Cirrhosis

by Stephanie Reid, MD FRCPC
March 7, 2023

What is cirrhosis?

Cirrhosis is a type of medical liver disease caused by scar formation in the liver. This type of scar tissue that develops in the liver is called fibrosis. Fibrosis is caused by damage that occurs in the liver over a long period of time.

What are the symptoms of cirrhosis?

People with cirrhosis can experience a variety of symptoms. Visible symptoms of cirrhosis include yellow skin or eyes, a swollen abdomen, bleeding of the esophagus or stomach, or swelling of the legs. Some people may have no symptoms and the disease is discovered incidentally when a radiologic image (for example a CT scan or ultrasound) of the abdomen is performed. In some cases, the person has no symptoms and the disease is only discovered after an abnormal blood test shows elevated liver enzymes. In these situations, your doctor may order a liver biopsy to determine if cirrhosis is present.

What causes cirrhosis?

Any condition that damages the liver can result in fibrosis and ultimately cirrhosis.

Causes of cirrhosis include:

• Steatohepatitis
• Infections by liver viruses for example hepatitis B and C.
• Autoimmune disorders for example primary biliary cholangitis, primary sclerosing cholangitis, and autoimmune hepatitis.
• Genetic diseases.

What are some complications of cirrhosis?

People with cirrhosis are at risk for complications such as liver cancer, bleeding in the esophagus or stomach, and kidney problems.

How is cirrhosis of the liver diagnosed?

The diagnosis is usually made by a combination of imaging studies, blood tests, and examination of tissue from the liver under the microscope.

What does cirrhosis look like under the microscope?

When examined under the microscope, a liver with cirrhosis shows a change called fibrosis. Fibrosis is a type of scar that replaces normal tissue with a specialized type of tissue called collagen. When a pathologist sees fibrosis on a biopsy of the liver, the amount of fibrosis is given a ‘stage’. Cirrhosis is the final stage of fibrosis and is characterized by large bands of fibrosis that divide the liver into round compartments called ‘nodules’. These nodules prevent the liver from carrying out its normal functions. Ultimately this can lead to a condition called ‘liver failure’.

What else do pathologists look for when examining a liver biopsy with cirrhosis?

If the cause of your cirrhosis is unknown, your pathologist will look for features that help identify the condition that caused the disease.  However, in some cases, it may not be possible for your pathologist to determine the cause of the cirrhosis. Because cirrhosis is also associated with an increased risk of developing a type of liver cancer called hepatocellular carcinoma, your pathologist will also closely examine your tissue for any signs of cancer.

What does it mean if the tissue is described as fragmented?

The condition of the liver biopsy when viewed under the microscope is usually described. If the liver biopsy is brittle and has broken apart this will be described in your report. Because fibrosis tends to make the sample of liver tissue fragile, a biopsy from a liver with cirrhosis is often in multiple pieces when viewed under the microscope.

Additional information that may be included in your report

Adequacy

The liver is divided into ‘zones’ and at the center of each zone is a structure called a ‘portal tract’. Portal tracts are important because they contain blood vessels and channels that move other substances such as bile in and out of the liver.

When examining a liver biopsy, your pathologist must first determine if the sample contains the minimum amount of portal tracts required to make an accurate diagnosis. The adequacy of the biopsy may be reported simply as “yes” or “no”, or the number of portal tracts seen may be stated.

Inflammation

The liver is made up of three main compartments:

1. Lobule – The lobule which contains the hepatocytes
2. Portal tract – The portal tract contains a vein, an artery, and a bile duct
3. Central vein -The central vein which brings blood into the liver

Inflammatory cells can enter any of these areas and prolonged inflammation can damage the liver. If inflammatory cells are seen in the tissue sample, your pathologist will describe their location and the types of inflammatory cells present.  The amount of inflammation will also be described on a scale of mild, moderate, or severe. The type and pattern of inflammation in your biopsy can help your pathologist determine what caused the cirrhosis.

Ballooning hepatocytes

Ballooning is a word pathologists use to describe damaged or dying hepatocytes. They are called ‘ballooning’ because the hepatocyte swells to several times its normal size and the body of the cell becomes clear.

Ballooning hepatocytes are required for the diagnosis of several medical liver diseases. The amount of hepatocyte ballooning present will be described as mild, moderate, or severe. If ballooning hepatocytes are seen in a liver with cirrhosis, it may help your pathologist determine the cause of the disease.

Mallory bodies

Mallory bodies form as a result of damage to hepatocytes. When viewed under the microscope, they look like dense pink material inside the cells. Mallory bodies are seen in specific forms of medical liver disease and their presence or absence helps guide pathologists to a diagnosis.

Bile ducts

The liver produces a substance called bile which is used to remove toxins from the body and digest food. The bile produced in the liver drains through channels called bile ducts into the small bowel. Each portal tract contains one bile duct. There is a category of medical liver disease that affect the bile ducts. For this reason, your pathologist will examine the bile ducts to see if the normal amount of bile ducts are present and if any of the bile ducts are damaged.

Cholestasis

Cholestasis is a word pathologists use to describe bile trapped in the liver. Seeing trapped bile is important because it can cause liver injury. If cholestasis is seen, your pathologist will describe its location within the liver and the amount of trapped bile will be described as mild, moderate, or severe. Because cirrhosis can prevent bile from draining, it is not uncommon to see cholestasis in a pathology report for cirrhosis.

Ground glass cells

Ground glass is a term pathologists use to describe hepatocytes that have been infected by a virus called Hepatitis B. Ground glass cells are full of virus particles which gives them the look of pink ‘glass’. Because Hepatitis B can cause cirrhosis and increases the risk of liver cancer, pathologists look for ground glass cells and describe them in your report if they are present.

Iron

Iron can build up within the liver as a result of the abnormal breakdown of iron-containing proteins, increased iron in the body (such as after multiple blood transfusions), or when the liver is not functioning properly (as in liver cirrhosis). This excess iron can be seen within the hepatocytes or within immune cells called macrophages. If iron is present in your tissue, your pathologist will report its location and severity.