Cirrhosis

Also called Liver disease, Fatty liver, Scarring of the liver

Scarring of the liver, usually silent until it is advanced. Liver disease is the one major cause of early death in the UK still rising, and much of it is preventable.

What it is

Long-term damage that replaces liver tissue with scar tissue. Once established the scarring does not reverse, but stopping the cause halts it, and a compensated liver can keep working for many years.

Three causes account for most of it in the UK: alcohol, fatty liver disease associated with obesity and type 2 diabetes, and viral hepatitis. All three are treatable, and the first two are common in people who have never been told their liver is involved.

It is usually silent. The liver has enormous reserve, so people feel well until the disease is advanced, and roughly three quarters of people with cirrhosis in the UK are first diagnosed in an emergency admission. Standard blood tests are frequently normal in significant liver disease, which is why a normal liver function test is not reassurance.

Decompensated cirrhosis, where the liver can no longer keep up, means jaundice, fluid in the abdomen, confusion, and bleeding from veins in the gullet. Each of those is an emergency the first time it happens.

Anybody with cirrhosis needs six-monthly ultrasound surveillance for liver cancer, and a large proportion do not get it.

Signs you might notice

Early: often nothing. Tiredness, weakness, loss of appetite, weight loss, or nausea.

Later: jaundice, yellowing of the skin and eyes; itching; swelling of the legs; a swollen abdomen from fluid; easy bruising; spidery blood vessels on the skin; red palms.

Confusion, drowsiness, disturbed sleep, or a flapping tremor of the outstretched hands. This is hepatic encephalopathy and needs same-day assessment; it is regularly mistaken for delirium, dementia or intoxication.

999 or A and E: vomiting blood or coffee-ground vomit; black tarry stools; new or worsening confusion; a swollen abdomen with fever or pain, which may be an infected fluid collection.

How it can affect day-to-day life

The stigma is a clinical problem, not just a social one. People with alcohol-related liver disease commonly delay presenting and are treated dismissively when they do, and that costs years.

Fatty liver disease carries no stigma and no symptoms, which is a different problem: nobody worries about it until it has become cirrhosis.

Diet matters more than people expect and in the opposite direction to what they assume. People with cirrhosis need MORE protein, not less, and frequent meals including a late evening snack, because the liver runs out of stored fuel overnight. Malnutrition and muscle loss are common and are strongly linked to poor outcomes. See dietetics and malnutrition.

Medicines need care: paracetamol is usually safe at reduced doses and is safer than anti-inflammatories, which can cause bleeding and kidney damage here.

Alcohol has to stop completely, and doing that safely may need medically supported withdrawal rather than willpower. See alcohol dependence.

Supporting someone well

Do not accept a normal liver blood test as proof the liver is fine. Ask about a fibrosis score or a FibroScan if there is a reason to worry.

Address the cause: alcohol, weight and diabetes, or antiviral treatment for hepatitis. Hepatitis C is now curable in most people with a course of tablets.

Never stop alcohol abruptly in a dependent drinker without advice; withdrawal can be dangerous.

Eat more protein and more often, including a snack before bed. This is the opposite of what most people assume.

Ask whether six-monthly ultrasound surveillance for liver cancer is in place, and chase it.

Get the vaccinations offered, including hepatitis A and B, flu and pneumococcal.

Learn to recognise confusion as a symptom of the liver rather than of the person. It is treatable and it is an emergency.

Ask about referral to a liver specialist rather than staying under general care.

Where to get help

A GP practice for assessment and for the cause.

The hepatology team once diagnosed, and ask for a specialist nurse.

999 or A and E for vomiting blood, black stools or new confusion.

British Liver Trust run a helpline on 0800 652 7330 and have the clearest patient information on liver disease.

Alcohol Change UK and local alcohol services for support with drinking.