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Cirrhosis of the Liver


Jesse M. Civan

, MD, Thomas Jefferson University Hospital

Last full review/revision Dec 2019| Content last modified Dec 2019

Cirrhosis is the widespread distortion of the liver's internal structure that occurs when a large amount of normal liver tissue is permanently replaced with nonfunctioning scar tissue. The scar tissue develops when the liver is damaged repeatedly or continuously.

  • Chronic abuse of alcohol, chronic viral hepatitis, and fatty liver not due to alcohol use are the most common causes of cirrhosis.
  • Symptoms, when they occur, include poor appetite, weight loss, fatigue, and a general feeling of illness.
  • Many serious complications, such as accumulation of fluid within the abdomen (ascites), bleeding in the digestive tract, and deterioration in brain function, can occur.
  • The diagnosis is based on symptoms and results of a physical examination, imaging studies, and sometimes a biopsy.
  • Doctors treat complications, but the damage due to cirrhosis is permanent.
  • People who have cirrhosis are at risk of liver cancer, so ultrasonography and, if needed, magnetic resonance imaging (MRI) or computed tomography (CT) are done regularly to check for cancer.

Cirrhosis is a common cause of death worldwide. In the United States, about 35,000 people die of complications of cirrhosis each year.

Various disorders, drugs, or toxins can repeatedly or continuously damage the liver. If damage is sudden (acute) and limited, the liver commonly repairs itself by making new liver cells and attaching them to the web of connective tissue (internal structure) that is left when liver cells die. Repair and full recovery can occur if people can survive long enough. However, with repeated damage, the liver's attempts to replace and repair damaged tissue lead to scarring (fibrosis of the liver). The scar tissue performs no function. When fibrosis is widespread and severe, the scar tissue forms bands throughout the liver, destroying the liver’s internal structure and impairing the liver’s ability to regenerate itself and to function. Such severe scarring is called cirrhosis.

Because liver function is impaired, the liver is less able to

  • Break down and remove drugs, toxins, and waste products made in the body
  • Process bile
  • Produce proteins that help blood clot (clotting factors)
  • Produce albumin (a protein that helps keep fluid from leaking out of blood vessels)

The liver processes many drugs, toxins, and body waste products. It breaks them down into substances that are less harmful and/or easier to remove from the body. The liver removes the substances by excreting them in bile, a brown or greenish yellow digestive fluid produced by cells in the liver. When the liver is less able to process these substances, they accumulate in the bloodstream. As a result, the effects of many drugs and toxins, including sometimes serious side effects, are increased. Such side effects may develop even when people are taking a dose that they previously took with no ill effects. Drugs may need to be stopped or used at lower doses and more cautiously. Some examples include opioids and some drugs used to treat anxiety or insomnia. Bilirubin is an important body waste product that the liver processes and removes. If the liver cannot process bilirubin quickly enough, it builds up in the blood and is deposited in the skin. The result is jaundice (a yellow coloring of the eyes and skin).

Within the liver, the bile moves into small channels (bile ducts) that join to form larger and larger ducts. These large ducts eventually leave the liver and connect to the gallbladder (which stores bile) or to the small intestine. Bile helps make fats easier to absorb in the intestine and carries toxins and waste products into the intestine so that they can be excreted in stool. When scar tissue blocks bile flow through the bile ducts, fats, including fat-soluble vitamins (A, D, E, and K), are not absorbed as well. In addition, fewer toxins and waste products are eliminated from the body.

Normally, a large part of bile (bile salts) is reabsorbed into the bloodstream from the intestine and circulated back to the liver. The liver extracts the bile salts and reuses them. However, in cirrhosis, the liver cannot extract bile salts normally. As a result, the liver cannot produce as much bile, further interfering with digestion and elimination of toxins and waste products.

In addition to interfering with liver function, scar tissue also can block blood flow into the liver from the portal vein (which carries blood from the intestine to the liver). The blockage results in high blood pressure in the portal vein (portal hypertension). Portal hypertension leads to high blood pressure in the veins connected to the portal vein, including veins in the stomach, esophagus, and rectum.

As scarring progresses, the liver shrinks.

Did You Know...

  • Cirrhosis can turn the skin and eyes yellow and cause fingertips to enlarge.

Causes of Cirrhosis

In the United States and other developed countries, the most common causes of cirrhosis are

One way that chronic alcohol abuse damages the liver is by causing fat to accumulate (fatty liver). Fatty liver that is not caused by alcohol (called nonalcoholic fatty liver) usually occurs in people who are overweight, have diabetes or pre-diabetes, and/or high cholesterol.

Any disorder, drug, or toxin that causes fibrosis (see table Some Conditions and Drugs That Can Cause Fibrosis of the Liver) can cause cirrhosis. Some specific causes include certain hereditary metabolic disorders, such as iron overload (hemochromatosis) and alpha-1 antitrypsin deficiency, and disorders that damage the bile ducts, such as primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC).

In many parts of Asia and Africa, cirrhosis often results from

Symptoms of Cirrhosis

Many people with cirrhosis have no symptoms and appear to be well for years. About one third never develop symptoms.

Others feel tired and generally unwell, lose their appetite, and lose weight:

  • Their fingertips may enlarge (called clubbing).
  • Jaundice can develop, making the skin and whites of the eyes look yellow and the urine look dark like cola.
  • When fats and fat-soluble vitamins are poorly absorbed, stools may be light-colored, soft, bulky, oily-looking, and unusually foul-smelling (called steatorrhea).

Many people are undernourished and lose weight because they have lost their appetite and because fats and vitamins are poorly absorbed. People may have a reddish purple rash of tiny dots or larger splotches, caused by bleeding from small blood vessels in the skin.

If the liver function has been impaired for a long time, people may itch all over, and small yellow bumps of fat can be deposited in the skin or eyelids.

Other symptoms may develop if cirrhosis is caused by chronic alcohol abuse or if people have a chronic liver disorder:

  • Muscles waste away (atrophy).
  • The palms become red (called palmar erythema).
  • The tendons of the hand shrink, causing the fingers to curl up (called Dupuytren contracture).
  • Small spiderlike blood vessels (spider angiomas) appear in the skin.
  • Salivary glands in the cheeks enlarge.
  • The nerves outside the brain and spinal cord (peripheral nerves) malfunction (called peripheral neuropathy).
  • Men may have enlarged breasts (gynecomastia) and shrunken testes (testicular atrophy) because the damaged liver cannot break down estrogens (female hormones) as it usually does. Hair in the armpits decreases.

Complications of cirrhosis

Advanced cirrhosis can cause additional problems.

Portal hypertension

Portal hypertension (high blood pressure in the portal vein) is the most serious complication. When it causes blood to back up in the veins connected to it, these veins may enlarge and twist (called varicose veins). Varicose veins may develop at the lower end of the esophagus (esophageal varices—see Portal Hypertension), in the stomach (gastric varices), or in the rectum (rectal varices). Varicose veins are fragile and prone to bleeding. People may vomit large amounts of blood if esophageal or gastric varices bleed (see Gastrointestinal Bleeding). If bleeding is slow and continues for a long time, it may cause anemia. If bleeding is rapid and more severe, it may result in shock and death.

Portopulmonary hypertension

Portal hypertension can cause high blood pressure in the arteries of the lungs (called portopulmonary hypertension). This problem can cause symptoms of heart failure, such as difficulty breathing, particularly when lying down, and fatigue.


Portal hypertension plus impaired liver function may lead to accumulation of fluid within the abdomen (ascites). As a result, the abdomen swells and may feel tight. Also, the fluid in the abdomen may become infected (called spontaneous bacterial peritonitis).

Poor absorption of fats and vitamins

Over time, poor absorption of fats, particularly fat-soluble vitamins, can lead to several problems. When vitamin D is poorly absorbed, osteoporosis can develop. When vitamin K (which helps blood clot) is poorly absorbed, people may bleed more easily.

Bleeding irregularities

Cirrhosis causes other problems that can interfere with how blood clots (disordered blood clotting). Some problems make people more likely to bleed. For example, the spleen may enlarge. The enlarged spleen may trap blood cells and platelets. Thus, fewer platelets (which help blood clot) are in the bloodstream. Also, the damaged liver is less able to produce the proteins that help blood clot (clotting factors).

However, some liver problems make blood more likely to clot. For example, the damaged liver is less able to produce the substances that prevent blood from clotting too much. Thus, blood clots may form in blood vessels (such as veins of the legs) and can travel to the lungs (a disorder called pulmonary embolism).

Increased risk of infection

The number of white blood cells may be reduced (called leukopenia) because the enlarged spleen traps them. When the number of white blood cells is low, the risk of infections increases.

Kidney failure

Liver failure can eventually lead to kidney failure—a condition called hepatorenal syndrome. In this syndrome, less urine is produced and excreted from the body, resulting in the buildup of toxic substances in the blood. Eventually, people with hepatorenal syndrome have difficulty breathing. This kidney problem can become severe enough to require dialysis.

Deterioration of brain function

Liver failure can also cause brain function to deteriorate (called hepatic encephalopathy) because the damaged liver can no longer remove toxic substances from the blood. These toxic substances then travel through the bloodstream and build up in the brain.

Liver cancer

Liver cancer (hepatocellular carcinoma, or hepatoma) can develop, particularly when cirrhosis is due to chronic hepatitis B or chronic hepatitis C, chronic alcohol abuse, hemochromatosis, alpha-1 antitrypsin deficiency, or glycogen storage diseases.

Complications of Cirrhosis


Possible Cause

Swelling of the abdomen

Ascites (accumulation of fluid within the abdomen)

Abdominal discomfort, often with fever

Spontaneous bacterial peritonitis (infection of fluid that has accumulated within the abdomen)

Calf pain or swelling

Deep vein thrombosis (blood clots in the veins of the legs)

Confusion and drowsiness

Hepatic encephalopathy (deterioration of brain function due to buildup of toxic substances normally removed by the liver)

Difficulty breathing

Hepatopulmonary syndrome (damage to the blood vessels in the lungs)

Portopulmonary hypertension (high blood pressure in the lungs' arteries due to high blood pressure in the portal vein, which carries blood from the intestine to the liver)

Pulmonary embolism (blockage of an artery in the lung, usually by a blood clot that has traveled from another location, such as the leg)

Ascites (enough fluid accumulation in the abdomen to limit the function of the diaphragm, making breathing more difficult)

Hepatic hydrothorax (fluid accumulation in the chest outside the lungs that prevents them from inflating fully)

Fatigue and pale skin

Liver cancer (can also cause weight loss)

Anemia due to any of the following:

  • Bleeding
  • An enlarged spleen
  • Undernutrition with a deficiency of folate, iron, or vitamin B12
  • Chronic alcohol abuse, which can interfere with the production of blood cells

Reduced urination and difficulty breathing

Hepatorenal syndrome (kidney failure due to liver failure)

Fractures, often due to a minor fall or slight trauma


Symptoms of infection

Leukopenia (reduced number of white blood cells)

Jaundice (yellowish discoloration of the skin and whites of the eyes)

Impaired processing of bilirubin (a waste product formed when old or damaged red blood cells are broken down)

Easy bruising or a tendency to bleed easily

A reddish purple rash of tiny dots or larger splotches, which indicate bleeding in the skin

An enlarged spleen, which traps platelets (needed to help blood clot)

Chronic alcohol abuse, which can interfere with the production of platelets

A deficiency of vitamin K

Reduced production of clotting factors (proteins that help blood clot) by the damaged liver

Itching (pruritis) and small yellow deposits of fat in the skin or eyelids

Impaired processing of bile

Rectal bleeding

Varicose veins in the rectum (rectal varices)

An enlarged spleen (splenomegaly)

Portal hypertension (high blood pressure in the vein that carries blood to the liver)

Light-colored, soft, bulky, oily-looking, and unusually foul-smelling stools (steatorrhea)

Impaired absorption of fats

Vomiting of blood

Varicose veins at the lower end of the esophagus (esophageal varices) or in the stomach (gastric varices) due to portal hypertension

Diagnosis of Cirrhosis

  • Blood tests, including liver tests
  • Sometimes imaging tests (for example, ultrasound)
  • Sometimes liver biopsy

Cirrhosis is usually strongly suspected based on symptoms, results of the physical examination, and a history of risk factors for cirrhosis such as chronic alcohol abuse. Often during the physical examination, a doctor notices problems that typically result from cirrhosis, such as an enlarged spleen, a swollen abdomen (indicating ascites), jaundice, or a rash indicating bleeding in the skin. Doctors typically then do tests to look for other disorders that can cause similar symptoms.

Laboratory tests

Blood tests to evaluate the liver are done. Results are often normal because these tests are relatively insensitive and the liver can function for a long time despite damage. The liver can carry out essential functions even when its function is reduced by 80%. A complete blood count (CBC) is done to check for anemia and other blood abnormalities. Blood tests are done to check for hepatitis and often other possible causes.

Liver imaging tests

Imaging tests can identify advanced cirrhosis but often does not identify early cirrhosis.

  • Ultrasonography or computed tomography (CT) can show whether the liver has shrunk or its structure is abnormal, suggesting cirrhosis.
  • Ultrasonography can detect portal hypertension and ascites.

Liver biopsy

If the diagnosis is still uncertain, a liver biopsy (removal of a tissue sample for examination under a microscope) is usually done to confirm it. Biopsy and sometimes blood tests can also help doctors determine the cause of cirrhosis.


If cirrhosis is confirmed, ultrasonography is done every 6 months to check for liver cancer. If ultrasonography detects abnormalities that suggest cancer, doctors do magnetic resonance imaging (MRI) or CT after injecting a substance that can be seen on MRI or x-rays (contrast agent).

When cirrhosis is confirmed, endoscopy of the upper digestive tract (inserting a flexible viewing tube) is done to check for varices. This test is repeated every two to three years. It is done more often if varices are detected.

Blood tests that assess the liver are done regularly.

Prognosis of Cirrhosis

Cirrhosis is permanent and usually progressive, but how quickly it will progress is often hard to predict. The outlook for people with cirrhosis depends on the cause, severity, presence of other symptoms and disorders, and effectiveness of treatment.

Stopping all consumption of alcohol prevents further scarring in the liver but cannot reverse damage already done. If people continue to drink alcohol—even small amounts—cirrhosis progresses, causing serious complications.

Once a major complication (such as vomiting of blood, accumulation of fluid within the abdomen, or deterioration in brain function) occurs, the outlook is grim.

Treatment of Cirrhosis

There is no cure for cirrhosis. The liver is damaged permanently and will never be normal again.

Treatment includes

  • Correcting or treating the cause, such as alcohol abuse, use of a drug, exposure to a toxin, hemochromatosis, or chronic hepatitis
  • Treating complications as they develop
  • Sometimes transplanting a liver

The best approach is to stop cirrhosis in its earliest stages by correcting or treating the cause. Treating the cause usually prevents any further damage and sometimes causes the person's condition to improve.

Treating causes

People are given the hepatitis A and B vaccines if they have not had them before.

To prevent cirrhosis from progressing, people should stop drinking alcohol completely, even if alcohol is not the main cause of their liver problem (see Alcohol : Treatment). Drinking even moderate amounts of alcohol can be very harmful to the liver once cirrhosis is present. Withdrawal symptoms, if they occur, are treated.

People must inform their doctor of all the drugs they are taking, including over-the-counter drugs, herbal products, and dietary supplements, because the damaged liver may not be able to process (metabolize) them. If people need to take drugs that are metabolized by the liver, much smaller doses are used to avoid further damage to the liver. Also, people may be taking a drug that can damage the liver and thus contribute to cirrhosis. Such drugs are stopped whenever possible, and another drug is substituted if needed.

For hemochromatosis, bloodletting is the best treatment.

Chronic hepatitis is treated with drugs, such as antiviral drugs or corticosteroids, and sometimes liver transplantation.

Treating complications

For complications, treatment includes

  • For accumulation of fluid within the abdomen (when cirrhosis is advanced): Restriction of sodium in the diet because excess sodium can contribute to fluid accumulation. Drugs can help eliminate excess fluid by increasing the amount of urine produced.
  • For vitamin deficiencies: Supplemental vitamins
  • For hepatic encephalopathy: Drugs to help bind toxins in the bowel (in the stool) and antibiotics to reduce the number of bacteria in the gastrointestinal tract that produce these toxins
  • For bleeding from the digestive tract varices: Beta-blockers to lower blood pressure in the liver's blood vessels and/or application of elastic bands to tie off the bleeding blood vessels (called endoscopic banding, or ligation)

To place the bands, doctors use a viewing tube (endoscope) inserted through the mouth. If beta-blockers or band ligation cannot be used or is unsuccessful, doctors may use one of the following procedures:

  • Endoscopic cyanoacrylate injection: Doctors pass an endoscope through the mouth and into the digestive tract. Working through the endoscope, they inject cyanoacrylate into the bleeding vein. The cyanoacrylate closes the blood vessel, and bleeding stops.
  • Balloon-occluded retrograde transvenous obliteration: After injecting a local anesthetic, doctors make a small incision in the skin over a large vein, typically in the neck or groin. Then they insert a thin, flexible tube (catheter) with a deflated balloon at its tip into the vein and thread the tube to the site of the bleeding. The balloon is inflated to block blood flow. Then a substance that causes scar tissue to form is injected in or near the vein to block it and stop the bleeding.
  • Transjugular intrahepatic portosystemic shunting (TIPS): Doctors insert a catheter into a vein in the neck and, using x-rays to guide them, thread the catheter to veins in the liver. The catheter is used to create a passage (shunt) that connects the portal vein (or one of its branches) directly with one of the hepatic veins, which carry blood from the liver to the body's largest vein, which returns blood to the heart. Thus, most of the blood that normally goes to the liver is rerouted to bypass the liver. This procedure lowers blood pressure in the portal vein because pressure is lower in the hepatic veins. By reducing this pressure, TIPS helps reduce bleeding from the veins in the digestive tract and accumulation of fluid within the abdomen.

Liver transplantation

For suitable candidates, liver transplantation may be done. If transplantation is successful, the transplanted liver typically functions normally, and the symptoms of cirrhosis and liver failure should disappear. Liver transplantation can be lifesaving for people with advanced cirrhosis or liver cancer. Liver transplantation is usually done based on how likely people are to die if they do not receive a liver transplant.

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