Fibrosis and cirrhosis: when fatty liver progresses

Hearing the word “cirrhosis” can be terrifying, and many people in India associate it only with heavy drinking. Today, fatty liver linked to diabetes and weight is becoming one of the major causes of cirrhosis. The encouraging part is that scarring develops slowly, can be detected early with simple tests, and often improves when the cause is tackled.

How fatty liver progresses

Fatty liver disease moves along a spectrum, although most people stay at the early stages:

1. Fatty liver (MASLD): extra fat in liver cells, without much inflammation.
2. Steatohepatitis (MASH): fat with inflammation and liver cell injury.
3. Fibrosis: repeated injury leads to scar tissue building up.
4. Cirrhosis: widespread scarring that changes the liver's structure and can affect how it works.
5. Complications: such as liver failure or liver cancer, in a minority of people with cirrhosis. Liver cancer can occasionally develop in fatty liver even before cirrhosis.

Our fatty liver disease guide covers the earlier stages.

Stages of fibrosis

Stages F2 and above are considered “at-risk” and usually need specialist follow-up. These stages were originally defined by liver biopsy, but today they are mostly estimated with blood tests and FibroScan.

Who is at risk of progression?

• People with type 2 diabetes, who are much more likely to develop advanced fibrosis
• Obesity, especially with fat around the waist
• Age over 50
• Alcohol use, even moderate, on top of fatty liver
• Smoking
• Other liver conditions, such as hepatitis B or C

How scarring is measured

• FIB-4 score: calculated from age, SGOT, SGPT and platelets. Below 1.3 means advanced scarring is unlikely; 1.3 to 2.67 is indeterminate; above 2.67 suggests advanced scarring is more likely.
• FibroScan (liver stiffness): below 8 kPa makes advanced scarring unlikely; higher values suggest more scarring and need specialist review. Our guide to fatty liver grades and FibroScan explains the test.
• Other blood tests or MR elastography in specialist centres.
• Liver biopsy is now used only when the picture is unclear or another cause is suspected.

The platelet count, albumin and bilirubin in routine blood tests also give clues; see liver function tests explained.

Can fibrosis be reversed?

Often, yes. The liver has a remarkable ability to repair itself when the cause of injury is removed. In studies of people with MASH, losing 10% or more of body weight improved fibrosis in many participants. Stopping alcohol, controlling diabetes and treating hepatitis B or C also help. Early fibrosis is the most likely to improve; established cirrhosis rarely goes away completely, but it can stabilise, and complications become less likely. A few medicines have been approved in some countries for people with MASH and moderate to advanced fibrosis; your hepatologist can tell you whether any are suitable and available for you.

Our guide to diet and exercise for fatty liver shows how to work towards these goals.

Cirrhosis: what it means

Cirrhosis means scarring has spread through the liver and formed nodules. Doctors describe two phases:

• Compensated cirrhosis: the liver still copes. Many people feel well and may not know they have it. Good care at this stage can keep people stable for many years.
• Decompensated cirrhosis: the liver can no longer keep up, and complications appear, such as fluid in the tummy, jaundice, bleeding from swollen veins, or confusion. This stage needs specialist care, and some people are assessed for a liver transplant.

Cirrhosis symptoms

Early cirrhosis often causes no symptoms. As it advances, people may notice:

• Tiredness, weakness and loss of appetite
• Weight loss and muscle wasting, even if the tummy swells
• A swollen tummy (ascites) and swollen legs
• Yellow eyes or skin (jaundice), and itching
• Easy bruising or bleeding gums and nose
• Small spider-like blood vessels on the skin, red palms
• Confusion, sleepiness or changes in personality (hepatic encephalopathy)
• Vomiting blood or black stools from swollen veins in the food pipe (varices)

Care and check-ups with cirrhosis

Guidelines recommend that people with cirrhosis are looked after by a liver specialist, with:

• Liver cancer screening with an ultrasound about every six months, sometimes with a blood test (AFP). Finding cancer early makes treatment much more effective.
• Checks for swollen veins (varices), by endoscopy or with FibroScan and platelet count, and treatment to prevent bleeding if needed.
• No alcohol at all.
• Good nutrition: enough protein and calories to protect muscle; people with cirrhosis should not go on strict diets without specialist advice, and a late-evening snack is often advised.
• Vaccines against hepatitis A and B, flu and pneumonia.
• Care with medicines: avoid painkillers such as ibuprofen and diclofenac, sleeping tablets and herbal products unless your doctor agrees, and check every new prescription is safe for the liver.

Questions to ask your doctor

• What stage of fibrosis do I have, and how was it measured?
• Is my liver disease compensated or decompensated?
• How often do I need ultrasound screening for liver cancer?
• Do I need an endoscopy to check for varices?
• Which medicines and supplements should I avoid?

Frequently asked questions

Sources

1. Rinella ME, et al. AASLD Practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease. Hepatology 2023;77(5):1797–1835.
2. European Association for the Study of the Liver, et al. EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). J Hepatol 2024;81(3):492–542.
3. Rinella ME, et al. A multisociety Delphi consensus statement on new fatty liver disease nomenclature. J Hepatol 2023;79(6):1542–1556.

This article is general information for adults in India and is not a diagnosis or a treatment plan. Always discuss results and any changes with your own doctor. Read our editorial policy.