When your liver gets damaged over years-whether from alcohol, fatty liver disease, or hepatitis-it doesn’t just heal. It scars. That scarring is called cirrhosis, and it’s not reversible. Once it sets in, the liver’s structure changes, blood flow gets blocked, and its ability to clean your blood, make proteins, or store energy starts to fail. This isn’t just a slow decline-it’s a ticking clock for serious, sometimes deadly, complications.

What Happens When the Liver Starts to Fail?

Cirrhosis doesn’t always show symptoms at first. Many people feel fine for years. That’s called compensated cirrhosis. But when the liver can’t keep up anymore, things fall apart quickly. This is decompensated cirrhosis, and it brings on a chain reaction of problems.

One of the first signs is fatigue-so bad it makes daily tasks impossible. About 72% of people with cirrhosis report this. Weight loss follows, often without trying. Bruising easily? That’s because the liver stops making clotting factors. Swelling in the legs? That’s edema. But the real red flags come later.

Jaundice-the yellowing of skin and eyes-means bilirubin is building up because the liver can’t process it. Ascites, or fluid buildup in the belly, affects half of people within 10 years of diagnosis. It’s not just uncomfortable; it can become infected. That’s spontaneous bacterial peritonitis (SBP), and it kills 20-40% of those who get it.

Portal Hypertension: The Root of Most Problems

All these complications tie back to one thing: portal hypertension. That’s when pressure builds in the vein that carries blood from your intestines to your liver. Scar tissue blocks the flow, so blood finds other paths-through veins in your esophagus and stomach. These veins swell up, becoming varices.

One in three people with cirrhosis will bleed from these varices. And when they do, up to 20% won’t survive the episode. That’s why doctors check for them early. If you have cirrhosis, you need an upper endoscopy to look for these enlarged veins. If they’re found, you’re put on beta-blockers like propranolol or nadolol. These drugs lower pressure in the portal system and cut bleeding risk by nearly half.

Carvedilol, another beta-blocker, works even better at reducing pressure. But it’s not for everyone-people with asthma or very low blood pressure can’t take it. The goal isn’t just to prevent bleeding-it’s to keep you out of the hospital.

Ascites and the Battle Against Fluid

Ascites isn’t just a symptom-it’s a medical emergency waiting to happen. When fluid builds up, it puts pressure on your lungs, makes eating hard, and increases infection risk. The first step is simple: cut salt to less than 2 grams a day. That’s harder than it sounds. A single slice of bread can have 200mg. Processed food is the enemy.

Diuretics come next. Spironolactone is the first-line drug. It’s often paired with furosemide. Most people respond well. But about 10% develop refractory ascites-fluid that won’t budge. That’s when doctors drain it directly from the belly using a needle. This is called large-volume paracentesis. It’s quick, but it can crash your circulation. That’s why albumin is given during the procedure. It keeps your blood pressure stable and cuts complications from 37% down to 10%.

But draining fluid doesn’t fix the problem. You’ll need to do it again. Some people go to the hospital every few weeks. One patient on Reddit said he missed 12 family events this year because he was too sick or recovering from the procedure. The emotional toll is as real as the physical one.

Hepatic Encephalopathy: The Brain Fog No One Talks About

Your liver filters toxins. When it fails, ammonia and other chemicals build up and reach your brain. That’s hepatic encephalopathy. It starts with mild confusion, forgetfulness, or trouble concentrating. People call it “brain fog.” It gets worse-slurred speech, personality changes, even coma.

It affects 30-45% of those with decompensated cirrhosis. The go-to treatment is lactulose. It’s a syrup you take three times a day. It pulls ammonia out of your gut through diarrhea. Sounds simple. But the side effects? Constant, painful diarrhea. One patient wrote: “I’ve missed 12 family events this year.”

There’s a better option now: rifaximin. It’s an antibiotic that doesn’t get absorbed into your bloodstream. It works in the gut to reduce ammonia-producing bacteria. Studies show it cuts hospital visits by 58% compared to placebo. But it costs $1,200 a month without insurance. Many patients can’t afford it.

Cancer Risk: The Silent Threat

Cirrhosis doesn’t just damage the liver-it makes it more likely to turn cancerous. Hepatocellular carcinoma (HCC) develops in 2-8% of cirrhotic patients every year. That’s why everyone with cirrhosis gets screened every six months with an ultrasound. It’s not perfect-it misses some tumors-but it catches 70% of them early, when they’re still treatable.

Without screening, tumors are often found too late. With it, patients can be treated with surgery, ablation, or even transplanted before the cancer spreads. The key is consistency. Skip a scan, and you’re gambling with your life.

How Management Has Changed-And What’s Coming

Ten years ago, cirrhosis management was mostly about treating symptoms. Now, it’s about stopping the cycle. For hepatitis C, direct-acting antivirals cure the infection in 95% of cases-even in cirrhosis. That halts further damage. For fatty liver disease (now called MASH), the FDA approved resmetirom in March 2024. In trials, it reduced liver scarring in over 20% of patients after one year.

AI is also stepping in. A new algorithm called CirrhoPredict uses routine lab tests to forecast who’s likely to decompensate in the next 90 days. That means doctors can intervene before someone ends up in the ER. It’s not standard yet-but it’s coming fast.

Transplant remains the only cure. But there aren’t enough livers. In 2022, over 11,000 people were on the waiting list. Only 8,391 got transplants. Twelve percent died while waiting. That’s why the organ system changed in February 2024. Now, quality of life matters as much as MELD scores. Someone with terrible brain fog but a lower score can now move up the list.

What You Can Do Right Now

If you have cirrhosis, here’s what works:

• See your hepatologist every month if you’re decompensated. Quarterly if you’re stable.
• Get screened for varices and HCC every six months.
• Take your beta-blockers and lactulose or rifaximin as prescribed-even if you hate the side effects.
• Absolutely stop alcohol. No exceptions.
• Track your weight daily. A 2-pound gain in a day could mean fluid is building up.
• Work with a dietitian. A 2g sodium diet is non-negotiable.
• Get vaccinated for hepatitis A, hepatitis B, pneumonia, and the flu.

Structured care programs that include nurses, social workers, and dietitians cut hospital visits by 40%. That’s huge. Don’t go it alone.

When to Call for Help

Don’t wait. If you have cirrhosis and notice:

• Sudden swelling in your belly or legs
• Fever or abdominal pain
• Confusion, drowsiness, or slurred speech
• Vomiting blood or black, tarry stools

Go to the ER immediately. These are not “wait and see” symptoms. They’re life-threatening.

Next Steps if You or a Loved One Has Cirrhosis

Start by getting your MELD and Child-Pugh scores. Ask your doctor for them. They tell you how advanced your disease is. Then, make a plan: see a hepatologist, get screened for varices and cancer, start diuretics if needed, and join a multidisciplinary care program. Talk to a social worker about financial aid-rifaximin and transplant costs are high. Connect with support groups. You’re not alone. And most importantly-don’t delay. Every day you wait is a day the liver gets closer to breaking down.