Liver Cirrhosis: Causes, Symptoms & Damage from Alcohol
What is Cirrhosis of the Liver?
Cirrhosis is a liver disease characterized by extensive scarring and disruption of normal liver structure.1 Over time, in response to injury, the liver tries to repair itself by forming scar tissue in place of damaged liver tissue. When repeated, this process leads to ever-increasing amounts of scar tissue. Excessive scar tissue impedes blood flow through the liver, impairing its ability to:2
- Metabolize drugs.
- Modify and/or sequester certain toxic substances circulating in the bloodstream.
- Prepare toxins for excretion from the body.
- Process and store certain nutrients.
- Create bile used by the body to absorb fats.
As cirrhosis progresses, additional scar tissue forms, further decreasing liver function until the condition eventually becomes life-threatening.
The symptoms of cirrhosis depend on the stage of the disease. Some people with cirrhosis have no symptoms in the early stages. Symptoms may not appear until liver damage becomes extensive. As the disease progresses, symptoms may include:3
- Fatigue or weakness.
- Nausea and vomiting.
- Loss of appetite.
- Unintentional weight loss.
- Right upper quadrant abdominal pain or tenderness.
- Increased bruising and/or bleeding.
- Jaundice, which may give the whites of the eyes a yellowish tint or start to make the skin appear yellow.
- Urticaria, or severe skin itching.
- Peripheral edema, or swelling in the ankles, legs, and feet.
- Bloating from a buildup of fluid in the abdomen, known as ascites.
- Hepatic encephalopathy—confusion, memory loss, personality changes.
- Darkening of urine color (from excretion of certain liver-made proteins).
What Causes Liver Cirrhosis?
Cirrhosis is most commonly caused by:3
- Alcoholic liver disease, which is defined as damage to the liver and its function due to alcohol abuse.
- Nonalcoholic fatty liver disease.
- Chronic viral infections of the liver, including hepatitis B and C.
According to data published in Alcohol Research & Health, between 10-15% of people who suffer from alcoholism develop cirrhosis.4 The amount of alcohol you consume is an important risk factor for developing alcoholic cirrhosis, with recent findings showing an association between binge drinking and increased risk for advanced liver disease.5
In addition to these common causes, anything that damages the liver can cause cirrhosis. A wide range of diseases and conditions that can lead to cirrhosis include:3
- Autoimmune hepatitis.
- Diseases that damage or destroy bile ducts, such as primary biliary cholangitis and primary sclerosing cholangitis.
- Genetic disorders that affect the liver’s ability to process copper and iron, including Wilson’s disease and hemochromatosis.
- Alpha-1-antitrypsin deficiency, a genetic condition that prevents the liver from properly making a protein to protect the lungs.
- Long-term use of certain drugs that can lead to liver injury, such as anabolic steroids, birth control pills, methotrexate, statins, and some anti-seizure medicines.
- Chronic heart failure with liver congestion, a condition in which blood flow through the liver and surrounding vasculature is impaired.
How Alcohol Affects the Liver
Alcohol is mainly processed by the parenchymal cells of the liver, which constitute about 70% of the total liver mass.6 The liver relies on two enzymes known as alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH) to process alcohol and break it down so it can be removed from the body.7 ADH transforms alcohol into a carcinogenic substance known as acetaldehyde, which is usually quickly converted by ALDH to acetate, a more inert substance that is then broken down into carbon dioxide and water for excretion.7
Alcohol negatively affects the liver because the liver is the body’s first and main line of defense for metabolizing alcohol.6 Excessive or chronic intake of alcohol can overwhelm the liver’s ability to effectively process alcohol, which, over time, can cause hepatic lesions that can lead to liver diseases such as steatosis, hepatitis, and fibrosis or cirrhosis.6
Excessive or chronic alcohol intake includes heavy drinking (consuming 8 or more standard drinks for women and 15 or more for men per week) and binge drinking (ingesting 4 or more standard drinks on one occasion for women and 5 or more for men).8 A standard drink contains about 14 grams of pure alcohol.9
While everyone is different and not everyone develops the same symptoms, heavy and long-term alcohol consumption, meaning 20-40 grams of ethanol per day (for women) and 40-80 grams per day (for men) for 10 to 12 years is a good predictor of liver disease, which could progress to cirrhosis.6
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Cirrhosis Statistics and Prevalence
Cirrhosis is the 7th leading cause of death in the United States for adults aged 25 to 64; research indicates it could be a growing problem.7,10-15
- 5 million adults were diagnosed with liver disease in 2018.
- Roughly 26,000 annual deaths from cirrhosis.
- Among the alcohol-related deaths reported in 2016, 21.3% of them were due to digestive diseases, primarily cirrhosis of the liver.
- In 2015, the proportion of alcohol-related cirrhosis deaths was highest among people ages 25 to 34.
- More than 90% of people who are heavy alcohol consumers develop fatty liver disease, but only 20% of those progress to severe alcoholic liver disease and cirrhosis.
- Alcohol-related liver disease was the main reason for 1 out of 3 liver transplants between 2010-2016.
- One study of 1,016,743 people who were hospitalized in the United States for chronic liver disease reports that mortality in people with alcoholic cirrhosis was 11.9%, which was higher than the rate for other types of liver disease.
How is Cirrhosis Diagnosed?
Cirrhosis may be suspected based on a history of alcohol abuse or medical conditions related to alcohol abuse. If cirrhosis is suspected, doctors may perform a physical exam, concentrating on the area in and around the abdomen. From there, doctors may recommend various tests to evaluate the liver, including:14
- Blood tests may be recommended to assess liver enzyme levels, measure the number and types of cells in the blood, test for viral infections like hepatitis B or C, and check for autoimmune liver conditions—all of which may help diagnose and determine the cause and severity of cirrhosis.
- Imaging tests (MRI, ultrasound, or X-ray) allow doctors to see the size, shape, texture, and stiffness of the liver and evaluate the scarring and fat present on the organ.
- Liver biopsy may be performed to identify the extent of scarring on the liver and might be ordered if other tests have produced non-conclusive results. With the biopsy, doctors can typically find the cause of the enlarged or damaged liver, whether it’s cirrhosis, cancer, or something else.
Risk Factors for Cirrhosis
Some of the risk factors for cirrhosis include: 15-18
- Drinking heavily. Consuming more than 1-2 drinks per day for women or 2-3 for men over long periods of time can lead to cirrhosis.
- Alagille syndrome. This rare genetic condition is associated with liver abnormalities that can lead to liver disease.
- Viral hepatitis. Not everyone with hepatitis B or C will develop cirrhosis, but it is one of the main causes of liver disease.
- Obesity and diabetes. Both are risk factors for nonalcoholic steatohepatitis (NASH), which can lead to significant liver injury and cirrhosis over time.
- Pre-existing liver conditions. In addition to hepatitis B or C, other chronic liver diseases, such as autoimmune hepatitis or Wilson’s disease, can be risk factors for cirrhosis.
- Hemochromatosis. This hereditary condition causes the body to absorb too much iron from food, resulting in toxic iron deposition in the liver and other tissues/organs.
Complications that can arise from cirrhosis include:19-22
- Portal hypertension. The most common and serious complication of cirrhosis is scar tissue that partly blocks and slows the normal flow of blood through the liver. As a result, pressure builds in the portal vein, responsible for carrying blood from the stomach, intestines, spleen, gallbladder, and pancreas to the liver.
- Edema. Legs, ankles, or feet swell due to fluid accumulation.
- Ascites. A buildup of fluid in the abdomen that can lead to serious infection.
- Enlarged veins. Varices, or veins, in the esophagus, stomach, or intestines can rupture and cause internal bleeding.
- Infections. The chances of bacterial infections like pneumonia or urinary tract infections increases.
- Malnutrition. Insufficient absorption and utilization of vitamins and other nutrients can negatively impact health.
- Hepatic encephalopathy. When the liver doesn’t work properly, toxins build up in the blood and travel to the brain, causing confusion and problems thinking.
- Hepatorenal syndrome. A form of kidney impairment that progresses and leads to renal failure.
- Bleeding disorders. Impaired production of clotting factors can result in clotting abnormalities, bleeding, and increased hemorrhage risk.
- Liver failure. Also called end-stage liver disease, liver failure requires a liver transplant.
- Liver cancer. Most people who develop liver cancer already have cirrhosis.
- Bone diseases. Osteoporosis can weaken bones and lead to easy fractures.
- Gallstones. Hard, pebble-like material that develops in the gallbladder.
- Bile duct issues. Problems can occur in the tubes that carry bile from the liver to the gallbladder (for storage) and the first part of the small intestine, called the duodenum (to aid in indigestion).
- Type 2 diabetes. Type 2 diabetes and insulin resistance can occur as a complication.
- Acute-on-chronic liver failure. A condition associated with organ failures and death.
When are Symptoms of an Emergency?
Most often caused by drugs (commonly acetaminophen) and hepatitis viruses, acute liver failure can have a rapid onset and progress quickly.23 Some of the signs of a liver emergency include:24
- Vomiting blood or having black, tarry stools.
- Altered mental status or feeling too tired and/or confused to do anything.
- Fever and chills.
- Jaundice or sudden yellowing of the eyes and/or skin.
If you suspect that you or someone you know are experiencing an emergency, you should call 911 or go to the emergency room right away.
Stages and Types of Cirrhosis
People with cirrhosis may be clinically categorized as having either compensated or decompensated cirrhosis (these broader categories may themselves be further differentiated with a 4-stage classification system, based on the presence of esophageal varices, ascitic fluid, and variceal bleeding)). Individuals with compensated cirrhosis are typically asymptomatic, although there may be signs of portal hypertension.25 Those with decompensated cirrhosis often show symptoms and complications of cirrhosis, such as jaundice or ascites.25 Survival rates are generally better for those with compensated cirrhosis.25
After a person is diagnosed with cirrhosis, physicians address the condition through ongoing medical evaluation, examination, and monitoring.25 They determine a treatment plan by evaluating factors such as:25
- Alcohol use.
- Injection drug use.
- Medication use.
- Comorbid medical conditions, especially those that can affect the liver, such as HIV or diabetes.
- Reviewing symptoms that may indicate a rapid progression of the disease (such as abdominal swelling).
- Psychiatric history, such as depression, which can lead to a poorer survival rate.
- Body mass index, which can affect liver disease progression.
- Overall physical exam for factors like muscle wasting, spider angiomas, or other skin conditions that could indicate later stages of cirrhosis.
- Mental status examination to evaluate for signs of confusion or impaired mental function.
There are two key scoring systems doctors may use to help determine the progression of cirrhosis and prognosis, but each system has limitations. Plus, there are liver diseases that do not have scoring systems at all.27 The two scoring systems that are used include:25
- Child-Turcotte-Pugh classification system (CTP). This is mainly used to assess mortality risk in people with cirrhosis, and it is widely used as a simple prognostic tool.
- Model for End-Stage Liver Disease (MELD). This is used to predict survival in people with advanced liver disease. It is also used to evaluate for liver transplantation and determine how quickly it is needed.
Cirrhosis and Life Expectancy
The life expectancy for cirrhosis of the liver can depend on whether you have compensated or decompensated cirrhosis. People with compensated cirrhosis can have an average life expectancy of 12 or more years, while people with decompensated cirrhosis can have an average life expectancy of 2 years.26 Regardless of whether the diagnosis is compensated or decompensated, individuals with cirrhosis should remain abstinent from alcohol.26
The prognosis can depend on individual scores on the MELD or CTP tests. For example, people with a MELD score of 15 or less have a predicted 3-month survival of 95%, but people with a MELD score of 30 can have an estimated 3-month survival of only 65%.25
Liver Cirrhosis Treatment: Is There a Cure?
There is no cure for cirrhosis, but doctors can treat many of the disease processes and/or manage other contributing factors that lead to cirrhosis. Treatment can include preventative measures, lifestyle changes, screening, and symptomatic management of complications.26
If you have been diagnosed with alcoholic liver disease, the single most important thing to do is stop drinking. Abstinence is the only way to possibly reverse liver damage, or at the minimum, prevent it from becoming worse. In some cases, decompensated cirrhosis can return to a compensated stage with resolution of contributing factors (e.g., quitting continued drinking). Know that attempts to suddenly quit drinking can pose certain health risks; however, a medically-supervised detox program can help you safely stop drinking by managing certain symptoms of withdrawal.
Cirrhosis Prevention Tips
Some of the steps you can take to reduce further liver damage and maintain health include:28-30
- Completely stop drinking alcohol.
- Eat a healthy diet.
- Avoid raw or undercooked shellfish, fish, and meat because potential bacteria and viruses in these foods can cause severe infections in people with cirrhosis.
- Exercise regularly.
- Limit salt intake (aim for less than 2 grams per day).
- Talk to your doctor about whether you should limit protein or fat intake.
- Get vaccinations for hepatitis A and B if you haven’t already or aren’t otherwise immune.
- Get a one-time pneumovax (to protect against infections such as peritonitis and pneumonia), yearly flu shots, and the Covid-19 vaccine if you have not already.
- Talk to your doctor about any medications, supplements, or vitamins you take.
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- Aberg, F., Helenius-Hietala, J., Puukka, P., & Jula, A. (2017) Binge drinking and the risk of liver events: A population-based cohort study. Liver International, 37(9), 1373-1381.
- Osna, N. A., Donohue, T. M., Jr, & Kharbanda, K. K. (2017). Alcoholic liver disease: pathogenesis and current management. Alcohol research: current reviews, 38(2), 147–161.
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- Smith, Andrew, M.D., Baumgartner, Katrina, M.D., and Bositis, Christopher, M.D. (2019). Cirrhosis: Diagnosis and Management. American Family Physician, 100(12), 759-770.
- Centers for Disease Control and Prevention. (2021, March 1). Chronic liver disease and cirrhosis.
- National Institute on Alcohol Abuse and Alcoholism. (2021, June). Alcohol facts and statistics.
- Hirode, G., Saab, S., & Wong, R. J. (2020). Trends in the burden of chronic liver disease among hospitalized US adults. JAMA network open, 3(4), e201997.
- National Institute of Diabetes and Digestive and Kidney Diseases. Diagnosis of Cirrhosis: How do doctors diagnose cirrhosis?
- Sanchez, W. & Talwalkar, J. (2012). Liver cirrhosis.
- Lin, H. (2020). Alagille syndrome.
- American Liver Foundation. (2019). Cirrhosis poster.
- American Gastroenterological Association. (2020). Cirrhosis.
- National Institute of Diabetes and Digestive and Kidney Diseases. (2018, March). Definition & facts for cirrhosis.
- Heidelbaugh, Joel J., M.D. and Sherbondy, Maryann, M.D. (2006). Cirrhosis and Chronic Liver Failure: Part II. Complications and Treatment. American Family Physician, 74(5), 767-776.
- Ng, Charles KF, Chan, Michael HM, Tai, Morris HL, Lam, Christopher WK. (2007). Hepatorenal Syndrome. The Clinical Biochemist, 28(1), 11-17.
- Arroyo, Vicente, Moreau, Richard, Kamath, Patrick, Jalan, Rajiv, Ginès, Pere, Nevens, Frederik, Fernández, Javier, Yo, Uyen, García-Tsao, Guadalupe, and Schnabl, Bernd. (2016). Acute-on-chronic liver failure in cirrhosis. Nature Reviews Disease Primers 2.
- Bernal, W., & Wendon, J. (2013). Acute liver failure. The New England journal of medicine, 369(26), 2525–2534.
- U.S. Department of Veterans Affairs. (2018, October 29). Viral hepatitis and liver disease: When to go to the emergency room.
- Thornton, K. (2021, June 1). Evaluation and prognosis of persons with cirrhosis.
- U.S. Department of Veterans Affairs. (2019, January 2). Viral hepatitis and liver disease: Stages of cirrhosis.
- Biselli, M., Gitto, S., Gramenzi, A., Di Donato, R., Brodosi, L., Ravaioli, M.… & Bernardi, M. (2010). Six score systems to evaluate candidates with advanced cirrhosis for orthotopic liver transplant: Which is the winner?. Liver transplantation, 16(8), 964–973.
- American Liver Foundation. (2018). Cirrhosis: What you need to know to prevent liver damage.
- National Institute of Diabetes and Digestive and Kidney Diseases. (2018, March). Eating, diet, & nutrition for cirrhosis.
- Riley, T. R., 3rd, & Bhatti, A. M. (2001). Preventive strategies in chronic liver disease: part II. Cirrhosis. American family physician, 64(10), 1735–1740.