What are the signs and symptoms of liver cirrhosis?

Signs and Symptoms of Liver Cirrhosis

Liver cirrhosis presents along a spectrum from asymptomatic compensated disease to life-threatening decompensated cirrhosis with portal hypertension complications, and approximately 40% of patients are only diagnosed when they present with decompensation such as ascites or hepatic encephalopathy. 1, 2

Compensated Cirrhosis (Asymptomatic Phase)

Most patients with compensated cirrhosis remain asymptomatic and may have completely normal physical findings. 3, 4 However, when present, early manifestations include:

Non-Specific Symptoms

• Fatigue and general malaise (most common) 3
• Right upper quadrant abdominal pain or discomfort 3, 5
• Anorexia and weight loss 3
• Nausea 3, 5
• Lethargy 3

Physical Examination Findings

• Hepatomegaly (occasionally painful) 3, 5
• Splenomegaly 3, 5
• Palmar erythema 3, 5
• Spider nevi (spider angiomas) 3, 5

Decompensated Cirrhosis (Symptomatic Phase)

The natural history of cirrhosis transitions from compensated to decompensated disease marked by the development of overt clinical signs including ascites, variceal bleeding, hepatic encephalopathy, and jaundice. 3

Portal Hypertension Complications

Ascites (most common decompensating event):

• Abdominal distension 3, 6
• Shifting dullness on percussion (detectable from 100 ml by ultrasound) 6
• Median survival of 1.1 years after onset 2

Variceal Bleeding:

• Hematemesis or melena 3
• Hemodynamic instability 3

Hepatic Encephalopathy:

• Altered mental status ranging from subtle cognitive changes to coma 3
• Median survival of 0.92 years after onset 2

Jaundice:

• Yellow discoloration of skin and sclera 3
• Fluctuating jaundice may occur 3

Additional Clinical Manifestations

Cutaneous Signs:

• Pruritus (39% prevalence) 3, 2
• Dilated abdominal wall veins (caput medusae) 5

Systemic Symptoms:

• Muscle cramps (64% prevalence) 2
• Poor-quality sleep (63% prevalence) 2
• Sexual dysfunction (53% prevalence) 2

Infectious Complications:

• Fever and chills (spontaneous bacterial peritonitis occurs in 11% annually) 3, 2
• Abdominal pain and tenderness (though one-third may be asymptomatic) 3

Renal Complications:

• Hepatorenal syndrome (8% annual incidence, median survival <2 weeks) 2
• Oliguria and acute kidney injury 3

Important Clinical Pitfalls

Up to one-third of patients may be entirely asymptomatic even with advanced complications like spontaneous bacterial peritonitis, presenting only with encephalopathy or acute kidney injury. 3 This necessitates a high index of suspicion and diagnostic paracentesis in any hospitalized cirrhotic patient with ascites, even without localizing symptoms. 3

Only one in three people with cirrhosis knows they have it, and one-third of patients at diagnosis have already developed cirrhosis despite minimal or no symptoms due to delayed diagnosis. 3, 4

Hepatocellular carcinoma develops in 1-4% of cirrhotic patients annually and is associated with only 20% five-year survival, emphasizing the need for surveillance ultrasound every six months. 2, 4