Liver cirrhosis

Alcoholic Liver Cirrhosis: Causes, Symptoms & Diagnosis

Liver cirrhosis

The liver is a large organ with an important job in your body. It filters the blood of toxins, breaks down proteins, and creates bile to help the body absorb fats. When a person drinks alcohol heavily over the course of decades, the body starts to replace the liver’s healthy tissue with scar tissue. Doctors call this condition alcoholic liver cirrhosis.

As the disease progresses, and more of your healthy liver tissue is replaced with scar tissue, your liver will stop functioning properly

According to the American Liver Foundation, between 10 and 20 percent of heavy drinkers will develop cirrhosis. Alcoholic liver cirrhosis is the most advanced form of liver disease that’s related to drinking alcohol.

The disease is part of a progression. It may start with fatty liver disease, then progress to alcoholic hepatitis, and then to alcoholic cirrhosis.

However, it’s possible a person can develop alcoholic liver cirrhosis without ever having alcoholic hepatitis.

Symptoms of alcoholic liver cirrhosis typically develop when a person is between the ages of 30 and 40. Your body will be able to compensate for your liver’s limited function in the early stages of the disease. As the disease progresses, symptoms will become more noticeable.

The symptoms of alcoholic liver cirrhosis are similar to other alcohol-related liver disorders. Symptoms include:

Damage from repeated and excessive alcohol abuse leads to alcoholic liver cirrhosis. When the liver tissue starts to scar, the liver doesn’t work as well as it did before. As a result, the body can’t produce enough proteins or filter toxins the blood as it should.

Cirrhosis of the liver can occur due to a variety of causes. However, alcoholic liver cirrhosis is directly related to alcohol intake.

The most significant risk factor for alcoholic liver disease is alcohol abuse. Typically, a person has drank heavily for at least eight years. The National Institute on Alcohol Abuse and Alcoholism defines heavy drinking as drinking five or more drinks in one day on at least five of the past 30 days.

Women are also more at-risk for alcoholic liver disease. Women don’t have as many enzymes in their stomachs to break down alcohol particles. Because of this, more alcohol is able to reach the liver and make scar tissue.

Alcoholic liver disease can also have some genetic factors. For example, some people are born with a deficiency in enzymes that help to eliminate alcohol. Obesity, a high-fat diet, and having hepatitis C can also increase a person’s lihood they will have alcoholic liver disease.

Alcoholic liver cirrhosis can cause serious complications. This is known as decompensated cirrhosis. Examples of these complications include:

  • ascites, or a buildup of fluid in the stomach
  • encephalopathy, or mental confusion
  • internal bleeding, known as bleeding varices
  • jaundice, which makes the skin and eyes have a yellow tint

Those with this the more severe form of cirrhosis often require a liver transplant to survive. According to the Cleveland Clinic, patients with decompensated alcoholic liver cirrhosis who receive a liver transplant have a five-year survival rate of 70 percent.

Doctors can reverse some forms of liver disease with treatment, but alcoholic liver cirrhosis usually can’t be reversed. However, your doctor can recommend treatments that may slow the disease’s progress and reduce your symptoms.

The first step in treatment is to help the person stop drinking. Those with alcoholic liver cirrhosis are often so dependent on alcohol that they could experience severe health complications if they try to quit without being in the hospital. A doctor can recommend a hospital or treatment facility where a person can start the journey toward sobriety.

Other treatments a doctor may use include:

  • Medications: Other medications doctors may prescribe include corticosteroids, calcium channel blockers, insulin, antioxidant supplements, and S-adenosyl-L-methionine (SAMe).
  • Nutritional Counseling: Alcohol abuse can lead to malnutrition.
  • Extra protein: Patients often require extra protein in certain forms to help reduce the lihood for developing brain disease (encephalopathy).
  • Liver Transplant: A person often must be sober for at least six months before they are considered a candidate for liver transplant.

Your outlook will depend on your overall health and whether you have developed any complications related to cirrhosis. This is true even when a person stops drinking.


Cirrhosis and Your Liver

Liver cirrhosis

If your doctor tells you that you have cirrhosis, it means you have a condition that causes scar tissue to gradually replace your healthy liver cells. It usually happens over a long period of time because of infection or alcohol addiction. Most of the time, you can't fix the damage to your liver, but if you catch it early, there are treatments that can keep problems in check.

Your liver is an organ that's about the size of a football with an important job. It filters toxins from your blood, makes enzymes that help you digest food, stores sugar and nutrients, and helps you fight infections.

Each time your liver gets hurt, it repairs itself and forms tough scar tissue. When too much scar tissue builds up, the organ can't work right.

You may not have any symptoms at first. But as time goes on, and the damage to your liver gets worse, you may notice things :

  • Fatigue and weakness
  • Lack of appetite and weight loss
  • Nausea

You could also bleed or bruise easily and have swelling in your legs or belly. You may also notice changes in your skin, such as:

  • Jaundice (when your skin and eyes turn yellow)
  • Intense itching
  • Spider web- blood vessels in your skin
  • Redness in the palms of your hands or whitening of your nails

You could have some changes to the way you think, such as problems with concentration or memory. If you're a woman, you may stop having periods. If you're a man, you could lose your sex drive, start to develop breasts, or see some shrinkage in your testicles.

Some other symptoms you might get are:

Keep in mind that you may not get all these symptoms, and some of these problems are also signs of other conditions.

Cirrhosis doesn't happen overnight. You get damage to your liver over a long period of time. The most common things that raise your odds for cirrhosis are:

Conditions that can lead to cirrhosis include:

Since you might not feel symptoms right away, you may not find out that you have cirrhosis until you get a routine checkup. When you visit your doctor, he'll ask about your alcohol use and medical history. He'll also examine you to check if your liver is tender or larger than it should be.

Tests. If your doctor suspects cirrhosis, he will do a blood test. It will check for signs that your liver isn't working right, such as:

  • High levels of certain liver enzymes
  • Buildup of bilirubin, which forms from the metabolism of heme. Heme iron comes from hemoglobin and is found in foods from animals such as chicken and red meat.
  • Low levels of proteins in your blood
  • Abnormal blood count
  • Infection with a virus
  • Antibodies that appear when you have an autoimmune liver disease

Your doctor may also do an imaging test of your belly, an MRI or ultrasound. You may also need a procedure called a biopsy, which removes a sample of your liver tissue to see how much damage has been done and potentially learn the cause of your liver disease.

Stages. Your doctor may also tell you what stage your cirrhosis is in. If he says you have compensated cirrhosis, it means your liver has scarring, but it still can do many of its key jobs. You might not notice any symptoms at this point.

If your doctor says you have decompensated cirrhosis, your liver is badly scarred and isn't working right. You'll probably have a lot of symptoms.

Your treatment depends on how badly your liver is injured. The goal is to protect the healthy tissue you have left.

The first step is to treat the condition that's causing your cirrhosis to prevent any more damage. This could mean a few different things:

  • Stop drinking alcohol right away. Your doctor can suggest a treatment program for addiction.
  • Lose weight if you are obese, especially if your cirrhosis is caused by fat buildup in your liver.
  • Take medications if you have hepatitis B or C.

You can also take medications to ease symptoms itching, fatigue, and pain.

Your doctor will also want to treat any complications that can happen with cirrhosis. He may suggest things :

Low-sodium diet. This can help control swelling. Your doctor may also ask you to take medications for this problem. If you have a severe fluid buildup, you may need to get it drained.

Blood pressure medications. They can lessen bleeding inside your body that's caused by swollen and burst blood vessels. You may need surgery if you have severely enlarged veins.

Antibiotics and vaccinations. They can treat and prevent other infections.

Your doctor may also suggest medications to lessen a buildup of toxins, if that's a problem for you. And if you have inflammation in your liver, steroids can help.

Your doctor may recommend regular testing to make sure you don't get liver cancer, which can be a complication of cirrhosis.

If your cirrhosis is severe, you may need a liver transplant. It's a major operation. You'll ly need to get on a waiting list for a new liver from an organ donor who has died. Sometimes people with cirrhosis can get part of a liver that is donated from someone who is living.

Usually, the damage that's already been done by cirrhosis can't be undone. But your liver can still work and bounce back even if two-thirds of it has been destroyed or removed.

If your cirrhosis is caused by long-term hepatitis, treating the infection can lower your chances of more problems if the damage is caught early. Most people with cirrhosis that's found in its early stage can live healthy lives.

If you are obese or have diabetes, losing weight and controlling your blood sugar can lessen damage caused by fatty liver disease. If the damage is caused by alcohol abuse, you can manage the cirrhosis better if you stop drinking right away.

A healthy lifestyle is a key part of preventing cirrhosis. If you drink alcohol, it's important to be moderate. If you're a man, don't have more than two drinks a day. If you're a woman, your limit should be one drink. If you have an addiction to alcohol, talk to your doctor about ways to quit.

Avoid risky behaviors that can lead to infections of hepatitis B and hepatitis C. Don't share needles when using illicit drugs, and use a condom when you have sex.

Also try to keep to a healthy weight and stay up to date with vaccines.


American Liver Foundation: “The Progression of Liver Disease.”

Athena Health: “Cirrhosis.”

British Liver Trust: “Alcohol & Drugs,” “Life After Liver Transplant.”

Cleveland Clinic: “Cirrhosis of the Liver.”

Hepatitis C Online: “Evaluation and Prognosis of Patients with Cirrhosis.”

Mayo Clinic: “Cirrhosis.”

Merck Manual: “Alcoholic Liver Disease.”

National Institute of Diabetes and Digestive and Kidney Diseases: “Diagnosis of Cirrhosis.”

University of Pittsburgh Medical Center: “Can You Live Without Your Liver?”

UpToDate: “Cirrhosis (Beyond the Basics).”

KidsHealth: “Your Liver.”

CDC: “Alcohol and Public Health: Frequently Asked Questions.”

HCV Advocate: “What is Cirrhosis?”

© 2019 WebMD, LLC. All rights reserved.


Chronic Liver Disease/Cirrhosis

Liver cirrhosis

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Cirrhosis is when scar tissue replaces healthy liver tissue. This stops the liver from working normally.

Cirrhosis is a long-term (chronic) liver disease. The damage to your liver builds up over time.

The liver is your body’s largest internal organ. It lies up under your ribs on the right side of your belly.

The liver does many important things including:

  • Removes waste from the body, such as toxins and medicines
  • Makes bile to help digest food
  • Stores sugar that the body uses for energy
  • Makes new proteins

When you have cirrhosis, scar tissue slows the flow of blood through the liver. Over time, the liver can’t work the way it should.

In severe cases, the liver gets so badly damaged that it stops working. This is called liver failure.

What causes cirrhosis?

The most common causes of cirrhosis are:

  • Hepatitis and other viruses
  • Alcohol abuse
  • Nonalcoholic fatty liver disease (this happens from metabolic syndrome and is caused by conditions such as obesity, high cholesterol and triglycerides, and high blood pressure)

Other less common causes of cirrhosis may include:

  • Autoimmune disorders, where the body’s infection-fighting system (immune system) attacks healthy tissue
  • Blocked or damaged tubes (bile ducts) that carry bile from the liver to the intestine
  • Use of certain medicines
  • Exposure to certain toxic chemicals
  • Repeated episodes of heart failure with blood buildup in the liver
  • Parasite infections

Some diseases passed from parent to child (inherited diseases) may also cause cirrhosis. These may include:

  • Alpha1-antitrypsin deficiency
  • High blood galactose levels
  • Glycogen storage diseases
  • Cystic fibrosis
  • Porphyria (a disorder in which certain chemicals build up in the blood)
  • Hereditary buildup of too much copper (Wilson disease) or iron (hemochromatosis) in the body

What are the symptoms of cirrhosis?

Your symptoms may vary, depending on how severe your cirrhosis is. Mild cirrhosis may not cause any symptoms at all.

Symptoms may include:

  • Fluid buildup in the belly (ascites)
  • Vomiting blood, often from bleeding in the blood vessels in the food pipe (esophagus)
  • Gallstones
  • Itching
  • Yellowing of the skin and eyes (jaundice)
  • Kidney failure
  • Muscle loss
  • Loss of appetite
  • Easy bruising
  • Spider- veins in the skin
  • Low energy and weakness (fatigue)
  • Weight loss
  • Confusion as toxins build up in the blood

The symptoms of cirrhosis may look other health problems. Always see your healthcare provider to be sure.

How is cirrhosis diagnosed?

Your healthcare provider will look at your past health. He or she will give you a physical exam.

You may also have tests including:

  • Blood tests. These will include liver function tests to see if the liver is working the way it should. You may also have tests to see if your blood is able to clot.
  • Liver biopsy. Small tissue samples are taken from the liver with a needle or during surgery. The samples are checked under a microscope to find out the type of liver disease.

Your healthcare provider may want you to have imaging tests including:

  • CT scan (computed tomography). This is an imaging test that uses X-rays and a computer to make detailed images of the body. A CT scan shows details of the bones, muscles, fat, and organs.
  • MRI (magnetic resonance imaging). This test makes detailed pictures of organs and structures inside your body. It uses a magnetic field and pulses of radio wave energy. A dye may be shot (injected) into your vein. The dye helps the liver and other organs to be seen more clearly on the scan.
  • Ultrasound. This shows your internal organs as they work. It checks how blood is flowing through different blood vessels. It uses high-frequency sound waves and a computer to create images of blood vessels, tissues, and organs.

You may also have an upper endoscopy (EGD). A lighted flexible camera is placed through your mouth into your upper digestive tract to look for enlarged blood vessels that are at risk of bleeding because of your cirrhosis. 

If you have fluid in the belly (ascites), you may need a low sodium diet, water pills (diuretics), and removal of the fluid with a needle (paracentesis).

How is cirrhosis treated?

Cirrhosis is a progressive liver disease that happens over time. The damage to your liver can sometimes reverse or improve if the trigger is gone, such as stop drinking alcohol or if the virus is treated.

The goal of treatment is to slow down the buildup of scar tissue and prevent or treat other health problems.

In many cases, you may be able to delay or stop any more liver damage. If you have hepatitis, it may be treated to delay worsening of your liver disease.

Your treatment may include:

  • Eating a healthy diet, low in sodium
  • Not having alcohol or illegal drugs
  • Managing any health problems that happen because of cirrhosis  

Talk to your healthcare provider before taking prescription medicines, over-the-counter medicines, or vitamins.

If you have severe cirrhosis, treatment can’t control other problems. A liver transplant may be needed.

Other treatments may be specific to your cause of cirrhosis, such as controlling excessive iron or copper levels, or using immune suppressing medicines.

Be sure to ask your healthcare provider about recommended vaccines. These include vaccines for viruses that can cause liver disease.

What are the complications of cirrhosis?

Cirrhosis can cause other health problems such as:

  • Portal hypertension. The portal vein carries blood from your intestines and spleen to your liver. Cirrhosis slows the normal flow of blood. That raises the pressure in the portal vein. This is called portal hypertension.
  • Enlarged blood vessels. Portal hypertension may cause abnormal blood vessels in the stomach (called portal gastropathy and vascular ectasia) or enlarged veins in the stomach and the food pipe or esophagus (called varices). These blood vessels are more ly to burst due to thin walls and higher pressure. If they burst, severe bleeding can happen. Seek medical attention right away.
  • Ascites. Fluid collecting in your belly. This can become infected. 
  • Kidney disease or failure
  • Easy bruising and severe bleeding. This happens when the liver stops making proteins that are needed for your blood to clot.
  • Type 2 diabetes. When you have cirrhosis, your body does not use insulin properly (insulin resistance). The pancreas tries to keep up with the need for insulin by making more, but blood sugar (glucose) builds up. This causes type 2 diabetes.
  • Liver cancer

Key points about cirrhosis

  • Cirrhosis is when scar tissue replaces healthy liver tissue. This stops the liver from working normally.
  • Cirrhosis is a long-term (chronic) liver disease.
  • The most common causes are hepatitis and other viruses, and alcohol abuse. Other medical problems can also cause it.
  • The damage to the liver usually can’t be reversed.
  • The goal of treatment is to slow down the buildup of scar tissue and prevent or treat any problems that happen.
  • In severe cases, you may need a liver transplant.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

  • Know the reason for your visit and what you want to happen.
  • Before your visit, write down questions you want answered.
  • Bring someone with you to help you ask questions and remember what your provider tells you.
  • At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
  • Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.
  • Ask if your condition can be treated in other ways.
  • Know why a test or procedure is recommended and what the results could mean.
  • Know what to expect if you do not take the medicine or have the test or procedure.
  • If you have a follow-up appointment, write down the date, time, and purpose for that visit.
  • Know how you can contact your provider if you have questions.


Cirrhosis: Incidence, Symptoms, and Treatment

Liver cirrhosis

Cirrhosis is the severe scarring of the liver and poor liver function seen at the terminal stages of chronic liver disease. The scarring is most often caused by long-term exposure to toxins such as alcohol or viral infections. The liver is located in the upper right side of the abdomen below the ribs. It has many essential body functions. These include:

  • producing bile, which helps your body absorb dietary fats, cholesterol, and vitamins A, D, E, and K
  • storing sugar and vitamins for later use by the body
  • purifying blood by removing toxins such as alcohol and bacteria from your system
  • creating blood clotting proteins

According to the National Institutes of Health (NIH), cirrhosis is the 12th leading cause of death due to disease in the United States. It’s more ly to affect men than women.

The liver is a very hardy organ and is normally able to regenerate damaged cells. Cirrhosis develops when the factors that damage the liver (such as alcohol and chronic viral infections) are present over a long period of time. When this happens, the liver becomes injured and scarred. A scarred liver can’t function properly, and ultimately this may result in cirrhosis.

Cirrhosis causes the liver to shrink and harden. This makes it difficult for nutrient-rich blood to flow into the liver from the portal vein. The portal vein carries blood from the digestive organs to the liver. The pressure in the portal vein rises when blood can’t pass into the liver.

The end result is a serious condition called portal hypertension, in which the vein develops high blood pressure.

The unfortunate consequence of portal hypertension is that this high-pressure system causes a backup, which leads to esophageal varices ( varicose veins), which can then burst and bleed.

The most common causes of cirrhosis in the United States are long-term viral hepatitis C infection and chronic alcohol abuse. Obesity is also a cause of cirrhosis, although it is not as prevalent as alcoholism or hepatitis C. Obesity can be a risk factor by itself, or in combination with alcoholism and hepatitis C.

According to the NIH, cirrhosis can develop in women who drink more than two alcoholic drinks per day (including beer and wine) for many years. For men, drinking more than three drinks a day for years can put them at risk for cirrhosis.

However, the amount is different for every person, and this doesn’t mean that everyone who has ever drunk more than a few drinks will develop cirrhosis.

Cirrhosis caused by alcohol is usually the result of regularly drinking more than these amounts over the course of 10 or 12 years.

Hepatitis C can be contracted through sexual intercourse or exposure to infected blood or blood products.

It’s possible to be exposed to infected blood through contaminated needles of any source, including tattooing, piercing, intravenous drug abuse, and needle sharing.

Hepatitis C is rarely transmitted by blood transfusion in the United States due to rigorous standards of blood bank screening.

Other causes of cirrhosis include:

  • Hepatitis B: Hepatitis B can cause liver inflammation and damage that can lead to cirrhosis.
  • Hepatitis D: This type of hepatitis can also cause cirrhosis. It’s often seen in people who already have hepatitis B.
  • Inflammation caused by autoimmune disease: Autoimmune hepatitis may have a genetic cause. According to the American Liver Foundation, about 70 percent of people with autoimmune hepatitis are women.
  • Damage to the bile ducts, which function to drain bile: One example of such a condition is primary biliary cirrhosis.
  • Disorders that affect the body’s ability to handle iron and copper: Two examples are hemochromatosis and Wilson’s disease.
  • Medications: Medications includingprescription and over-the-counter drugs acetaminophen, some antibiotics, and some antidepressants, can lead to cirrhosis.

Learn About Alcohol’s Effects on the Body »

The symptoms of cirrhosis occur because the liver is unable to purify the blood, break down toxins, produce clotting proteins, and help with absorption of fats and fat-soluble vitamins. Often there are no symptoms until the disorder has progressed. Some of the symptoms include:

  • decreased appetite
  • nose bleeds
  • jaundice (yellow discoloration)
  • small spider-shaped arteries underneath the skin
  • weight loss
  • anorexia
  • itchy skin
  • weakness

More serious symptoms include:

  • confusion and difficulty thinking clearly
  • abdominal swelling (ascites)
  • swelling of the legs (edema)
  • impotence
  • gynecomastia (when males start to develop breast tissue)

A diagnosis of cirrhosis begins with a detailed history and physical exam. Your doctor will take a complete medical history. The history may reveal long-term alcohol abuse, exposure to hepatitis C, family history of autoimmune diseases, or other risk factors. The physical exam can show signs such as:

  • pale skin
  • yellow eyes (jaundice)
  • reddened palms
  • hand tremors
  • an enlarged liver or spleen
  • small testicles
  • excess breast tissue (in men)
  • decreased alertness

Tests can reveal how damaged the liver has become. Some of the tests used for evaluation of cirrhosis are:

  • complete blood count (to reveal anemia)
  • coagulation blood tests (to see how quickly blood clots)
  • albumin (to test for a protein produced in the liver)
  • liver function tests
  • alpha fetoprotein (a liver cancer screening)

Additional tests that can evaluate the liver include:

  • upper endoscopy (to see if esophageal varices are present)
  • ultrasound scan of the liver
  • MRI of the abdomen
  • CT scan of the abdomen
  • liver biopsy (the definitive test for cirrhosis)

If your blood is unable to pass through the liver, it creates a backup through other veins such as those in the esophagus. This backup is called esophageal varices. These veins are not built to handle high pressures, and begin to bulge from the extra blood flow.

Other complications from cirrhosis include:

  • bruising (due to low platelet count and/or poor clotting)
  • bleeding (due to decreased clotting proteins)
  • sensitivity to medications (the liver processes medications in the body)
  • kidney failure
  • liver cancer
  • insulin resistance and type 2 diabetes
  • hepatic encephalopathy (confusion due to the effects of blood toxins on the brain)
  • gallstones (interference with bile flow can cause bile to harden and form stones)
  • esophageal varices
  • enlarged spleen (splenomegaly)
  • edema and ascites

Treatment for cirrhosis varies what caused it and how far the disorder has progressed. Some treatments your doctor might prescribe include:

  • beta blockers or nitrates (for portal hypertension)
  • quitting drinking (if the cirrhosis is caused by alcohol)
  • banding procedures (used to control bleeding from esophageal varices)
  • intravenous antibiotics (to treat peritonitis that can occur with ascites)
  • hemodialysis (to purify the blood of those in kidney failure)
  • lactulose and a low protein diet (to treat encephalopathy)

Liver transplantation is an option of last resort, when other treatments fail.

All patients must stop drinking alcohol. Medications, even over-the-counter ones, should not be taken without consulting your doctor.

Practicing safe sex with condoms can reduce the risk of getting hepatitis B or C. The U.S. Centers for Disease Control and Prevention recommend that all infants and at-risk adults (such as healthcare providers and rescue personnel) be vaccinated against hepatitis B.

Becoming a nondrinker, eating a balanced diet, and getting adequate exercise can prevent or slow cirrhosis.

The World Health Organization reports that only 20 to 30 percent of people infected with hepatitis B will develop cirrhosis or liver cancer.

The National Institute of Health reports that 5 to 20 percent of people infected with hepatitis C will develop cirrhosis over a period of 20 to 30 years.

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Liver Cirrhosis

Liver cirrhosis

PATHOLOGYThis peculiar transformation of the liver was identified by the first anatomic pathologist, Gianbattista Morgagni in his 500 autopsies published in 1761 but the name of “cirrhosis” (greek=orange color) was given by Laennec in 1826 because of the yellowish-tan color of the cirrhotic liver. Only in 1930, one hundred years later, however, the first theory as to the pathogenesis of this disorder was advanced by Roessle: parenchymal degeneration, regeneration and scarring which is now understood according to the following sequence:
which is considered by most experts as a self-perpetuating irreversible process. Regenerative nodules may form in the fibrous septa but they are not necessary for the histological diagnosis of cirrhosis: as nodules alone without fibrosis do not constitute cirrhosis. In this disease, the nodularity of the liver is mostly the result of fibrosis dissecting the parenchyma in small uniform acinar or subacinar nodules in micronodular types and in lobular and plurilobular large non-uniform nodules in macronodular forms. Regenerative nodules develop in the midst of scars but are a late phenomenon. They are important, however, for the advancement and neoplastic transformation of the cirrhosis.
Classification of cirrhosis According to World Health Organization(Anthony P.P. et al. J.Clin.Pathol. 31:395,1978)
MORPHOLOGIC: Macronodular   Micronodular   Mixed HISTOLOGIC: Portal, Post-necrotic, Post Hepatitic, Biliary, CongestiveETIOLOGIC AGENTS: Genetic, Toxic, Infectious, Biliary, Vascular, Cryptogenic
GROSS INSPECTION. Grossly, with the naked eye, a cirrhotic liver appears nodular, “hub-nailed”, on the external surface and nodular on the cut surface. Variation in size, color, shape and consistency is relevant and may help in the identification of the etiology. The liver is usually indurated shrunken and yellowish-tan but it may be enlarged and yellow as in alcoholic fatty cirrhosis, rusty as in hemochromatosis or large and green as in biliary obstruction. It is usually the privilege of the surgeon to inspect the liver in vivo, therefore he must acquaint himself with the gross changes of cirrhosis and develop the ability of detecting discolorations of possible neoplastic nodules in order to obtain adequate samples for histological examination.

Micronodular cirrhosis Fig.77 – MICRONDULAR CIRRHOSIS: Small rather uniform 2m nodules seperated by thin fibroussepta usually due to a chemicalagent as alcohol which diffuseuniformly throught the liver.
Macronodular cirrhosis Fig.78 – MACRONODULAR CIRRHOSIS: Larger nodules separated by wider scars and irregularly distributed throughout the liver usually due to an infectious agent such as viral hepatitis which does not diffuse uniformly throughout the liver.
MICROSCOPIC CHANGES. Presence of nodules and fibrous septa with effacement of the lobular architecture. The nodules are of two types: Dissection type and Hyperplastic Regenerative type.
Dissection nodules Fig.79 – DISSECTION NODULES:
  • contain remnants of portal tracts an central veins.
  • are separated by wide scars but contain thin fibrous septa.
  • contain dilated sinusoids especially at their periphery looking multiple central veins obviously produced by the inflow of arterial blood coming from the surrounding wide scars.
  • the portal tracts within large nodules may be hypoplastic containing portal venule and arteriole but no bile ducts giving the impression of a disappearing bile duct disorder.
  • within wide scars regenerative nodules may develop.
Hypoplastic portal field Fig.79a – HYPOPLASTIC PORTAL FIELD: In a dissecting nodule. Notice presence of portal vein, portal artery but no bile duct.This case was interpreted as “vanishing duct syndrome”.
Regenerative nodules Fig.80 – REGENERATIVE NODULES:
  • these occur in micro and macro nodular cirrhosis.
  • they arise in the midst of scars favored by the rich arterial blood of scar tissue.
  • they are round nodules with a fibrous pseudo capsule with bile ductules due to obstruction of bile flow.
  • they have embryonal type of cell plates, two cells thick, “twinning of cell plates”.
  • nuclei are aligned at the sinusoidal pole of the plates.
  • they often show focal cholestasis.
  • they may undergo dysplastic and malignant changes.
  • they compress the vessels of the capsule contributing to the perpetuation of the cirrhosis.


Are, with nodules, the other characteristic component of cirrhosis and they are visible even with the naked eye. They have been termed “fibro-vascular membranes” which provide a diversion of the blood flow through an alternative route along these fibrous septa instead of through the acinar sinusoids, thus affecting the physiology of the hepatocytes (Rappaport AM et al. virchows Archiv. A402:107-137, 1983). The fibrous septa are basically granulation tissue more or less active according to the degree of edema, capillarization, inflammatory cell infiltration and fibrosis. They reflect the activity of the cirrhotic process.
Passive septa Fig.81 – PASSIVE SEPTA: Slender connective tissue bands containing few chronic inflammatory cells and sharp demarcation with parenchymal liver tissue.
Active septa Fig.82 – ACTIVE SEPTA: Thick connective tissue bands containing edema, many chronic inflammatory cells and irregular demarcation with the parenchymal liver tissue.


The evolution can be assessed on degree of fibrosis and nodule formation. The following stages can be identified with some approximation even on a needle biopsy specimen:

1-INCOMPLETE SEPTAL (Incomplete bridging fibrosis, no nodules) 2-EARLY (Thin bridging fibrosis with dissecting nodules) 3-MODERATELY ADVANCED (Thick bridging fibrosis with dissecting nodules) 4-ADVANCED (Wide septa with regenerative hyperplastic nodules)


Incomplete septal cirrhosis Fig.83 – INCOMPLETE SEPTAL CIRRHOSIS: Presence of very slender septa radiating from enlarged fields toward the center of the lobule. There are distended efferent vessels around the septum. This type of cirrhosis produces only portal hypertension and no liver failure. The prognosis is very good if the portal hypertension is controlled.
Early cirrhosis Fig.84 – EARLY CIRRHOSIS: Thin fibrous septa with dissecting nodules. No regenerative nodules. Presence of multiple efferent vessles. (Reticulim stain by silver impregnation).
Advanced cirrhosis Fig.85 – ADVANCED CIRRHOSIS: Wide scars containing clusters of regenerative hepatocytes. Large scars may contain large portal fields recognizable with a stain for elastic fibers.

Activity is assessed by extent of cell damage, inflammatory reaction within the scar tissue, piecemeal necrosis along fibrous septa, edema of the septa and changes in the parenchymal nodules such as necrosis and cholestasis. Activity indicates the progression of the cirrhotic process and is graded as:
INACTIVE No inflammation and intact limiting plates around septa whiich are fibrotic SLIGHT Mild inflammation; segmental erosion of limiting plates MODERATE Moderate inflammation and damage of limiting plates SEVERE Marked inflammation, extensive damage of limiting plates, piecemeal necrosisand parenchymal damage, i.e.: necrosis, cholestasis, dysplasia, malignant transformation.
About one third of cirrhosis are compensated and, do not produce any clinical symptoms and are accidentally discovered during a medical examination or an operation or at autopsy. The rest are decompensated and produce complications mainly due to liver failure and portal hypertension. They are:

Malignant transformation Fig 86 – MALIGNANT TRANSFORMATION: of a regenerative nodule. Notice the capsule, the peripheral zone of the regenerative nodule and the inner zone of hepatocellular carcinoma.
Underdiagnosis is more frequent than overdiagnosis due to the frequent absence of regenerative nodules. A pathology report should include the above parameters and known clinical complications. Treatment and prognosis depend on the correct assessment of these paramenters.



Cirrhosis of the Liver

Liver cirrhosis

The liver is the largest solid organ in the body. It performs many important functions, including:

  • Making blood proteins that aid in clotting, transporting oxygen, and helping the immune system.
  • Storing excess nutrients and returning some of the nutrients to the bloodstream.
  • Manufacturing bile, a substance needed to help digest food.
  • Helping the body store sugar (glucose) in the form of glycogen.
  • Ridding the body of harmful substances in the bloodstream, including drugs and alcohol.
  • Breaking down saturated fat and producing cholesterol.

Cirrhosis is a slowly developing disease in which healthy liver tissue is replaced with scar tissue.

The scar tissue blocks the flow of blood through the liver and slows the liver’s ability to process nutrients, hormones, drugs and natural toxins (poisons).

It also reduces the production of proteins and other substances made by the liver. Cirrhosis eventually keeps the liver from working properly.