Merck Manual

Please confirm that you are a health care professional

Loading

Cirrhosis

By

Jesse M. Civan

, MD, Thomas Jefferson University Hospital

Last full review/revision Dec 2019| Content last modified Dec 2019
Click here for Patient Education
NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
Topic Resources

Cirrhosis is a late stage of hepatic fibrosis that has resulted in widespread distortion of normal hepatic architecture. Cirrhosis is characterized by regenerative nodules surrounded by dense fibrotic tissue. Symptoms may not develop for years and are often nonspecific (eg, anorexia, fatigue, weight loss). Late manifestations include portal hypertension, ascites, and, when decompensation occurs, liver failure. Diagnosis often requires liver biopsy. Cirrhosis is usually considered irreversible. Treatment is supportive.

Cirrhosis is a leading cause of death worldwide.

Etiology

The causes of cirrhosis are the same as those of fibrosis (see table Disorders and Drugs That Can Cause Hepatic Fibrosis). In developed countries, most cases result from chronic alcohol abuse or chronic hepatitis C. In parts of Asia and Africa, cirrhosis often results from chronic hepatitis B (see table Characteristics of Hepatitis Viruses for additional information on hepatitis B and C). Cirrhosis of unknown etiology (cryptogenic cirrhosis) is becoming less common as many specific causes (eg, chronic hepatitis C, steatohepatitis) are identified. Injury to the bile ducts also can result in cirrhosis, as occurs in mechanical bile duct obstruction, primary biliary cholangitis, and primary sclerosing cholangitis.

Pathophysiology

There are 2 primary ingredients:

  • Hepatic fibrosis

  • Regenerating liver cells

In response to injury and loss, growth regulators induce hepatocellular hyperplasia (producing regenerating nodules) and arterial growth (angiogenesis). Among the growth regulators are cytokines and hepatic growth factors (eg, epithelial growth factor, hepatocyte growth factor, transforming growth factor-alpha, tumor necrosis factor). Insulin, glucagon, and patterns of intrahepatic blood flow determine how and where nodules develop.

Angiogenesis produces new vessels within the fibrous sheath that surrounds nodules. These vessels connect the hepatic artery and portal vein to hepatic venules, restoring the intrahepatic circulatory pathways. Such interconnecting vessels provide relatively low-volume, high-pressure venous drainage that cannot accommodate as much blood volume as normal. As a result, portal vein pressure increases. Such distortions in blood flow contribute to portal hypertension, which increases because the regenerating nodules compress hepatic venules.

The progression rate from fibrosis to cirrhosis and the morphology of cirrhosis vary from person to person. Presumably, the reason for such variation is the extent of exposure to the injurious stimulus and the individual’s response.

Complications

Portal hypertension is the most common serious complication of cirrhosis, and it, in turn, causes complications, including

Ascites fluid can become infected (spontaneous bacterial peritonitis). Portopulmonary hypertension can manifest with symptoms of heart failure. Complications of portal hypertension tend to cause significant morbidity and mortality.

Cirrhosis can cause other cardiovascular complications. Vasodilation, intrapulmonary right-to-left shunting, and ventilation/perfusion mismatch can result in hypoxia (hepatopulmonary syndrome).

Progressive loss of hepatic architecture impairs function, leading to hepatic insufficiency; it manifests as coagulopathy, acute kidney injury (hepatorenal syndrome), and hepatic encephalopathy. Hepatocytes secrete less bile, contributing to cholestasis and jaundice. Less bile in the intestine causes malabsorption of dietary fat (triglycerides) and fat-soluble vitamins. Malabsorption of vitamin D may contribute to osteoporosis. Undernutrition is common. It may result from anorexia with reduced food intake or, in patients with alcoholic liver disease, from malabsorption due to pancreatic insufficiency.

Blood disorders are common. Anemia usually results from hypersplenism, chronic GI bleeding, folate deficiency (particularly in patients with alcoholism), and hemolysis.

Cirrhosis results in decreased production of prothrombotic and antithrombotic factors. Hypersplenism and altered expression of thrombopoietin contribute to thrombocytopenia. Thrombocytopenia and decreased production of clotting factors can make clotting unpredictable, increasing risk of both bleeding and thromboembolic disease (even though international normalized ratio [INR] is usually increased). Leukopenia is also common; it is mediated by hypersplenism and altered expression of erythropoietin and granulocyte-stimulating factors.

Pearls & Pitfalls

  • Consider thromboembolic complications in patients with cirrhosis, even if INR is elevated.

Hepatocellular carcinoma frequently complicates cirrhosis, particularly cirrhosis resulting from

Histopathology

Cirrhosis is characterized by regenerating nodules and fibrosis. Incompletely formed liver nodules, nodules without fibrosis (nodular regenerative hyperplasia), and congenital hepatic fibrosis (ie, widespread fibrosis without regenerating nodules) are not true cirrhosis.

Cirrhosis can be micronodular or macronodular. Micronodular cirrhosis is characterized by uniformly small nodules (< 3 mm in diameter) and thick regular bands of connective tissue. Typically, nodules lack lobular organization; terminal (central) hepatic venules and portal triads are distorted. With time, macronodular cirrhosis often develops. The nodules vary in size (3 mm to 5 cm in diameter) and have some relatively normal lobular organization of portal triads and terminal hepatic venules. Broad fibrous bands of varying thickness surround the large nodules. Collapse of the normal hepatic architecture is suggested by the concentration of portal triads within the fibrous scars. Mixed cirrhosis (incomplete septal cirrhosis) combines elements of micronodular and macronodular cirrhosis. Differentiation between these morphologic types of cirrhosis has limited clinical value.

Symptoms and Signs

Cirrhosis may be asymptomatic for years. One third of patients never develop symptoms. Often, the first symptoms are nonspecific; they include generalized fatigue (due to cytokine release), anorexia, malaise, and weight loss (see table Common Symptoms and Signs Due to Complications of Cirrhosis). The liver is typically palpable and firm, with a blunt edge, but is sometimes small and difficult to palpate. Nodules usually are not palpable.

Clinical signs that suggest a chronic liver disorder or chronic alcohol use but are not specific for cirrhosis include muscle wasting, palmar erythema, parotid gland enlargement, white nails, clubbing, Dupuytren contracture, spider angiomas (< 10 may be normal), gynecomastia, axillary hair loss, testicular atrophy, and peripheral neuropathy.

Once any complication of cirrhosis develops, additional decompensation is much more likely.

Table
icon

Common Symptoms and Signs Due to Complications of Cirrhosis

Symptom or Sign

Possible Cause

Abdominal distention

Abdominal discomfort with fever or hepatic encephalopathy (infrequently with peritoneal signs)

Calf pain or swelling, symptoms of pulmonary embolism

Thromboembolism

Clubbing

Confusion, lethargy

Hepatic encephalopathy

Dyspnea, hypoxia

Hepatopulmonary syndrome

Fatigue, pallor

Anemia due to bleeding, hypersplenism, undernutrition with deficiency of folate (or iron or vitamin B12), chronic disease, or effects of alcohol (eg, bone marrow suppression)

Fluid overload, oliguria, symptoms of renal failure

Hepatorenal syndrome

Fragility fracture (due to a fall from standing height or less)

Symptoms of infection

Jaundice

Petechiae, purpura, bleeding

Thrombocytopenia caused by splenomegaly due to portal hypertension or the direct effects of alcohol on bone marrow

Coagulopathy due to impaired liver synthetic function, vitamin K deficiency, or both

Pruritus, xanthelasmas

Cholestasis

Rectal bleeding

Rectal varices

Splenomegaly

Steatorrhea

Portal hypertensive gastropathy

Diagnosis

  • Liver tests, coagulation tests, complete blood count (CBC), and serologic tests for viral causes

  • Sometimes biopsy (eg, when clinical and noninvasive tests are inconclusive, or when biopsy results may change management)

  • Sometimes ultrasound elastography or magnetic resonance elastography

  • Identification of cause based on clinical evaluation, routine testing for common causes, and selective testing for less common causes

General approach

Cirrhosis is suspected in patients with manifestations of any of its complications (see table Common Symptoms and Signs Due to Complications of Cirrhosis), particularly portal hypertension or ascites. Early cirrhosis should be considered in patients with nonspecific symptoms or characteristic laboratory abnormalities detected incidentally during laboratory testing, particularly in patients who have a disorder or take a drug that might cause fibrosis.

Testing seeks to detect cirrhosis and any complications and to determine its cause.

Laboratory tests

Diagnostic testing begins with liver tests, coagulation tests, CBC, and serologic tests for chronic viral hepatitis (see tables Hepatitis B Serology and Hepatitis C Serology). Laboratory tests alone may increase suspicion for cirrhosis but cannot confirm or exclude it. Liver biopsy becomes necessary if a clear diagnosis would lead to better management and outcome.

Test results may be normal or may indicate nonspecific abnormalities due to complications of cirrhosis or alcohol use disorder. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels are often modestly elevated. Alkaline phosphatase and gamma-glutamyl transpeptidase (GGT) are often normal; elevated levels indicate cholestasis or biliary obstruction. Bilirubin is usually normal but increases when cirrhosis progresses, particularly in primary biliary cholangitis. Decreased serum albumin and a prolonged prothrombin time (PT) directly reflect impaired hepatic synthesis—usually an end-stage event. Albumin can also be low when nutrition is poor. Serum globulin increases in cirrhosis and in most liver disorders with an inflammatory component.

Anemia is common and usually normocytic with a high red blood cell distribution width (RDW). Anemia is often multifactorial; contributing factors may include chronic gastrointestinal bleeding (usually causing microcytic anemia), folate deficiency (causing macrocytic anemia, especially in alcohol abuse), hemolysis, and hypersplenism. CBC may also detect leukopenia, thrombocytopenia, or pancytopenia.

Diagnostic imaging

Conventional imaging tests are not highly sensitive or specific for the diagnosis of cirrhosis by themselves, but they can often detect its complications. Ultrasound elastography, magnetic resonance elastography, and acoustic radiation force impulse imaging are useful in detection of early cirrhosis when conventional imaging findings are equivocal and portal hypertension is not evident.

In advanced cirrhosis, ultrasonography shows a small, nodular liver. Ultrasonography also detects portal hypertension and ascites.

CT can detect a nodular texture, but it has no advantage over ultrasonography. Radionuclide liver scans using technetium-99m sulfur colloid may show irregular liver uptake and increased spleen and bone marrow uptake. MRI is more expensive than other imaging tests and has little advantage.

Identification of the cause

Determining the specific cause of cirrhosis requires key clinical information from the history and examination, as well as selective testing.

Alcohol is the likely cause in patients with a documented history of alcoholism and clinical findings such as gynecomastia, spider angiomas (telangiectasia), and testicular atrophy plus laboratory confirmation of liver damage (AST elevated more than ALT) and liver enzyme induction (a greatly increased GGT). Fever, tender hepatomegaly, and jaundice suggest the presence of alcoholic hepatitis.

Detecting hepatitis B surface antigen (HBsAg) and IgG antibodies to hepatitis B (IgG anti-HBc) confirms chronic hepatitis B. Identifying serum antibody to hepatitis C (anti-HCV) and HCV-RNA points to hepatitis C. Most clinicians also routinely test for the following:

  • Autoimmune hepatitis: Suggested by a high antinuclear antibody titer (a low titer is nonspecific and does not always mandate further evaluation) and confirmed by hypergammaglobulinemia and the presence of other autoantibodies (eg, anti–smooth muscle or anti-liver/kidney microsomal type 1 antibodies)

  • Hemochromatosis: Confirmed by increased serum iron and transferrin saturation and possibly results of genetic testing

  • Alpha-1 antitrypsin deficiency: Confirmed by a low serum alpha-1 antitrypsin level and genotyping

If these causes are not confirmed, other causes are sought:

  • Presence of antimitochondrial antibodies (in 95%) suggests primary biliary cholangitis.

  • Strictures and dilations of the intrahepatic and extrahepatic bile ducts, seen on magnetic resonance cholangiopancreatography (MRCP), suggest primary sclerosing cholangitis.

  • Decreased serum ceruloplasmin and characteristic copper test results suggest Wilson disease.

  • The presence of obesity and a history of diabetes suggest nonalcoholic steatohepatitis (NASH).

Liver biopsy

If clinical criteria and noninvasive testing are inconclusive, liver biopsy is usually done. For example, if well-compensated cirrhosis is suspected clinically and imaging findings are inconclusive, biopsy should be done to confirm the diagnosis. Sensitivity of liver biopsy approaches 100%. Nonalcoholic fatty liver disease (NAFLD) may be evident on ultrasound scans. However, NASH, often associated with obesity, diabetes, or the metabolic syndrome, requires liver biopsy for confirmation.

In obvious cases of cirrhosis with marked coagulopathy, portal hypertension, ascites, and liver failure, biopsy is not required unless results would change management. In patients with coagulopathy and thrombocytopenia, the transjugular approach to biopsy is safest. When this approach is used, pressures can be measured and thus the transsinusoidal pressure gradient can be calculated.

Monitoring

All patients with cirrhosis, regardless of cause, should be screened regularly for hepatocellular carcinoma. Currently, abdominal ultrasonography is recommended every 6 months, and if abnormalities compatible with hepatocellular carcinoma are detected, contrast-enhanced MRI or triple-phase CT of the abdomen (contrast-enhanced CT with separate arterial and venous phase images) should be done. Contrast-enhanced ultrasonography appears promising as an alternative to CT or MRI but is still under study in the US.

Upper endoscopy to check for gastroesophageal varices should be done when the diagnosis is made and then every 2 to 3 years. Positive findings may mandate treatment or more frequent endoscopic monitoring.

Prognosis

Prognosis is often unpredictable. It depends on factors such as etiology, severity, presence of complications, comorbid conditions, host factors, and effectiveness of therapy. Patients who continue to drink alcohol, even small amounts, have a very poor prognosis.

Child-Turcotte-Pugh classification for severity of liver disease

The Child-Turcotte-Pugh scoring system uses clinical and laboratory information to stratify disease severity, surgical risk, and overall prognosis (see tables Child-Turcotte-Pugh Scoring System and Interpretation of the Child-Turcotte-Pugh Scoring System). The Child-Turcotte-Pugh scoring system does, however, have limitations; for example, assessments of the severity of ascites and encephalopathy are subjective; inter-rater reliability of results is thus decreased.

Table
icon

Child-Turcotte-Pugh Scoring System

Clinical or Laboratory Factor

Degree of Abnormality

Points Assigned*

Encephalopathy (grade†)

None

1

1–2

2

3–4

3

None

1

Mild (or controlled by diuretics)

2

At least moderate despite diuretic treatment

3

Albumin

> 3.5 g/dL (35 g/L)

1

2.8–3.5 g/dL (28–35 g/L)

2

< 2.8 g/dL (28 g/L)

3

Bilirubin

< 2 mg/dL (34 micromol/L)

1

2–3 mg/dL (34– 51 micromol/L)

2

> 3 mg/dL (51 micromol/L)

3

PT (seconds prolonged)

< 4

1

4–6

2

> 6

3

or, instead of PT

INR

< 1.7

1

1.7–2.3

2

> 2.3

3

* Risk (grade) is based on the total number of points:

  • Low (A): 5–6

  • Moderate (B): 7–9

  • High (C): 10–15

† Encephalopathy is graded based on symptoms:

  • 1: Sleep disturbances; impaired concentration; depression, anxiety, or irritability

  • 2: Drowsiness, disorientation, poor short-term memory, uninhibited behavior

  • 3: Somnolence; confusion; amnesia; anger, paranoia, or other bizarre behavior

  • 4: Coma

INR = international normalized ratio; PT = prothrombin time.

Table
icon

Interpretation of the Child-Turcotte-Pugh Scoring System

Points

Risk (Grade)

Survival Rate (%)

1-year

2-year

5–6

Low (A)

100

85

7–9

Moderate (B)

80

60

10–15

High (C)

45

35

Model for end-stage liver disease (MELD)

In contrast to the Child-Turcotte-Pugh classification, the model for end-stage liver disease (MELD) score estimates the severity of end-stage liver disease, regardless of cause, based solely on objective results of laboratory tests: serum creatinine, serum total bilirubin, and international normalized ratio (INR). The MELD score is used to determine allocation of available organs to liver transplant candidates because it can sort candidates by mortality risk (see table MELD Score and Mortality). Variations of the MELD score are sometimes used for other purposes (eg, to estimate risk of 90-day mortality in patients with alcoholic hepatitis, to predict risk of postoperative mortality in patients with cirrhosis). A variation of the MELD score that incorporates serum sodium measurement (MELD-Na) more accurately predicts mortality in cirrhotic patients than the conventional MELD score, and is now used by the United Network for Organ Sharing (UNOS)/Organ Procurement and Transplantation Network (OPTN) to prioritize patients on the liver transplant waiting list.

Table
icon

MELD Score and Mortality

MELD Score

3-Month Mortality*

<9

1.9%

10–19

6.0%

20–29

19.6%

30–39

52.6%

>40

71.3%

* Adult patients awaiting liver transplantation.

Adapted from Wiesner R, Edwards E, Freeman R, et al: Model for end-stage liver disease (MELD) and allocation of donor livers. Gastroenterology 124(1):91-96, 2003.

For selected patients with hepatocellular carcinoma (HCC), specific imaging criteria may be used to increase the MELD score, and this score changes over time according to a set schedule (the hepatocellular carcinoma MELD exception). In 2019, UNOS implemented a major policy update on how the HCC MELD exception is handled. Previously, HCC patients meeting criteria would receive adjusted MELD scores which increased every 3 months. However, under the new policy, patients are awarded a set adjusted MELD-Na score that varies regionally across the United States but is now constant over time. For patients who are 12 to 17 years old and who have a urea cycle disorder, organic acidemia, or hepatoblastoma, the MELD score is set at 30. Higher MELD scores predict higher risk.

Pediatric end-stage liver disease (PELD) score

For patients < 12 years, the corresponding pediatric end-stage liver disease (PELD) score is calculated. Higher PELD scores predict higher risk.

Treatment

  • Supportive care

In general, treatment is supportive and includes stopping injurious drugs, providing nutrition (including supplemental vitamins), and treating the underlying disorders and complications. Doses of drugs metabolized in the liver should be reduced. All alcohol and hepatotoxic substances must be avoided. Withdrawal symptoms during hospitalization should be anticipated in patients who have cirrhosis and have continued to abuse alcohol. Patients should be vaccinated against viral hepatitis A and B unless they are already immune.

Patients with varices need therapy to prevent bleeding (see Portal Hypertension : Treatment). No evidence supports treating small esophageal varices. Medium and large esophageal varices should be treated prophylactically with nonselective beta-blockers or endoscopic banding (ligation). If gastric varices are not amenable to endoscopic banding and do not respond to nonselective beta-blockers, balloon-occluded retrograde transvenous obliteration or endoscopic cyanoacrylate injection may be used.

Transjugular intrahepatic portosystemic shunting (TIPS) should be considered if patients have complications of portal hypertension that are refractory to standard treatments, including ascites and recurrent variceal bleeding.

Liver transplantation is indicated for patients with end-stage liver disease or hepatocellular carcinoma. Risk of death without liver transplantation begins to exceed risks of transplantation (eg, perioperative complications, chronic immunosuppression) when the MELD score is more than about 15. Thus, if the score is ≥ 15 or if cirrhosis has decompensated clinically, patients should be referred to a transplantation center.

Key Points

  • Morbidity and mortality in cirrhosis usually result from its complications (eg, complications of portal hypertension, liver failure, hematologic problems).

  • Do liver biopsy if a clear diagnosis would lead to better management and outcome.

  • Evaluate all patients with cirrhosis for autoimmune hepatitis, hereditary hemochromatosis, and alpha-1 antitrypsin deficiency, as well as for the more common causes, alcoholic and viral hepatitis.

  • Evaluate all patients periodically for gastroesophageal varices and hepatocellular carcinoma.

  • Predict prognosis using the Child-Turcotte-Pugh and MELD scoring systems, and refer patients with a MELD score ≥ 15 to be evaluated for a liver transplant.

  • Treat cirrhosis supportively, including using therapies to prevent bleeding.

More Information

  • Londoño MC, Cárdenas A, Guevara M: MELD score and serum sodium in the prediction of survival of patients with cirrhosis awaiting liver transplantation. Gut 56(9):1283-1290, 2007. 

Click here for Patient Education
NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
Professionals also read

Also of Interest

Videos

View All
Overview of Gallstones
Video
Overview of Gallstones
3D Models
View All
Hepatic Lobules
3D Model
Hepatic Lobules

SOCIAL MEDIA

TOP