What Are The Four Stages Of Cirrhosis Of The Liver?

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Cirrhosis of the liver has four stages: (i) Inflammation, (ii) Fibrosis, (iii) Cirrhosis, and (iv) Liver failure

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The Four Stages Of Liver Disease

(i) Inflammation (Steatosis)

Inflammation is the body's organic immune response to injury.

In the case of liver disease, inflammation occurs when the liver is "irritated" or senses exposure to a harmful agent such as chemicals or viral infections.

Acute inflammation resolves itself within a few hours or days and healthy tissue regenerates.

If the liver continually signals an immune response--such as when it's subjected to ongoing exposure to alcohol--chronic inflammation occurs.

This has the potential to lead to cell death, which begins to compromise the liver's capability to function properly and results in Stage I liver disease [6].

Alterations to the liver at this stage in the disease are reversible through lifestyle changes and medication, depending on the cause of inflammation.

If the damage is not corrected, it will lead to the second stage of liver disease.

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(ii) Fibrosis

During this phase, also known as compensated cirrhosis, healthy liver tissue is replaced by non-functioning scar tissue.

The smooth, undamaged, fibrous-free parts of the liver continue to function during this stage, meaning that, while the scar tissue cannot be undone, the rest of the liver has the chance to operate (and survive).

The prognosis for liver disease at this stage is relatively promising [7].

However, if appropriate measures are not taken to halt the damage--from ceasing or curbing alcohol consumption to treating hepatitis b or c (depending on the cause of scarring)--healthy liver cells will continue to erode as fibrosis spreads.

(iii) Cirrhosis

This phase, or Stage III liver disease, is signified by the widespread progression of fibrosis, which obstructs blood flow to the liver while also enlarging the organ [8].

The symptoms of liver damage begin to present at this stage as liver function deteriorates.

At this point in the progression, the damage that has occurred to the liver cannot be repaired.

The focus during this stage of cirrhosis is on alleviating the symptoms of liver disease and minimising further damage [9].

(iv) Liver Failure/End Stage Liver Disease

Liver failure, or decompensated cirrhosis, is the final stage of cirrhosis, or advanced liver disease [10].

More prominent symptoms of liver failure present at this stage, including yellowing of the eyes, abdominal distension, fever, trembling hands, and frequent muscle cramps.

The only available treatments for this stage of cirrhosis are symptom management and/or a liver transplant.

What Is Cirrhosis?

Cirrhosis is the advanced stage of scarring--or fibrosis--of the liver due to several liver conditions [1].

Fibrosis of the liver occurs when the organ attempts to repair itself and scar tissue forms during the healing process.

Scarring is a natural human reaction to injury, but when the liver is continually damaged--either through prolonged, heavy alcohol consumption, viral hepatitis, non-alcoholic fatty liver disease, or another cause--dead, non-functioning scar tissue accumulates [2].

The more scar tissue that accumulates, the more it constricts blood flow to the liver.

Known as portal hypertension, this reaction deprives liver cells and leads to cell death [3].

As a result, the organ gets caught in a cycle of damage and scarring until the liver is comprised of hardened scar tissue and loses its facility to function.

The entire body is affected by the liver's inability to function properly, including the capacity to produce blood-clotting proteins, draw in--and eliminate--toxins, and aid with the absorption of fat and fat-soluble vitamins such as Vitamins A, D, E, and K [4].

Together, this has the potential to lead to life threatening complications, and death.

Symptoms of Cirrhosis

The symptoms of a diseased liver arrive in the third stage of cirrhosis [11]:

  • Unintentional weight loss
  • Weakness and fatigue
  • General malaise
  • Swollen or enlarged veins
  • Nausea and vomiting
  • Spider angiomas, or broken, spiderlike capillaries, especially above the waist
  • Red and/or blotchy palms
  • Reduced appetite
  • Muscle wasting
  • Pain and tenderness on the upper right corner of the abdomen

As the disease progresses and the liver continues to lose its functions, symptoms appear as [12]:

  • Jaundice, or a yellowing of the eyes and skin
  • Hair loss
  • Right shoulder pain
  • Impotence and/or decreased libido
  • Oedema, or swelling of bodily issues, particularly in the lower extremities (such as the ankles and feet)
  • Bleeding and bruising easily, and blood that doesn't clot
  • Sleep disturbances
  • Clubbed fingers, wherein the end of the fingers appear thicker or wider
  • Whitening of the nails
  • Bleeding gums
  • Dark, tarry stools
  • Tachycardia, or very rapid heartrate
  • Dizziness
  • Tendency to fall
  • Anaemia, or extreme fatigue
  • Severe skin itching
  • Ascites, or bloating, from fluid buildup in the abdomen
  • Poor recall and concentration
  • Personality changes
  • Confusion and disorientation
  • Testicular atrophy
  • Gastrointestinal bleeding [13]

The final symptoms of liver disease are indicative of acute liver failure and are deemed a medical emergency [14]:

  • Loss of consciousness
  • Hepatic encephalopathy [15]
  • High-temperature fever
  • Marked confusion and drowsiness
  • Shortness of breath
  • Vomiting blood

What Are The Causes Of Cirrhosis Of The Liver?

Alcohol Use Disorder (AUD) is one of the leading causes of liver disease [15].

Other causes of cirrhosis include [16]:

  • Primary Sclerosis Cholangitis
  • Nonalcoholic Fatty Liver Disease (NAFLD)
  • Chronic Hepatitis B
  • Chronic Hepatitis C
  • Hepatitis D
  • Non-alcoholic Steatohepatitis (NASH)
  • Hemochromatosis
  • Autoimmune Disorders, such as Primary Biliary Cirrhosis
  • Wilson's Disease

Cirrhosis is also caused by over-the-counter (OTC) and prescription drugs, including antibiotics, anti-depressants, and pain relievers such as acetaminophen [17].

Further, a poor diet and obesity are contributing factors to the development of nonalcoholic fatty liver disease [18].

The use of illegal drugs, such as cocaine, also increases the chances of liver disease [19].


Why Is Cirrhosis Especially Prevalent In Alcoholics?

Alcohol is metabolised in the body in a three-pronged enzymatic process [20].

When the body is consistently overwhelmed with alcohol from excessive and protracted consumption, the efficiency of this process falters and a carcinogenic toxin called acetaldehyde amasses in the liver.

This creates protein adducts the body interprets as pathogens and the early stage of cirrhosis--inflammation--is initiated.

Unless alcohol abuse ends, inflammation continues and fibrosis ensues, resulting in chronic liver failure.

Prevalence Of Cirrhosis

According to the National Institutes of Health, 1 in 400 Americans have cirrhosis of the liver [21], while the British Liver Trust reports that 4,000 patients die of cirrhosis in the U.K. annually [22].

Additionally, 700 liver transplants are performed in the U.K. every year.

While cirrhosis of the liver is more ubiquitous among men overall, a 2019 metanalysis of studies reveals that women are more vulnerable to the disease at any level of alcohol consumption; the risk for males, on the other hand, increases if they consume more than one drink daily [23].


Rate Of Cirrhosis In Alcoholism

Alcohol related cirrhosis occurs in 10 to 20% of heavy alcohol drinkers and is dependent on the duration of alcohol use disorder and the amount of alcohol consumed on a daily or regular basis [24].

Complications Of Liver Disease

Cirrhosis has the potential to lead to several complications [25]:

  • Urinary tract infections (UTIs)
  • Cerebral oedema
  • Malnutrition
  • Gallstones
  • Kidney failure
  • Liver cancer

How Is Cirrhosis Of The Liver Identified?

The early stages of cirrhosis are largely asymptomatic, rendering liver disease difficult to detect.

Indeed, the British Liver Trust reports that most cases of cirrhosis are discovered during exams for unassociated illnesses [26].

As the disease progresses, however, symptoms begin to emerge.

The Child-Pugh score evaluates the severity of liver disease by conducting blood tests and assessing for the presence of ascites and other advanced-stage symptoms [27].

This score grades cirrhosis from A (mild) to C (severe), and helps medical professionals determine the most urgent candidates for a liver transplant.

The overall health of the liver is also examined in a liver panel, which examines the proteins, enzymes, and other substances manufactured by the liver.

The most conclusive test for cirrhosis is a liver biopsy.

Prevention Of Cirrhosis

Preventative measures include:

  • Moderate alcohol consumption or ceasing alcohol intake altogether
  • Maintain a healthy weight/lose weight as needed
  • Receive treatment for viral hepatitis
  • Monitor liver health
  • Engage in early treatment for liver disease, ideally involving behavioural changes in a structured rehab programme for alcohol recovery.
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About the author

Robyn Russell

Robyn Russell, has appeared in PsychCentral [1] [2] [3], Women's Health, Livestrong, She Knows, and Brevity, among others. She holds an MFA in writing from the University of San Francisco.

Content reviewed by Laura Morris (Clinical Lead).

Last Updated: April 5, 2024