated by hepatologists, gastroenterologists, primary care clinicians, dietitians, and other specialists as needed.
Treatment of the underlying cause is the cornerstone of management. For MASLD/MASH, weight loss, regular physical activity, a heart-healthy diet, control of diabetes and lipid abnormalities, treatment of obstructive sleep apnea, and limiting alcohol are foundational. In selected patients with steatohepatitis, newer disease-modifying medications are increasingly available. Bariatric surgery can be a powerful option in severe obesity. For alcohol-related liver disease, abstinence from alcohol is the single most important intervention, along with support for alcohol use disorder, nutritional support, and management of complications. Chronic viral hepatitis is treated with antiviral medications; hepatitis C is now curable in most patients with direct-acting antivirals, and hepatitis B is managed long-term with effective antivirals. Autoimmune liver diseases are treated with immunosuppressive or specific medications under specialized care. Hemochromatosis is treated with phlebotomy, Wilson disease with chelation, and other metabolic and biliary conditions with disease-specific therapies.
Management of complications includes nonselective beta-blockers and endoscopic banding to reduce variceal bleeding risk; diuretics, sodium restriction, paracentesis, and antibiotic prophylaxis for ascites and spontaneous bacterial peritonitis; lactulose, rifaximin, and other therapies for hepatic encephalopathy; and transjugular intrahepatic portosystemic shunt (TIPS) in selected patients with refractory variceal bleeding or ascites. Vaccinations against hepatitis A and B, influenza, pneumococcal infection, COVID-19, and other infections are important.
Surveillance for hepatocellular carcinoma—typically with periodic ultrasound, often combined with alpha-fetoprotein testing—is recommended in patients with cirrhosis and in other high-risk groups. Early detection significantly improves outcomes and the range of treatment options.
Liver transplantation is the ultimate treatment for advanced cirrhosis and offers the potential for long-term recovery and good quality of life in carefully selected patients. Evaluation for transplantation is performed in specialized centers and takes into account the severity of liver disease, overall health, presence of cancer, ability to abstain from alcohol when relevant, and many other factors.
Lifestyle measures support overall health and may slow progression: nutritional optimization, regular physical activity (individualized for each patient), abstinence from alcohol, weight management, careful use of medications (since many drugs are metabolized by the liver), and treatment of associated conditions such as diabetes, sleep apnea, and metabolic syndrome.
Patients with cirrhosis and their families benefit from clear education about the disease, complications to watch for, medication use, dietary considerations, and importance of follow-up.
Red flag symptoms include severe upper abdominal pain, persistent vomiting, vomiting blood or coffee-ground material, black or tarry stools, severe abdominal swelling with shortness of breath or fever, severe jaundice or pruritus, confusion, severe lethargy or difficulty arousing, signs of infection (such as fever or chills), severe leg swelling with shortness of breath, or signs of shock. These warrant prompt or urgent medical evaluation, as they may indicate life-threatening complications of cirrhosis.