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Health condition · Clinically reviewed

Cirrhosis, a modern UK view of causes, complications and care.

Most cirrhosis is silent until it isn\'t. Modern hepatology - non-invasive fibrosis assessment, six-monthly HCC surveillance and new MASH treatments - changes what is possible.

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A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a UK hepatology-informed clinician before publication.

  • 02

    Sourced from guidance

    Cross-checked against NICE, BASL, EASL and British Liver Trust standards you can see at the end.

  • 03

    Current for 2026

    Includes non-invasive fibrosis assessment, HCC surveillance and the new MASH treatment landscape.

Key facts

Cirrhosis at a glance.

The essentials, in plain English - what it is, the main UK causes and how modern hepatology approaches it.

  • What it is

    End-stage chronic liver disease with fibrosis, regenerative nodules and distortion of the liver architecture.

  • Main causes UK

    Alcohol, non-alcoholic fatty liver disease (MASLD/MASH), viral hepatitis B and C, and autoimmune liver disease.

  • Compensated

    Often silent, picked up on incidental blood tests, imaging or a slightly enlarged liver on examination.

  • Decompensated

    Jaundice, ascites, variceal bleeding or hepatic encephalopathy - hospital-level care and transplant assessment.

  • HCC surveillance

    Six-monthly ultrasound plus AFP for hepatocellular cancer, the annual risk is 2 to 4 per cent in cirrhosis.

  • Modern MASH therapy

    Resmetirom (Rezdiffra) is a first-in-class thyroid hormone receptor-beta agonist for MASH with F2-F3 fibrosis.

Why this guide matters

Silent for years, then suddenly urgent.

Cirrhosis rewards early action - treating the cause, staging fibrosis and starting HCC surveillance dramatically changes long-term outcomes.

  • MASLD/MASH is now a leading cause

    Obesity and type 2 diabetes are pushing MASLD past viral hepatitis - and there is finally a drug for it in resmetirom.

  • Non-invasive tests changed staging

    FibroScan, FIB-4 and ELF have largely replaced routine liver biopsy for staging fibrosis in the UK.

  • Surveillance saves lives

    Six-monthly ultrasound and AFP finds HCC when it is still curable by resection, ablation, TARE Y90 or transplantation.

How the diagnosis is made

From abnormal LFTs to a clear plan.

The steps a UK GP and hepatologist will normally follow, in order - so you know what to expect and why.

  1. 01

    Assessing

    History and risk factors

    Alcohol pattern, weight, diabetes, family history, hepatotoxic medications, viral risk and autoimmune symptoms.

  2. 02

    Assessing

    Examination for stigmata

    Spider naevi, palmar erythema, gynaecomastia, Dupuytren's, splenomegaly and signs of decompensation.

  3. 03

    Assessing

    Blood tests

    LFTs, INR, albumin, FBC (thrombocytopenia), U&Es, AFP, hepatitis B/C, autoimmune screen, iron studies, ceruloplasmin, alpha-1 antitrypsin.

  4. 04

    Confirming

    Imaging

    Abdominal ultrasound with Doppler, MRI or CT with contrast for HCC characterisation and portal vein assessment.

  5. 05

    Confirming

    FibroScan and blood scores

    Transient elastography, FIB-4, APRI and ELF to non-invasively stage fibrosis - biopsy reserved for uncertain cases.

  6. 06

    Confirming

    OGD for varices

    Upper GI endoscopy to screen for oesophageal and gastric varices and guide primary prophylaxis.

  7. 07

    Planning

    Scoring and MDT

    MELD and Child-Pugh scores, transplant assessment and specialist liver-unit MDT at a commissioned UK centre.

Typical timeline: from first abnormal LFTs to a specialist hepatology plan in weeks.

Symptoms

What cirrhosis actually looks like.

Compensated cirrhosis is often silent. Decompensation is a distinct set of complications with a clear treatment ladder.

  • Compensated cirrhosis

    Often asymptomatic - fatigue, mild right upper quadrant discomfort or incidental abnormal LFTs.

  • Skin stigmata

    Spider naevi, palmar erythema, white nails, gynaecomastia, testicular atrophy and Dupuytren's contracture.

  • Jaundice

    Yellow sclera and skin, dark urine, pale stools - a sign the liver is decompensating.

  • Ascites and oedema

    Abdominal swelling and ankle oedema driven by portal hypertension and low albumin.

  • Variceal bleeding

    Haematemesis and melaena from oesophageal or gastric varices - a medical emergency.

  • Hepatic encephalopathy

    Confusion, poor concentration, sleep reversal, asterixis, drowsiness and, in severe cases, coma.

  • Hepatorenal and pulmonary

    Kidney injury, breathlessness and low oxygen levels from hepatorenal, hepatopulmonary or portopulmonary syndromes.

  • Red flag - HCC

    Hepatocellular cancer risk is 2 to 4 per cent per year - six-monthly ultrasound and AFP is standard.

Treatment

How cirrhosis is treated in the UK.

Treat the underlying cause first, then protect against complications - variceal bleeding, ascites, encephalopathy and HCC.

  • Treat the underlying cause

    Alcohol abstinence, DAAs for HCV, antivirals for HBV, immunosuppression for AIH, UDCA for PBC, venesection for haemochromatosis, chelation for Wilson's.

  • MASH-directed therapy

    Weight loss, tight metabolic control, GLP-1 agonists (semaglutide, tirzepatide) and resmetirom (Rezdiffra) for F2-F3 MASH - NICE appraisal pending in the UK.

  • Nutrition and micronutrients

    1.2 to 1.5 g/kg protein daily, adequate calories, zinc, vitamin D and a late-evening snack - malnutrition is the rule, not the exception.

  • Vaccinations

    Hepatitis A and B, influenza, pneumococcal and COVID-19 - infection precipitates decompensation.

  • HCC surveillance

    Six-monthly ultrasound and AFP in eligible cirrhotic patients per NICE and BASL - the earliest tumours are the most curable.

  • Variceal prophylaxis

    Non-selective beta-blocker (carvedilol or propranolol) or endoscopic band ligation - acute bleeds need terlipressin, antibiotics and endoscopy.

  • Ascites management

    Sodium restriction, spironolactone and furosemide, therapeutic paracentesis, TIPS in selected cases and SBP prophylaxis with ciprofloxacin.

  • Liver transplantation

    For decompensated disease (MELD 15+), HCC within Milan criteria or acute liver failure - assessed at a commissioned UK transplant centre.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP or hepatologist knows your history and can tell you which parts apply to you. If in doubt, get seen.

  • NICE NG50. Cirrhosis in over 16s: assessment and management.

  • NICE QS152. Quality standard for cirrhosis.

  • British Society of Gastroenterology (BSG) and BASL guidance on cirrhosis and portal hypertension.

  • EASL Clinical Practice Guidelines on decompensated cirrhosis and MASLD.

  • British Liver Trust. Patient information and support.

Red flags

When cirrhosis needs urgent attention.

Cirrhosis can decompensate quickly. These are the situations that need immediate action and specialist input.

  • Variceal haemorrhage

    Vomiting blood or passing black tarry stools - call 999 or go to the nearest emergency department immediately.

  • New confusion or drowsiness

    Hepatic encephalopathy can progress rapidly - urgent hospital review, treat precipitants and start lactulose.

  • Rapidly enlarging abdomen

    New or worsening ascites needs same-day assessment - consider spontaneous bacterial peritonitis (SBP).

  • Fever with ascites

    Any fever, abdominal pain or unexplained deterioration in a cirrhotic patient with ascites needs an urgent diagnostic tap for SBP.

  • Deepening jaundice

    Rising bilirubin with rising INR suggests decompensation and warrants specialist hepatology input.

  • Rising creatinine

    Acute kidney injury in cirrhosis is high-risk - stop nephrotoxins, review diuretics and consider hepatorenal syndrome.

  • New focal liver lesion

    A nodule on surveillance ultrasound needs contrast MRI or CT and hepatobiliary MDT review - do not ignore.

  • Coagulopathy and bruising

    Rising INR, spontaneous bruising or minor bleeding that won't stop needs urgent assessment.

  • Paracetamol and NSAID caution

    Cap paracetamol at 2 to 3 g per day in cirrhosis and avoid NSAIDs - they precipitate renal failure and bleeding.

Living with it

A serious condition, with a clear plan.

Four things that make the biggest difference day to day - treat the cause, keep surveillance appointments, eat enough and stay linked to a specialist team.

A quiet reminder

Small steady steps outperform occasional heroics.

Abstinence, weight, medications and appointments - kept up over years - do more than any single intervention.

  1. 01 Cause

    Treat the driver first

    Alcohol abstinence, weight loss, antivirals or immunosuppression - modifying the cause slows or reverses fibrosis.

  2. 02 Surveillance

    Keep every scan appointment

    Six-monthly liver ultrasound and AFP is not optional - it is the single biggest lever on cirrhotic cancer outcomes.

  3. 03 Nutrition

    Eat enough - and often

    High-protein, high-calorie meals plus a late-evening snack protect muscle and reduce decompensation.

  4. 04 Team

    Stay linked to hepatology

    A specialist nurse, dietitian and hepatology team keep small problems small - British Liver Trust support helps too.

Frequently asked

Everything we get asked about cirrhosis.

Quick answers on causes, staging, HCC surveillance, resmetirom and transplantation.

  • What is cirrhosis?

    Cirrhosis is the end stage of many chronic liver diseases. Repeated injury leads to fibrosis and regenerative nodules that distort the normal liver architecture and impair function. It can be compensated (silent) or decompensated (jaundice, ascites, variceal bleeding, encephalopathy).

  • What are the main causes in the UK?

    Alcohol-related liver disease, non-alcoholic fatty liver disease (MASLD/MASH), chronic viral hepatitis B and C, and autoimmune liver diseases (AIH, PBC, PSC). Less commonly, metabolic conditions such as haemochromatosis, Wilson's disease and alpha-1 antitrypsin deficiency, biliary disease, vascular disease and drug-induced liver injury. Around one in ten cases remain cryptogenic.

  • Can cirrhosis be reversed?

    Fibrosis can regress significantly if the underlying cause is treated early - alcohol abstinence, HCV cure with DAAs, HBV viral suppression, weight loss in MASLD/MASH, iron removal in haemochromatosis. Established cirrhosis rarely reverses fully, but progression can be halted and decompensation prevented.

  • What is resmetirom (Rezdiffra)?

    Resmetirom is a first-in-class thyroid hormone receptor-beta agonist approved by the FDA in 2024 for MASH with moderate to advanced fibrosis (F2-F3). It targets the liver directly and has been shown to reduce steatohepatitis and fibrosis in trials. In the UK, NICE appraisal is pending and availability may be through specialist hepatology.

  • Why do I need scans every six months?

    People with cirrhosis have a 2 to 4 per cent annual risk of hepatocellular carcinoma (HCC). Six-monthly ultrasound with AFP catches tumours when they are small and potentially curable by resection, ablation, transplantation or TARE Y90 selective internal radiation. Missing scans is the single most avoidable cause of late diagnosis.

  • When is liver transplantation considered?

    Transplantation is considered for decompensated cirrhosis with a MELD score of 15 or above, HCC within Milan criteria, refractory complications (recurrent variceal bleeding, refractory ascites, hepatorenal syndrome) or acute liver failure. Assessment happens at a commissioned UK transplant centre such as King's, Royal Free, Birmingham QE, Leeds, Newcastle Freeman, Edinburgh, Cambridge Addenbrooke's, Manchester or Cardiff.

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