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Cirrhosis

  • Condition in which the liver is scarred due to liver disease
  • Symptoms include easy bleeding or bruising, fatigue, jaundice, itchy skin, swelling in abdomen or legs
  • Treatments include medications, lifestyle changes, and liver transplantation
  • Involves hepatology, digestive diseases, liver center program, transplant program

Overview

Cirrhosis is the condition that results when a chronic health problem affecting the liver has progressed to its final stage of scarring (fibrosis). If the condition advances unchecked, it can lead to liver failure. At that point, a liver transplant may be the only treatment option.  

Though cirrhosis is not uncommon—it is the 12th leading cause of death in the United States—about one-third of those with the condition are unaware of it. That’s because liver disease typically has no symptoms until it reaches advanced stages.  

Cirrhosis is more common in men than women, and also occurs more frequently after age 50.     

“There are many causes of chronic liver disease, and each one can lead to cirrhosis over time if not detected,” says Yale Medicine hepatologist David N. Assis, MD. “It is very important to identify the cause of the liver disease so that treatment can be started to prevent the development of cirrhosis—or prevent progression of cirrhosis if it is already present.”

What is cirrhosis?

Cirrhosis is a blanket term that’s used to refer to the final, advanced stage of a number of diseases affecting the liver that cause scarring and permanent damage. A liver that’s affected by cirrhosis is unable to function properly, which causes serious health problems.  

A healthy liver helps to break down and eliminate toxic substances in the body. The liver also creates bile, which is necessary for digestion. A damaged liver leads to liver inflammation and scarring. Over time, these interfere with blood flow to the liver, its bile output levels, and its effectiveness in eliminating waste. These challenges eventually result in advanced disease and liver failure. Cirrhosis is also a common cause of liver cancer (hepatocellular carcinoma).

What causes cirrhosis?

Because many different conditions may lead to cirrhosis, there are a variety of causes for the condition.  

The most common causes of cirrhosis are:

Other conditions that may lead to cirrhosis include:

  • Autoimmune diseases that affect the liver, including autoimmune hepatitis, primary biliary cholangitis, and primary sclerosing cholangitis
  • Inherited diseases that affect the liver, like hemochromatosis, Wilson disease, and alpha1-antitrypsin deficiency
  • Conditions that limit blood flow to and from the liver, including Budd-Chiari syndrome and heart failure affecting the right side of the heart
  •  Certain medications that may cause liver damage as a side effect

What are the symptoms of cirrhosis?

Most early signs of cirrhosis are silent, so many people may not realize that they have the condition until it’s more advanced.  

Symptoms of cirrhosis may include:

  • Fatigue and weakness
  • Loss of appetite, unexplained weight loss
  • Pain in the right upper quadrant of the abdomen, under the rib cage
  • Nausea and/or vomiting
  • Blood in the feces or vomit
  • Diarrhea
  • Loss of chest hair and/or breast enlargement in men
  • Atrophy or shrinking of the testicles
  • Irregular menstrual cycle or absence of menstruation
  • Bloating due to fluid collecting in the abdomen
  • Swelling of the ankles or lower legs
  • Muscle wasting
  • Sleep problems
  • Abnormally low blood pressure
  • Rapid heartbeat
  • Itchy skin
  • Jaundice, a yellowing of the skin and/or the whites of the eyes
  • Spider angiomas: Small red splotches on the skin that have thin, wiggly lines radiating outward from the center, which look like a spider’s legs or the webbing of a spider web
  • Redness on the palms of the hands

How is cirrhosis diagnosed?

Doctors diagnose cirrhosis after asking about a patient’s medical history, performing a physical exam and blood, imaging, and other diagnostic tests.    

When obtaining a health history, patients will be asked if they have diabetes, an autoimmune disease, HIV, hepatitis B or C or other diseases of the liver, including inherited conditions. They will also be asked for a list of medications they are taking. The doctor will also ask about  alcohol consumption, including how often and in what quantity a person drinks, and whether they’ve been diagnosed with alcohol use disorder.  

During a physical exam, doctors look for signs that may suggest cirrhosis, such as jaundice, red blotches on the palms of the hands or spider angiomas on the face, torso, or arms. If the patient has a distended abdomen filled with fluid or swollen ankles, the doctor will take note of those symptoms, which could suggest more advanced cirrhosis. 

There isn’t a single test that is used to diagnose cirrhosis, but when doctors suspect the condition after an exam, they may offer the following tests:

  • Blood tests, which can check for a number of possible causes of cirrhosis. They detect impaired liver function and can also confirm the presence or absence of hepatitis B or C or inherited conditions like hemochromatosis, Wilson’s disease, or alpha1-antitrypsin deficiency.
  • Imaging tests, such as ultrasound, CT scan or MRI, which can document scarring of liver tissue, a buildup of fat within the liver, or hypertension in the portal vein, which supplies blood to the liver, as well as other symptoms. Imaging is an important part of screening for liver cancer in patients with cirrhosis.
  • Transient elastography, a non-invasive test using ultrasound technology to determine liver tissue stiffness. Stiff liver tissue is an indication of the presence of scar tissue in the liver.
  • Liver biopsy, in which doctors remove a small piece of liver tissue to check for the presence of scar tissue. (This method is becoming less common as transient elastography becomes more widely used although it is still important when the underlying cause of the liver disease is not clear.)
  • Portal venous pressure testing, which measures blood pressure levels in the portal vein, which brings blood to the liver from the spleen, stomach and heart.  

How is cirrhosis treated?

There’s no direct treatment or cure for cirrhosis, but treating the diseases that cause it may help to stop its progression. In some cases, treatment of underlying health conditions may help to reverse the associated liver damage.  

  • When cirrhosis is caused by alcoholic liver disease, permanent abstinence and improved nutrition can halt further liver damage.
  • For people with hepatitis B or C, antiviral treatments may help to reverse some liver damage, which may stabilize symptoms.
  • For those whose cirrhosis is caused by non-alcoholic fatty liver disease, weight loss and bariatric surgery with the resulting weight loss may help to reverse some cirrhosis symptoms.
  • When a patient develops hypertension of the portal vein, a complication of cirrhosis, prescription beta blockers may help by reducing pressure levels. 

Doctors may also recommend lifestyle changes to people with cirrhosis, such as:

  • Abstaining from alcohol
  • Quitting smoking
  • Eating a healthy, balanced diet

Some people with advanced cirrhosis may be candidates for liver transplantation, although many factors about their health must be considered before moving forward.

What is the outlook for people with cirrhosis?

The prognosis for a person diagnosed with cirrhosis depends, in large part, on their overall health. Many live for more than a decade, if the condition is stable. Those with more advanced cirrhosis with serious complications, called decompensated cirrhosis, may only live for months or one to two years.  

Some people with advanced cirrhosis may benefit from liver transplantation.  

People with cirrhosis caused by alcohol use live longer and have a better quality of life if they are able to permanently abstain from alcohol.

What makes Yale Medicine unique in its treatment of cirrhosis?

Yale Medicine is home to one of the leading clinical and research centers in the U.S. in the care of patients with liver disease. The clinical faculty of Yale Digestive Diseases and Yale New Haven Health (YNHH) Digestive Health includes over 20 hepatologists with expertise in the care of patients with cirrhosis, and offers access to state-of-the-art clinical programs across all causes of liver disease, including fatty liver disease, autoimmune and cholestatic liver disorders, Wilson disease, viral hepatitis, and genetic and metabolic liver disorders, as well as the YNHH Liver Transplantation Program and Smilow Liver Cancer Program.   

Yale faculty are national and international leaders in hepatology and are authors of national society practice guidelines, which define the highest standards of care in the management of all forms of chronic liver disease, cirrhosis, and portal hypertension. Patients have unique access to novel therapies through clinical trials, and other patient-oriented research conducted within the Yale Liver Center, one of four NIH-sponsored liver research centers in the U.S.  

Patients hospitalized at YNHH with cirrhosis receive specialized care within a liver-disease specific hospital unit on the Klatskin Firm, which is staffed by medical and nursing professionals trained in the care of patients with end-stage liver disease. This unit represents the leading referral center for the care of complex patients with cirrhosis within Connecticut and the surrounding region.