Cirrhosis

Cirrhosis is scarring of the liver, caused by continuous, long-term liver damage. Scar tissue replaces healthy tissue in the liver and stops it from working properly.

The damage can't be reversed. It can eventually become so extensive that your liver stops functioning, which is called liver failure.

Cirrhosis can be fatal if the liver fails. But it usually takes years for the condition to reach this stage, and treatment can help slow its progression.

Each year in the UK, around 4,000 people die from cirrhosis and 700 people with the condition need a liver transplant to survive.

In the early stages, cirrhosis usually causes few symptoms. As your liver gradually loses its ability to work properly, though, you're likely to notice a loss of appetite, nausea and itchy skin.

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

Cirrhosis doesn't cause many obvious symptoms in its early stages, so it's often found by chance, during tests for some other illness.

See a doctor if you have any of these symptoms:

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

The most common causes of cirrhosis are:

• drinking too much alcohol (alcohol misuse) over many years
• being infected with the hepatitis C virus for a long time
• a condition called non-alcoholic steatohepatitis (NASH), which causes excess fat to build up in the liver

NASH is on the rise, because more people are obese and fewer are physically active. It's likely to overtake alcohol and hepatitis C as the most common cause of cirrhosis.

Less common causes include hepatitis B infection and inherited liver diseases, such as haemochromatosis.

There's no cure for cirrhosis at the moment. But you can manage the symptoms and any complications, and you can slow how fast the condition gets worse.

Treating the underlying condition that may be causing it can also stop cirrhosis getting worse. One example is using anti-viral medicine to treat a hepatitis C infection.

You may be advised to cut down or stop drinking alcohol, or to lose weight if you're overweight. Many alcohol support services are available.

In the more advanced stages, the scarring caused by cirrhosis can make your liver stop working. When that happens, a liver transplant is the only treatment option.

The best way to prevent alcohol-related cirrhosis is to stay within the recommended limits for alcohol.

Hepatitis B and C are infections you can catch through unprotected sex or by sharing needles to inject drugs. If you use a condom during sex and don't inject drugs, you lower your risk of developing hepatitis B and C, and so of cirrhosis.

There is a vaccine for hepatitis B. For hepatitis C, though, there's no vaccine at the moment.

In the early stages, cirrhosis usually causes few symptoms. The liver is damaged, but it can still do its work properly. Noticeable problems tend to appear as the damage grows, because by then some of the liver's functions are affected.

Symptoms of cirrhosis can include:

• tiredness and weakness
• loss of appetite
• weight loss and muscle wasting
• feeling sick (nausea) and vomiting
• tenderness or pain around the liver area
• tiny red lines (blood capillaries) on the skin above waist level
• very itchy skin
• yellowing of the skin and the whites of the eyes (jaundice)
• a tendency to bleed and bruise more easily, such as frequent nosebleeds or bleeding gums
• hair loss
• fever and shivering attacks
• swelling in the legs, ankles and feet due to a build-up of fluid (oedema)
• swelling in your abdomen (tummy), due to a build-up of fluid known as ascites (severe cases can make you look heavily pregnant)

You may also notice changes in your personality, problems sleeping (insomnia), memory loss, confusion and difficulty concentrating. This is known as encephalopathy. It happens when toxins affect your brain because your liver can't remove them from your body.

In the later stages of cirrhosis, you may vomit blood or pass tarry, black stools. This happens because blood can't flow through the liver properly, so the pressure rises in the vein that carries blood from the gut to the liver (the portal vein).

That higher pressure forces blood through smaller, fragile vessels that line your stomach and gullet. These vessels are called varices, and they can burst under the pressure. The result is internal bleeding, which shows up in your vomit, your stools, or both.

Over time, toxins that a healthy liver would normally clear from the body can build up and cause multiple organ failure, followed by death.

See a doctor if you have signs and symptoms of cirrhosis that don't go away.

Get medical help straight away if you develop any of the following symptoms, particularly if you've already been diagnosed with cirrhosis:

• fever and shivering attacks
• shortness of breath
• vomiting blood
• very dark or black tarry stools
• periods of mental confusion or drowsiness

There are many different causes of cirrhosis. In the UK, the most common are drinking excessive amounts of alcohol and long-term hepatitis C infection.

In some cases, no specific cause is found.

Your liver breaks down toxins (poisons) such as alcohol. But too much alcohol can scar and damage the liver's cells, and that can lead to cirrhosis. Men and women who drink more than 14 units of alcohol a week are considered to be drinking too much.

If you're a heavy drinker, your chances of developing cirrhosis go up. But cirrhosis of the liver isn't only a condition of people who are dependent on alcohol. You can develop it if you're a heavy social drinker too.

Alcohol-related cirrhosis usually develops after 10 or more years of heavy drinking. Some people are more prone to liver cell damage than others, and the reasons aren't known. Women who drink heavily are more prone to liver damage than men, partly because of their different body size and build.

People who drink excessively and keep drinking heavily develop cirrhosis in 3 separate stages.

The first stage of alcohol-related liver disease is known as "fatty liver", and almost all excessive drinkers develop it. It's a side effect of the liver breaking alcohol down, and it disappears when you drink less.

The second stage is alcoholic hepatitis. Around 20% to 30% of people who continue to drink heavily develop it. The liver becomes inflamed during this stage. If alcoholic hepatitis gets worse and reaches its most extreme form (liver failure), it can lead to death.

About 10% of heavy drinkers go on to develop cirrhosis, which is the third stage of alcohol-related liver disease.

This risk of cirrhosis, along with the risk of alcoholic hepatitis, is one of the main reasons the government recommends that men and women should not regularly drink more than 14 units a week. If you do drink as much as 14 units a week, you are advised to spread your drinking over 3 or more days.

A unit of alcohol is roughly equal to half a pint of normal-strength lager or a single measure (25ml) of spirits. A small glass of wine (125ml) is about 1.5 units.

If you're finding it difficult to cut down the amount you drink, your doctor can give you help and advice.

Hepatitis is inflammation of the liver. If it isn't treated, it can damage the liver slowly over many years and in the end lead to cirrhosis.

Hepatitis C is the most common form of hepatitis, and the hepatitis C virus usually spreads through blood-to-blood contact. The most common way is by sharing needles used to inject drugs.

Two other types of hepatitis infection, hepatitis B and D, can also cause cirrhosis.

Non-alcoholic steatohepatitis (NASH) is a serious liver condition that can lead to cirrhosis. It starts much as alcohol-related liver disease does, with excess fat building up in the liver. That fat is linked with inflammation and scarring, and the scarring can go on to become cirrhosis.

NASH can develop in people who are obese, have diabetes, have high levels of fat in the blood (high cholesterol) and have high blood pressure. Most people with NASH feel well and don't know anything is wrong until cirrhosis sets in and the liver stops working as it should.

NASH is becoming more common in the UK because more people are obese and people are less physically active. It's likely to overtake alcohol and hepatitis C as the most common cause of cirrhosis.

Several other conditions can stop the liver working as it should, and these can lead to cirrhosis. They include:

• autoimmune liver disease: normally the immune system makes antibodies to attack bacteria and viruses, but if you have an autoimmune disease, such as autoimmune hepatitis, primary biliary cirrhosis or primary sclerosing cholangitis (PSC), your immune system makes antibodies that attack healthy organs
• 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 pancreatic cancer
• Budd-Chiari syndrome, which is caused by blood clots blocking the veins that carry blood from the liver

Less commonly, some medicines, such as amiodarone and methotrexate, can also cause cirrhosis.

If your doctor suspects cirrhosis, they'll go through your medical history and examine you for signs of long-term liver disease.

If they think your liver is damaged, you'll be sent for tests to confirm the diagnosis.

Blood tests can show how well your liver is working and how much damage it has taken. If you have cirrhosis, your doctor may check the levels of two liver enzymes in your blood, alanine transaminase (ALT) and aspartate transferase (AST). These rise when the liver is inflamed, which is called hepatitis.

You may have an ultrasound scan, a transient elastography scan, a computerised tomography (CT) scan or a magnetic resonance imaging (MRI) scan of your liver. A transient elastography scan is similar to the ultrasound scan done during pregnancy (it's sometimes known as a Fibroscan).

These scans can produce detailed images of your liver, or check how stiff it is, to identify any scarring.

The Lab Tests Online website has more information.

A liver biopsy is a test where a doctor puts a fine needle into your body, usually between your ribs, and takes out a small sample of liver cells. The sample goes to a laboratory, where it is looked at under a microscope.

You'll usually have the biopsy under local anaesthetic. Some people go home the same day, and others stay in hospital overnight. The result will confirm a diagnosis of cirrhosis and may tell you more about the cause. That said, a test called transient elastography is being used more and more instead of a biopsy to diagnose cirrhosis.

In an endoscopy, a doctor passes an endoscope down your throat and into your stomach. The endoscope is a thin, long, flexible tube with a light and a video camera at the end.

The camera sends images of your oesophagus (the tube from your throat to your stomach) and your stomach to a screen outside your body. If you have varices (swollen vessels), which are a sign of cirrhosis, they can be seen on that screen.

Doctors use a few different systems to grade how serious cirrhosis is. One is the Child-Pugh score. It's based on your examination and your laboratory tests, and it grades cirrhosis from A (relatively mild) to C (severe).

Another system is called model of end-stage liver disease (MELD). It uses the result of a blood test to help identify people who need an urgent liver transplant.

Cirrhosis can't be cured, so the aim of treatment is to manage the symptoms and any complications, and to stop the condition getting worse.

Liver damage that has already happened usually can't be reversed. Recent research suggests this may eventually become possible in cases where the underlying cause of the damage can be treated successfully.

You are likely to be treated at a hospital with a specialist hepatology unit, which deals with disorders of the liver, gall bladder and biliary ducts.

The medicine you need for cirrhosis depends on what has caused the damage to your liver.

If viral hepatitis is the cause, your doctor may prescribe anti-viral medicines. If you have autoimmune hepatitis, you may be given steroid medicine (corticosteroids) or medicine that suppresses your immune system (immunosuppressants).

If you have cirrhosis, there are several things you can do to stay healthier and lower your chances of further problems:

• completely avoid alcohol, whatever the cause of your cirrhosis, because drinking makes the condition progress faster
• lose weight if you're overweight or obese
• take regular exercise to reduce muscle wasting
• practise good hygiene to reduce your chances of getting infections
• speak to your doctor about vaccinations you may need, such as the annual flu vaccine or travel vaccines
• speak to your doctor or pharmacist if you're taking over-the-counter or prescription medicines, because cirrhosis can affect the way your body processes some medicines

Malnutrition is common in people with cirrhosis, so a balanced diet matters. It helps you get all the nutrients you need.

Avoiding salty foods and not adding salt to your meals can lower your risk of swelling in your legs, feet and abdomen (tummy), which is caused by a build up of fluid. See the tips for a lower salt diet for more information.

Damage to your liver can also leave it unable to store glycogen, a carbohydrate that gives you short-term energy. When that happens, your body uses its own muscle tissue for energy between meals, and this leads to muscle wasting and weakness. So you may need extra calories and protein in your diet.

Healthy snacks between meals can top up your calories and protein. It may also help to eat 3 or 4 small meals a day instead of 1 or 2 large ones.

Several treatments can ease the symptoms of cirrhosis, including:

• a low-sodium (salt) diet or tablets called diuretics, which reduce the amount of fluid in your body
• tablets to reduce high blood pressure in your portal vein (the main vein that carries blood from the gut to the liver) and to prevent or treat any infection
• creams to reduce itching

If you vomit blood or pass blood in your stools, you probably have swollen veins in your oesophagus (the long tube that carries food from the throat to the stomach). These are called oesophageal varices.

This needs urgent medical attention. See your doctor or go to the hospital emergency department nearest you immediately.

Some procedures can help stop the bleeding and lower the risk of it happening again. They include:

• banding: an endoscopy is done (a thin, flexible tube is passed down your throat) and a small band is placed around the base of the varices to help control the bleeding
• injection glue therapy: after an endoscopy, a type of medical 'super glue' is injected into the varices to make the blood clot, which helps stop the bleeding
• a Sengstaken tube with a balloon on the end: a special tube is passed down your throat into your stomach and the balloon is inflated. This puts pressure on the varices and helps stop the bleeding, and you'll be heavily sedated during the procedure
• a transjugular intrahepatic portosystemic stent shunt (TIPSS): a metal tube called a stent is passed across your liver to join 2 large veins (the portal vein and hepatic vein). This creates a new route for your blood to flow through, so it relieves the pressure that causes the varices

You may also be given a type of medicine called a beta-blocker, such as propanolol, to lower the risk of bleeding or to make any bleed that does happen less severe.

Ascites is a build-up of fluid around your stomach area. Peripheral oedema is fluid around your legs and ankles. Both are common complications of advanced cirrhosis, and both need attention as soon as possible.

You may have 20 to 30 litres of free water in your stomach area (the abdomen), and that can make it hard to eat or breathe properly. The main treatments for ascites and oedema are cutting down the sodium (salt) in your diet and taking diuretic tablets, such as spironolactone or furosemide.

If the fluid around your stomach becomes infected, you may need antibiotics. In people at high risk of infection, antibiotics may instead be taken regularly to prevent it.

In severe ascites, tubes may be used to drain the fluid from your abdomen. This usually has to be repeated every few weeks.

People with cirrhosis can sometimes develop problems with brain function, which doctors call encephalopathy. It happens because the liver isn't clearing toxins properly.

The main treatment for encephalopathy is lactulose syrup. It works as a laxative (it helps clear the bowels), and it helps the body get rid of the toxins that build up when the liver is failing. In some cases, doctors may use other laxatives or an enema as well.

Cirrhosis can affect how well your liver helps the blood to clot (thicken). This means you are at risk of severe bleeding if you cut yourself. In an emergency, doctors can give vitamin K and a blood product called plasma to treat episodes of bleeding. If you get a cut that bleeds, you'll need to press on it firmly.

Because of this, you should get specialist advice before having any medical procedure, including dental work.

If cirrhosis leaves your liver severely damaged by scarring, it may stop functioning. In that situation a liver transplant is the only option. It's a major procedure, where your diseased liver is removed and replaced with a healthy donor liver.

You'll probably have to wait a long time for a transplant, though, because there are more people waiting than there are donors.

The NHSBT Organ Donation website has more information about transplants and joining the Organ Donor Register.

You can lower your chances of developing cirrhosis by limiting how much alcohol you drink and by protecting yourself from a hepatitis infection.

Heavy drinking is one of the most common causes of cirrhosis of the liver, and one of the best ways to avoid it is to keep within the recommended limits.

• men and women are advised not to regularly drink more than 14 units a week
• if you drink as much as 14 units a week, spread it over 3 days or more

If you already have cirrhosis, you should stop drinking alcohol straight away. Alcohol speeds up the rate at which the condition progresses, whatever the cause.

Cirrhosis can be caused by infections such as hepatitis B and C. You can catch both by having unprotected sex or by sharing needles to inject drugs.

Using a condom when you have sex will help you avoid the risk of getting hepatitis, and so will staying away from injecting drugs.

Anyone at risk of hepatitis B, such as police officers and social care workers, can be protected by being vaccinated against it. There's currently no vaccine for hepatitis C, though.

People born in parts of the world where hepatitis B and C are widespread, such as parts of South Asia and Africa, need to be screened for hepatitis. Early treatment can help prevent cirrhosis from developing.