Terminology related to cirrhosis

Cirrhosis is defined by characteristic distortion of the normal liver architecture due to extensive scarring (fibrosis) and nodule formation. With the availability of noninvasive tests for liver fibrosis, histopathologic diagnosis of cirrhosis by liver biopsy is now uncommon. Patients with cirrhosis are at higher risk of liver-related complications, hepatocellular carcinoma and death.

Clinically significant portal hypertension is defined as an increased portal venous pressure of 10 mmHg or more (as measured by the hepatic venous pressure gradient). This confers a worsened prognosis due to an increased risk of portal-hypertensive complications of cirrhosis, such as variceal formation and haemorrhage, ascites and hepatic encephalopathy. In the absence of clinical, endoscopic or radiographic signs, noninvasive tests for liver fibrosis can be used to detect clinically significant portal hypertension in specific situations—a liver stiffness of 25 kPa or more (measured by vibration-controlled transient elastography [VCTE]) rules in cirrhosis with clinically significant portal hypertension in patients with:
  • alcohol-related or viral-related chronic liver disease
  • nonobese (body mass index [BMI] less than 30 kg/m2) nonalcoholic fatty liver disease.

Compensated cirrhosis is a stable phase of disease, with good long-term prognosis if the cause of cirrhosis is treated. Clinically significant portal hypertension may exist (on imaging or endoscopy as nonbleeding varices, or on noninvasive tests for liver fibrosis), but there are no clinical signs of decompensation.

Decompensated cirrhosis is associated with high short-term mortality and is defined clinically by the presence of the following complications: ascites, hepatic encephalopathy, variceal haemorrhage or nonobstructive jaundice. Patients may move between decompensated and compensated disease states, with improvement often due to treatment of the underlying disease (eg alcohol abstinence, antiviral therapy, nutritional intervention) and deterioration due to an acute precipitant (eg infection, drugs or toxins, alcohol) or progressive disease.

The Child–Pugh score is used to assess prognosis in patients with cirrhosis. It incorporates total bilirubin, serum albumin, international normalised ratio (INR), degree of ascites and degree of hepatic encephalopathy. An online calculator is available.

Advanced chronic liver disease has been proposed as a more accurate term than cirrhosis to classify patients with chronic liver disease who are at increased risk of death or liver-related complications, whether diagnosed using noninvasive testing or on histology. Advanced chronic liver disease can similarly be divided into compensated and decompensated disease states. These guidelines use the term 'cirrhosis', but either term (eg 'compensated advanced chronic liver disease' or 'compensated cirrhosis') is acceptable.

Liver failure refers to impairment of the synthetic or metabolic functions of the liver and can be:

  • acute (fulminant)—rapid onset of jaundice and encephalopathy in the absence of known liver disease; acute liver failure is a medical emergency and requires urgent hospital referral
  • chronic—occurs in established chronic liver disease, often in the context of decompensated cirrhosis
  • acute-on-chronic—a recently described syndrome of extrahepatic organ failure together with worsening liver function in the presence of cirrhosis, with high short-term mortality; definitions vary and consensus is yet to be achieved.

The Model for End-stage Liver Disease (MELD) score is a measure of the severity of liver failure and is based on serum bilirubin, creatinine and INR. An online calculator is available.