Cirrhosis

Page last reviewed: 13/07/2011

Cirrhosis is scarring of the liver as a result of long-term, continuous damage to the liver.

It is a serious condition where healthy tissue in the liver is destroyed and replaced by scar tissue, which starts to block the flow of blood through your liver.

Cirrhosis progresses slowly, over many years, gradually causing your liver to stop functioning (see box). This is called liver failure.

The damage caused by cirrhosis is permanent, so cannot be reversed.

What are the signs?

In the early stages of cirrhosis, there are very few symptoms. But as your liver loses its ability to function properly, you typically start to experience loss of appetite, nausea and very itchy skin

In the later stages, symptoms can include jaundice, vomiting of blood, dark, tarry stools, and a build-up of fluid in the legs and abdomen.

How does it happen?

The two most common causes of cirrhosis in Ireland are drinking excessive amounts of alcohol and becoming infected with the hepatitis C virus.

Less common causes include hepatitis B infection, an inherited liver disease (such as haemochromatosis), and a condition called non-alcoholic steatohepatitis (NASH).

How common is it?

Every year, more than 3000 people in Ireland die from cirrhosis. The number of people with cirrhosis appears to be increasing.

Outlook

Many people with cirrhosis can feel quite well and live for many years without needing a liver transplant, because the liver is able to function even when it is damaged (called compensated cirrhosis).

Symptoms and later-stage complications can be managed with medication (for example, creams to relieve itching), water tablets and a low-salt diet to reduce excess fluid in your body, and surgery to treat swollen veins in your food pipe

However, when cirrhosis leads to liver failure, the only option is to have a liver transplant.

The liver

Your liver is your body’s "factory", carrying out hundreds of jobs that are vital for life, including:

  • storing glycogen (carbohydrate that produces short-term energy)
  • making bile, which helps to digest fats
  • making substances that clot the blood
  • processing and removing any alcohol, toxins and drugs

You only have one liver, but it is very tough. It keeps going when badly damaged and can continue repairing itself until it is severely damaged.

Page last reviewed: 13/07/2011

In the early stages of cirrhosis, there are very few symptoms.

But as healthy liver tissue is destroyed and scar tissue builds up, the liver loses its ability to function properly. At this stage, you may develop one or more of the following symptoms:

  • tiredness and weakness
  • loss of appetite
  • weight loss
  • feeling sick
  • very itchy skin
  • tenderness or pain around the liver
  • tiny red lines (blood capillaries) on the skin above waist level
  • blotchy red palms
  • problems sleeping

In the later stages, symptoms can include:

  • jaundice (see box, right)
  • hair loss
  • oedema (a build-up of fluid in the legs, ankles and feet)
  • ascites (a build-up of fluid in your abdomen that can make you look heavily pregnant)
  • dark urine
  • black, tarry stools (see box, left) or very pale-coloured stools
  • frequent nosebleeds and bleeding gums
  • a tendency to bruise easily
  • vomiting blood (see box, left)
  • muscle cramps
  • right shoulder pain
  • loss of sexual desire
  • dizziness and fatigue
  • breathlessness
  • rapid heartbeat
  • fever and shivering attacks (because you are more prone to infections)
  • memory loss and confusion
  • changes in your personality (due to toxins in the bloodstream affecting your brain)
  • staggering when walking
  • increased sensitivity to alcohol and drugs (because the liver cannot process them)
  • more weight loss from the body and upper arms

Black stools and vomiting blood

In later-stage cirrhosis, you may vomit blood or have tarry, black stools. This is because:

  • Blood cannot flow through the liver properly.
  • This causes high blood pressure in the portal vein, which carries blood from the gut to the liver.
  • Blood is then forced through smaller, fragile vessels lining the stomach and gullet, called varices.
  • Varices burst under the high blood pressure, leading to internal bleeding.
  • This blood may be seen in the vomit and/or stools.

Jaundice

Jaundice is the yellowing of the skin and the whites of the eyes.

It results from either:

  • a blockage in the bile duct (the tube that transfers bile from the liver to the gallbladder)
  • damage to the liver so it cannot process a yellow substance in your blood called bilirubin (a by-product of red blood cells)

Page last reviewed: 13/07/2011

There are many different causes of cirrhosis, but excessive alcohol consumption and hepatitis C infection are the most common causes in Ireland.

Alcohol-related cirrhosis

Men who drink more than 21 standard drinks a week (14 for women) are in the category of excessive alcohol consumption.

The liver breaks down toxins and poisons, such as alcohol, but too much alcohol can damage the cells of the liver.

If you are a heavy drinker, your chances of developing cirrhosis are increased. However, cirrhosis of the liver is not just a condition that affects people who are dependent on alcohol (alcoholics). If you are a heavy social drinker, you can also develop cirrhosis.

Alcohol-related cirrhosis usually develops after 10 or more years of heavy drinking. Some people are more susceptible to liver cell damage than others, although the reasons for this are unknown.

Women who drink heavily are more susceptible to liver damage than men, partly because of their different body size and build.

Almost all excessive drinkers will develop the first stage of alcoholic liver disease, known as "fatty liver" (see below). This is a side effect of the liver breaking alcohol down into carbon dioxide and water. It disappears when you drink less.

For people who continue drinking heavily, 20%-30% will develop the next stage of alcoholic liver disease: alcoholic hepatitis. At this stage, the liver becomes inflamed. If it continues deteriorating into its most extreme form, liver failure, it can lead to death.

Around 10% of heavy drinkers then develop cirrhosis, which is the third stage of alcoholic liver disease.

This risk of cirrhosis, along with the risk of alcoholic hepatitis, is one of the main reasons the government recommends that men should not regularly drink more than 21 standard drinks a week and women should not drink more than 14.

Hepatitis-related cirrhosis

Hepatitis C is an infection carried in the blood that can cause damage to the liver, which, over time, may develop into cirrhosis. It is caused by the hepatitis C virus and is one of the most common causes of cirrhosis iIreland.

The two other forms of the infection, hepatitis B and D, can also cause cirrhosis.

Non-alcoholic steatohepatitis

Non-alcoholic steatohepatitis (NASH) is a severe liver condition that can lead to cirrhosis. As with alcoholic liver disease, the early stage of NASH is the build-up of excess fat in the liver. This fat is associated with inflammation and scarring, which could lead to cirrhosis.

NASH can occur in people with obesity, diabetes, high levels of fat in the blood and high blood pressure. Most people with NASH feel well and are not aware they have a problem.

Other causes

A number of other conditions and inherited diseases that prevent healthy liver function can also lead to cirrhosis. For example:

  • Autoimmune hepatitis - normally, the immune system makes antibodies to attack bacteria and viruses. However, if you have an autoimmune disease, such as autoimmune hepatitis, your immune system will make antibodies that attack healthy organs of the body, such as the liver.
  • Some rare, genetic conditions such as haemochromatosis (a build-up of iron in the liver and other parts of the body) and Wilson's disease (a build-up of copper in the liver and other parts of the body).
  • Any condition that causes the bile ducts to become blocked, such as cancer of the bile ducts or cancer of the pancreas.
  • Budd-Chiari syndrome, which is caused by blood clots blocking the veins carrying blood from the liver.

The use of certain drugs and exposure to certain environmental poisons and toxins can also cause cirrhosis.

Page last reviewed: 13/07/2011

In the early stages of cirrhosis, there are very few symptoms and it is often picked up during tests for an unrelated illness.

See your GP as soon as possible if you are experiencing any of the following symptoms:

  • fever and shivering
  • shortness of breath
  • vomiting blood
  • very dark or black, tarry stools (faeces)
  • periods of confusion or drowsiness

If your GP suspects that you have cirrhosis, they will take your medical history and carry out a physical examination to see whether your liver feels enlarged or harder than normal.

Your GP will then refer you for a number of tests.

Tests

You may have any of the following tests:

  • A blood test. This is done to measure your liver function and damage. The test will measure, for example, levels of the liver enzymes alanine transaminase (ALT) and aspartate aminotransferase (AST) in your blood (these will be raised if you have hepatitis).
  • Imaging tests. An ultrasound, computerised tomography (CT) or magnetic resonance imaging (MRI) scan may be done of your liver. These scans can provide detailed images of your liver and show up any scarring.
  • Liver biopsy. A fine needle is inserted into your body (usually between your ribs) and a small sample of liver cells is taken and sent to a laboratory to be examined under a microscope. The biopsy is usually done under local anaesthetic, as a day case or with an overnight stay in hospital. The outcome of the biopsy will confirm a diagnosis of cirrhosis and may provide more information about the cause.
  • Endoscopy. A thin, long, flexible tube that contains a light source and a video camera (called an endoscope) is passed down your oesophagus (food pipe) and into your stomach. This relays images of your oesophagus and stomach to an external screen. The doctor will be looking for varices (swollen vessels), which are a sign of cirrhosis. 

Grading

There are systems for grading cirrhosis acording to how serious it is. One system is the Child-Pugh score, which grades cirrhosis from A (relatively mild) to C (severe) based on your examination and laboratory tests.

Page last reviewed: 13/07/2011

The way cirrhosis is treated depends on the underlying cause. Cirrhosis cannot be cured, but treatment aims to:

  • stop the cirrhosis getting worse
  • manage symptoms and complications of cirrhosis

It is usually not possible to reverse any liver damage that has already occurred.

Stop the cirrhosis getting worse

Ways to stop the cirrhosis from worsening include:

  • Taking medication to treat an underlying disease that has caused liver damage. For example, if you have viral hepatitis you may be prescribed interferon, and if you have autoimmune hepatitis you may be given steroid-based drugs.
  • Making lifestyle changes. You may be advised to cut down on your alcohol intake or to lose weight if you are overweight or obese.

Ease symptoms

A number of treatments can help to ease the symptoms of cirrhosis, including:

  • a low-sodium (salt) diet or water tablets will help reduce the amount of fluid in your body
  • tablets will help to reduce high blood pressure in your portal vein (main vein from the liver) and prevent or treat any infection
  • creams will reduce itching

Manage end-stage complications

With advanced cirrhosis, you can only treat the end-stage complications. You cannot treat jaundice (yellowing of the skin and the whites of the eyes) because it is just a reflection of the fact that your liver is not working properly.

Treating swollen varices

If you vomit blood or pass blood in your faeces, you probably have swollen veins in your oesophagus (food pipe), called oesophageal varices . You will need urgent medical attention, which means seeing your GP or going to A&E immediately.

Certain procedures can help stop the bleeding and reduce the risk of it happening again. Any of the following techniques may be used to correct the cause of your bleeding:

  • Banding. You have an endoscopy (a thin, flexible tube is passed down your throat and oesophagus) and a small band is placed around the base of the varices to control the bleeding.
  • Injection sclerotherapy. Following an endoscopy, a substance is injected into the varices to cause the blood to clot and scar tissue to form, which helps stop bleeding.
  • A Sengstaken tube with a balloon on the end is another option if bleeding cannot be stopped by endoscopy. This tube is passed down your throat into your stomach. The balloon is inflated, putting pressure on the varices, which stops bleeding. You will be heavily sedated.
  • A transjugular intrahepatic portosystemic stent shunt (TIPSS). This is used if bleeding cannot be controlled by the above methods. A metal tube (stent) is passed across your liver to join two large veins (the portal vein and hepatic vein). This creates a new route for your blood to flow through, relieving the pressure causing the varices.

Treating fluid in the abdomen and legs

Ascites (a build-up of fluid around your stomach area) and peripheral oedema (fluid around your legs and ankles) are very common complications of advanced cirrhosis that will need to be addressed as soon as possible.

You may have 20 to 30 litres of free water in your abdomen (stomach area), which can make it hard for you to eat and breathe properly, and the fluid may become infected.

The main treatments are restricting sodium (salt) in your diet and taking diuretic tablets, such as spironolactone or furosemide.

If the ascites is severe, tubes may be put into your body to drain off the fluid in your abdomen, and this is usually repeated every few weeks. TIPSS can also be used to treat ascites (see above).

Treating encephalopathy

People with cirrhosis can find that problems develop with their brain function (encephalopathy) because the liver is not clearing toxins properly. This can affect your brain and impair its function, causing confusion and drowsiness and, at a later stage, a coma.

Early-stage treatment involves antibiotics and clearing the bowel out with laxatives.

Treating bleeding

Cirrhosis can affect the liver's ability to make the blood clot, leaving you at risk of severe bleeding if you cut yourself. Vitamin K and plasma can be given in medical emergencies to treat episodes of bleeding, and you will need to apply pressure to any cuts that bleed.

Liver transplant

If your liver is extremely damaged by scarring, it may stop functioning. In this situation, a liver transplant is the only option. Your diseased liver is removed and replaced with a healthy donor liver

Where will I be treated?

People with cirrhosis are usually treated at a hospital with a specialist hepatology unit (which treats disorders of the liver, gall bladder and biliary ducts).

If the cirrhosis is due to excessive alcohol intake, there are a range of services available to help you reduce your drinking, or stop completely.

Page last reviewed: 13/07/2011

Stick to recommended alcohol limits

Heavy alcohol consumption is one of the most common causes of cirrhosis of the liver. Therefore, the best way to prevent alcohol-related cirrhosis developing is to stick to the recommended limits. These are:

  • men: up to 21 standard drinks a week
  • women: up to 14 standard drinks a week

If you are a heavy drinker, you need to cut down because the more alcohol that you consume above the recommended amounts, the greater the risk that you will develop cirrhosis.

If you have cirrhosis, stop drinking alcohol immediately because it speeds up the rate at which the condition progresses, regardless of the cause.

Protect yourself from hepatitis

Cirrhosis can be caused by infectious diseases, such as hepatitis B and C. Hepatitis B and C can be caught through unprotected sex (without using a condom) or by sharing needles to inject drugs.

Use a condom when having sex to avoid the risk of hepatitis, and avoid injecting drugs.

People who are at risk of getting hepatitis B, such as doctors, nurses, police officers and social care workers, can be protected by being vaccinated against the condition. In fact, anyone can be vaccinated against hepatitis B and it is part of the national mimmunisation programme for children.

There is currently no vaccine for hepatitis C.

Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.

Browse Health A-Z