Last updated: February 27, 2023

Summarytoggle arrow icon

Cirrhosis is a condition caused by chronic damage to the liver, most commonly due to excessive alcohol consumption, nonalcoholic fatty liver disease, or hepatitis C. Other causes include inflammatory or metabolic diseases, such as primary biliary cirrhosis and hemochromatosis. Cirrhosis is characterized by hepatic parenchymal necrosis and an inflammatory response to the underlying cause. Subsequent hepatic repair mechanisms lead to fibrosis and abnormal tissue architecture, which impair liver function. Patients can present with a range of symptoms, including ascites; hepatosplenomegaly; and skin manifestations of cirrhosis, such as jaundice, spider angioma, and/or palmar erythema. Men may also display signs of feminization (e.g., gynecomastia, hypogonadism). In severe cases, the accumulation of toxic metabolites or involvement of additional organs can lead to complications such as hepatic encephalopathy and hepatorenal syndrome (HRS). Laboratory studies show signs of hepatocyte damage (e.g., elevated liver enzymes, hyperbilirubinemia) and/or impaired hepatic synthetic function (e.g., prolonged prothrombin time, low albumin). Abdominal ultrasound typically shows shrunken, heterogeneous liver parenchyma with a nodular surface. A biopsy is the method of choice for confirming the diagnosis; however, it is usually only performed if the results from other diagnostic modalities are inconclusive. Management consists of treatment of the underlying disease (e.g., avoidance of toxic substances, antiviral drugs), adequate calorie intake, and medication for treating complications (e.g., spironolactone for ascites). In cases of decompensated cirrhosis, interventional procedures may be used to alleviate symptoms (e.g., paracentesis to drain ascites) or as a bridge until liver transplantation is possible.

Epidemiologytoggle arrow icon

  • Prevalence: approx. 0.27% in US adults [1]
  • Sex: > (2:1) [2]
  • Mortality [2]
    • Responsible for approx. 1–2% of all deaths in the US (12th leading cause of death)
    • Most deaths occur in the fifth to sixth decade of life.

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

Cryptogenic cirrhosis is a diagnosis of exclusion and should only be considered after a complete patient evaluation has ruled out all other possible causes of cirrhosis.

Hepatitis C, alcoholic liver disease, and NASH are the most common causes of cirrhosis in the US.

Pathophysiologytoggle arrow icon

Clinical featurestoggle arrow icon

Patients with cirrhosis can be asymptomatic (compensated cirrhosis). Disease progression leads to fatigue, weight loss, abdominal distention, and spider angiomata followed by decompensated cirrhosis, manifesting with bleeding varices, ascites, encephalopathy, and jaundice.

Nonspecific features

  • Patients are often initially asymptomatic.
  • Fatigue, malaise, anorexia, and weight loss

Specific features

Dermal features

Abdominal features

Hormonal disorders


Specific clinical features due to rare causes

Diagnosticstoggle arrow icon

General principles [10][11]

Patients with cirrhosis are usually either asymptomatic with incidental abnormal findings on laboratory studies or imaging, or present late with features of decompensated cirrhosis.

Laboratory studies

Routine laboratory studies [10][12][13]

Liver chemistries may be normal in early compensated cirrhosis. [10]

Some CBC abnormalities are due to the combination of increased hepatic and splenic sequestration of thrombocytes (portal hypertension leads to splenomegaly with hypersplenism) and decreased production of hematopoietic factors by the liver.

Hepatocyte injury: ↑ AST, ALT, ALP, GGT. Synthetic dysfunction: ↑ bilirubin and PT/INR; ↓ albumin and platelets

Additional laboratory studies [10][13][14][15]

These studies may help to identify the underlying etiology and further evaluate liver function. Modification may be required based on clinical features and the presence of risk factors.


Abdominal ultrasound with Doppler [10][18]

CT abdomen [18][21]

Liver biopsy [10][13]

  • Indications
    • In cases of diagnostic uncertainty (gold standard)
    • Grading and staging of inflammation and fibrosis (e.g., using the IASL score or METAVIR score)
    • Monitoring treatment response (e.g., in autoimmune hepatitis)
    • Evaluation of focal lesions
  • Findings: See “Pathology.”

Screening for complications

Advanced testing

Noninvasive liver fibrosis scoring systems [10][23]

These biomarker-based tools can be used as an adjunct to confirm and stage cirrhosis of certain etiologies.

  • AST-to-platelet ratio index (APRI)
    • Used for cirrhosis caused by HCV or HBV
    • An APRI > 1 is suggestive of cirrhosis.
  • Fibrosis-4 score
  • NAFLD fibrosis score

Liver elastography [10][25][26]

Stagingtoggle arrow icon

Model for end-stage liver disease score (MELD score) [28]

  • Used to predict the three-month mortality rate of patients with cirrhosis
  • Primarily used to prioritize patients for liver transplantation [28]
  • Patients are given a score from 6 to 40 based on serum bilirubin, INR, and creatinine levels.
  • Patients with high scores have the worst prognosis without intervention and should therefore be prioritized for transplantation (if appropriate)

Child-Pugh score [22]

  • A prognostic grading scale that assesses survival rate and predicts the likelihood of developing complications based on bilirubin and albumin levels, prothrombin time, and the presence of ascites and encephalopathy
  • Can be used as a prognostic scoring system [29]
    • Child‑Pugh class A: one-year survival rate of ∼ 100%
    • Child‑Pugh class B: one-year survival rate of ∼ 80%
    • Child‑Pugh class C: one-year survival rate of ∼ 45%
Child-Pugh score
Findings Points
1 2 3
Serum albumin (g/dL) > 3.5 2.8–3.5 < 2.8
Serum bilirubin (mg/dL) < 2.0 2.0–3.0 > 3.0
INR < 1.7 1.7–2.3 > 2.3
Ascites None Mild Moderate
Hepatic encephalopathy None Minimal Advanced
  • Child-Pugh class A: 5–6 points
  • Child-Pugh class B: 7–9 points
  • Child-Pugh class C: 10–15 points

CHILD's ABCDEs: Albumin, Bilirubin, Coagulation (i.e., INR), Distended abdomen (i.e., ascites), and Encephalopathy

Treatmenttoggle arrow icon

General principles [10][30]

Patients with cirrhosis are typically managed in consultation with specialists.

Supportive care [10][30][31][32]

Liver transplant [33]

Pathologytoggle arrow icon

  • Fibrosis (fibrous septa)
  • Replacement of normal liver tissue with collagenous regenerative nodules (histological staging is based on the size of the regenerative nodules) [34]
  • Abnormal cell activation with infiltration of inflammatory cells
  • Loss of physiological vessel architecture (central vein disappearance)
Size of the regenerative nodules Occurrence
  • 1–3 mm
  • > 3 mm
  • 1–3 mm and > 3 mm
  • Possible in every type of liver‑damaging disease

Complicationstoggle arrow icon

Overview [35]

Overview of common complications of cirrhosis [10][31][36][37]
Portal hypertension complications
Cardiopulmonary complications
Hemostatic abnormalities (coagulopathy)
Metabolic complications

Cirrhosis-associated ascites and edema and elevated bleeding risk increase the risk for hypovolemic shock.

Vitamin K infusion may improve clotting function in select patients with vitamin K deficiency; it is unlikely to be effective in patients with advanced liver disease and coagulopathy.

We list the most important complications. The selection is not exhaustive.

Decompensated cirrhosistoggle arrow icon

Pulmonary complications of cirrhosistoggle arrow icon

Hepatopulmonary syndrome


A condition characterized by hypoxemia, intrapulmonary vasodilatation, and portal hypertension in the presence of cirrhosis


Clinical features [41]

Diagnostics [41]

Treatment [31][41]

Portopulmonary hypertension (POPH) [41]

Definition [41]

Portopulmonary hypertension is a diagnosis of exclusion made in patients with pulmonary arterial hypertension and portal hypertension after other causes have been ruled out.


Clinical features [31][41]

Risk factors [41]

  • Female sex
  • Autoimmune liver disease

Diagnostics [41]

Congestive heart failure and severe POPH (mPAP ≥ 45 mm Hg) are absolute contraindications to elective TIPS. [41]

Treatment [31][41]

Hepatic hydrothorax [42]

Ascites may be absent in up to 20% of cases of hepatic hydrothorax. [42]

Other pulmonary complications

Special patient groupstoggle arrow icon

Liver cirrhosis in pregnancy [43][44]

Referencestoggle arrow icon

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