Untreated chronic hepatitis damages liver cells over years or even decades, leading the liver to become scarred and hardened. When this scarring is advanced it is known as ‘cirrhosis’.

The liver can continue to carry out its functions despite the scarring for a long time and can compensate for the damage ('compensated cirrhosis'). Later, however, the liver becomes restricted in its functions ('decompensated cirrhosis').

Symptoms of cirrhosis may include:

• Muscle wasting.
• Swollen spleen.
• Ascites: swelling of the abdomen, caused by the accumulation of fluid. It is treated by reduced salt intake, controlled fluid intake and diuretics (drugs which promote urination). If this fails to improve the ascites, fluid may be withdrawn via paracentesis.¹ A device called ALFApump may reduce ascites by channelling the fluid from the abdomen to the bladder.
• Oedema: swelling, usually of the feet, ankles, and lower legs, due to the accumulation of fluid.
• Varices (abnormally distended blood vessels). Blood vessels around the gullet and stomach enlarge because the blood is trying to find a way around the scarred liver. Varices can bleed into the stomach, causing vomiting of blood or passing of black stools. Burst varices require immediate medical attention.
• Circulatory changes. The damaged liver may fail to produce blood-clotting proteins, leading to easy bruising and prolonged bleeding. Patients may also develop high blood pressure (portal hypertension) as blood backs up in the scarred liver. Drugs called beta-blockers may be used to relieve portal hypertension.
• Pruritis (itching). People with cirrhosis may experience an itching sensation of the skin or internal organs due to the build-up of bile and other toxic chemicals.
• Encephalopathy. Patients may experience impaired mental function and personality changes because the liver is not breaking down waste products such as ammonia in the blood as efficiently as it should or because blood is bypassing the liver. At its most severe, this can lead to coma or death. Laxatives (lactulose), ornithin aspartate or a specific antibiotic (rifaximin) are sometimes used to treat this.