Cirrhosis and hepatitis: causes, symptoms, treatment and when a transplant is needed

What are hepatitis and cirrhosis?

Hepatitis means inflammation of the liver. It can be acute (short-lived) or chronic (lasting more than six months). Causes include viruses, alcohol, fat build-up, some medicines and toxins, and autoimmune disease.

Cirrhosis develops when years of damage leave the liver full of fibrous scar tissue and nodules. Blood struggles to flow through it, and its functions – making proteins and clotting factors, clearing toxins, producing bile – gradually decline. Cirrhosis is described as compensated (the liver is still coping, often with no symptoms) or decompensated (complications have developed).

Types of viral hepatitis

Chronic hepatitis B and C often cause no symptoms for decades and are found by chance. According to the WHO, millions of people worldwide live with chronic infection without knowing it. Testing is simple – a blood test your GP can arrange.

Other causes of cirrhosis

• Alcohol – long-term heavy drinking damages the liver, and the risk rises with the amount and duration.
• Metabolic dysfunction-associated steatotic liver disease (MASLD, formerly NAFLD) – linked to obesity, type 2 diabetes and raised cholesterol. It is an increasingly common cause of cirrhosis.
• Autoimmune hepatitis, primary biliary cholangitis and primary sclerosing cholangitis.
• Inherited conditions – haemochromatosis (iron overload), Wilson's disease (copper overload) and alpha-1 antitrypsin deficiency.
• Some medicines and toxins, and long-standing heart failure.

Symptoms

In the early stages, cirrhosis and chronic hepatitis often cause no symptoms, or only tiredness and vague discomfort. As the disease progresses you may notice:

• jaundice – yellowing of the skin and eyes, dark urine;
• a swollen abdomen (ascites) and swollen legs;
• bruising and bleeding easily;
• itching, muscle loss and weight loss;
• small spider-like blood vessels on the skin and red palms;
• confusion, drowsiness or changes in behaviour (hepatic encephalopathy);
• vomiting blood or passing black stools – signs of bleeding varices, which is an emergency.

Tests

Diagnosis starts with blood tests: liver enzymes (ALT, AST, GGT, alkaline phosphatase), bilirubin, albumin, INR, blood count (platelets are often low), hepatitis B and C tests and checks for other causes. Other investigations include:

• Abdominal ultrasound – shows the structure of the liver and spleen and any fluid.
• Elastography (for example FibroScan) – a non-invasive measure of liver stiffness, which reflects fibrosis.
• CT or MRI – where needed, including to assess liver nodules.
• Upper endoscopy – to look for swollen veins (varices) in the oesophagus.
• Liver biopsy – in selected cases when the cause is unclear.

The severity of cirrhosis is graded with the Child-Pugh and MELD scores, which also help decide when to refer for a transplant.

Treatment

Treating the cause is the most important step:

• Hepatitis C – modern direct-acting antiviral medicines, usually taken for 8–12 weeks, cure most people.
• Hepatitis B – antiviral medicines suppress the virus long term and lower the risk of cirrhosis and cancer.
• Alcohol-related damage – stopping alcohol completely, with medical and psychological support.
• Fatty liver disease – gradual weight loss, a healthy diet, physical activity and control of diabetes and cholesterol.
• Autoimmune and inherited conditions – specific treatment guided by your liver specialist.

Treating complications: for ascites, less salt, diuretics and draining fluid if needed; for varices, medicines that lower portal vein pressure and endoscopic banding; for encephalopathy, medicines that reduce the build-up of toxins. Nutrition should provide enough calories and protein, as undernutrition is common in cirrhosis.

People with cirrhosis have a higher risk of liver cancer, so European guidelines (EASL) recommend an ultrasound scan every six months, sometimes with an alpha-fetoprotein blood test (a tumour marker).

When is a liver transplant considered?

With decompensated cirrhosis (ascites, bleeding, encephalopathy, jaundice), a high MELD score or limited liver cancer, your liver specialist will refer you to a transplant centre. A liver transplant can use a whole liver from a deceased donor via the national waiting list, or part of a liver from a living donor – only someone close to you, unpaid and approved by an ethics committee. See our guides to the pre-transplant evaluation and organ transplantation.

Some patients from Bulgaria and the rest of Europe seek a second opinion, or a living donor transplant from a family member, at large accredited hospital groups in Istanbul. Living donation there follows Turkish law, and buying an organ is a crime everywhere. Check the accreditation, the team's experience, the written plan and follow-up at home. An organiser such as New City Clinic can coordinate the hospital, doctor, hotel, transfers and interpreter.

Prevention and when to see a doctor

Prevention includes hepatitis B vaccination (and hepatitis A where appropriate), safer sex, using only sterile equipment for tattoos, piercings and medical or cosmetic procedures, drinking little or no alcohol and keeping a healthy weight.

Ask your GP for a hepatitis B and C test if you have never been tested, have raised liver enzymes, have risk factors or a family member with hepatitis. See a doctor if you develop jaundice, a swollen abdomen or unexplained tiredness. Call 112 if you vomit blood, pass black stools, or become very drowsy or confused.