What is Cirrhosis?
Cirrhosis is a late stage of chronic liver disease where the normal liver tissue is progressively replaced by scar tissue (fibrosis). This scarring distorts the normal structure of the liver, blocking blood flow through the organ and impairing its ability to function. The liver performs over 500 vital functions, including filtering toxins from the blood, producing bile for digestion, making proteins for blood clotting, and storing energy.
Cirrhosis develops slowly over months to years. The damage is generally irreversible, but early detection and treatment of the underlying cause can slow or halt progression and prevent life-threatening complications.
Common Causes in Sri Lanka
| Cause | Details |
|---|---|
| Alcohol-Related Liver Disease | Chronic heavy alcohol consumption is a leading cause of cirrhosis in Sri Lanka. The liver can only process a limited amount of alcohol. Years of excess drinking leads to fatty liver, then alcoholic hepatitis, and eventually cirrhosis. The risk increases significantly with consumption of illicit alcohol (kasippu), which may contain additional toxic substances. |
| Non-Alcoholic Fatty Liver Disease (NAFLD) | The fastest-growing cause of liver disease globally, including in Sri Lanka. Fat accumulates in the liver due to obesity, diabetes, and metabolic syndrome. In some patients, it progresses to non-alcoholic steatohepatitis (NASH) and eventually cirrhosis. Closely linked to the rising prevalence of diabetes and obesity in Sri Lanka. |
| Hepatitis B | A viral infection transmitted through blood, sexual contact, or from mother to child at birth. Chronic hepatitis B can cause ongoing liver inflammation leading to cirrhosis and liver cancer. Vaccination is available and included in Sri Lanka's childhood immunisation programme. |
| Hepatitis C | Transmitted primarily through blood (contaminated needles, unsafe blood transfusions). Chronic infection can lead to cirrhosis over 20-30 years. Now curable with antiviral medications in most cases. |
| Medications and Toxins | Long-term use of certain medications (e.g., methotrexate, some herbal and ayurvedic preparations) and paracetamol overuse can damage the liver. Exposure to environmental toxins and contaminated food (aflatoxins) may also contribute. |
Stages of Cirrhosis
Compensated Cirrhosis
The liver is scarred but still able to perform most of its functions. Patients may have few or no symptoms. The liver compensates for the damage. Early detection at this stage allows for interventions that can significantly slow progression. Regular monitoring is essential.
Decompensated Cirrhosis
The liver can no longer adequately perform its functions. Serious complications develop, including ascites (fluid in the abdomen), variceal bleeding, jaundice, and hepatic encephalopathy (confusion). This stage carries a much poorer prognosis and may require evaluation for liver transplantation.
Symptoms
Early cirrhosis (compensated) often has no obvious symptoms. As the disease progresses, symptoms may include:
- Fatigue and weakness: Persistent tiredness that does not improve with rest
- Easy bruising and bleeding: The liver produces clotting factors; reduced production leads to easy bruising, bleeding gums, and nosebleeds
- Jaundice: Yellowing of the skin and whites of the eyes due to buildup of bilirubin
- Swollen abdomen (ascites): Fluid accumulation in the abdominal cavity, causing the belly to swell and feel tight
- Leg swelling (oedema): Swelling of the ankles and feet due to fluid retention
- Confusion and drowsiness (hepatic encephalopathy): Toxins that the liver normally filters accumulate in the blood and affect brain function
- Spider naevi: Small, spider-like blood vessels visible on the skin, especially on the chest and face
- Reddened palms (palmar erythema): The palms of the hands become unusually red
- Loss of appetite and weight loss
- Itchy skin (pruritus): Due to bile salt deposits in the skin
- Dark urine and pale stools
Diagnosis
| Test | Purpose |
|---|---|
| AST and ALT (Liver Enzymes) | May be mildly elevated or even normal in advanced cirrhosis. The AST:ALT ratio greater than 1 is suggestive of cirrhosis. |
| Albumin | Low albumin levels indicate poor liver synthetic function. Albumin is a protein made by the liver; low levels contribute to fluid retention. |
| Bilirubin | Elevated bilirubin causes jaundice. Rising bilirubin levels indicate worsening liver function. |
| PT/INR (Prothrombin Time) | Prolonged clotting time indicates impaired production of clotting factors by the liver. An important marker of liver function severity. |
| Full Blood Count | Low platelet count (thrombocytopenia) is common in cirrhosis due to an enlarged spleen (splenomegaly). |
| Ultrasound Abdomen | Shows liver size, surface irregularity, spleen enlargement, ascites, and portal vein changes. The first-line imaging investigation. |
| FibroScan (Transient Elastography) | A non-invasive test that measures liver stiffness. Higher stiffness indicates more fibrosis/cirrhosis. Increasingly available in Sri Lanka. |
| Hepatitis B and C Screening | Blood tests (HBsAg, Anti-HCV) to identify viral causes of cirrhosis that may be treatable. |
Complications
- Variceal bleeding: Increased pressure in the portal vein (portal hypertension) causes enlarged, fragile veins (varices) in the oesophagus and stomach. These can rupture and cause life-threatening bleeding — vomiting large amounts of blood or passing black, tarry stools.
- Ascites: Accumulation of fluid in the abdominal cavity. Causes abdominal swelling, discomfort, and shortness of breath. Can become infected (spontaneous bacterial peritonitis — SBP), which is a medical emergency.
- Hepatic encephalopathy: Buildup of toxins (especially ammonia) in the blood affects brain function, causing confusion, disorientation, personality changes, slurred speech, and in severe cases, coma.
- Hepatocellular carcinoma (liver cancer): Cirrhosis significantly increases the risk of liver cancer. Regular screening with ultrasound and alpha-fetoprotein (AFP) blood tests every 6 months is recommended.
- Kidney failure (hepatorenal syndrome): Advanced cirrhosis can cause the kidneys to fail, a serious complication with a poor prognosis.
- Infections: Patients with cirrhosis have weakened immune function and are more susceptible to bacterial infections.
Management
How Cirrhosis is Managed
- Treat the underlying cause: Stop alcohol completely. Treat hepatitis B or C with antiviral medications. Manage fatty liver through weight loss and diabetes control.
- Avoid alcohol completely: Even small amounts of alcohol can accelerate liver damage. This is the single most important step for patients with alcohol-related cirrhosis.
- Low-salt diet: Restrict salt to less than 2 grams per day to help control ascites and fluid retention. Avoid processed foods, pickles, dried fish, and papadam.
- Diuretics: Medications such as spironolactone and furosemide help the body remove excess fluid.
- Lactulose: A laxative that helps remove ammonia from the body, used to prevent and treat hepatic encephalopathy.
- Beta-blockers: Propranolol or carvedilol may be prescribed to reduce portal pressure and prevent variceal bleeding.
- Avoid hepatotoxic drugs: Minimise use of paracetamol and avoid NSAIDs (ibuprofen, diclofenac). Always inform your doctor and pharmacist that you have liver disease.
- Regular screening: Ultrasound and AFP blood test every 6 months for liver cancer surveillance. Upper GI endoscopy to check for varices.
- Liver transplant evaluation: In advanced decompensated cirrhosis, liver transplantation may be the only definitive treatment. Referral to a specialist hepatology centre should be considered.
Living with Cirrhosis
- Take all medications as prescribed — do not skip doses or stop without medical advice
- Get vaccinated: Hepatitis A and B vaccines (if not already immune), annual influenza vaccine, and pneumococcal vaccine
- Eat adequate protein: Contrary to old advice, most cirrhosis patients need adequate protein (1.2-1.5 g/kg/day) unless specifically advised otherwise by their doctor
- Avoid raw shellfish and undercooked meat: Increased risk of serious infections
- Do not use herbal or ayurvedic remedies without consulting your doctor — many can worsen liver damage
- Weigh yourself daily: Sudden weight gain may indicate fluid accumulation
- Attend all follow-up appointments: Regular blood tests and imaging are essential to monitor liver function and detect complications early
When to Seek Immediate Medical Help
Go to a hospital or call us immediately if you experience:
- Vomiting blood or passing black, tarry stools — may indicate variceal bleeding, which is a life-threatening emergency
- Confusion, disorientation, or unusual drowsiness — signs of hepatic encephalopathy
- Severe abdominal swelling that is worsening rapidly or accompanied by fever and pain (possible infected ascites)
- Fever in a patient with known cirrhosis — even mild fever can indicate a serious infection
- Worsening jaundice (increasing yellowing of skin and eyes)
- Reduced urine output despite adequate fluid intake
- Difficulty breathing due to large ascites pressing on the lungs
- New or worsening leg swelling
Important: This information is for educational purposes only. If you are unsure about your symptoms or they are severe, please consult a doctor. Our doctors are available for home visits and telemedicine consultations.