Your pathology report for cirrhosis

by Stephanie Reid, MD FRCPC
December 21, 2025

Cirrhosis is a long-term condition in which the normal structure of the liver is replaced by scar tissue and regenerative nodules. Over time, repeated liver injury causes bands of scar tissue to form. These bands divide the liver into round areas called nodules, each composed of regenerating liver cells. Although these cells try to repair the damage, the abnormal structure prevents the liver from working correctly.

Cirrhosis represents the final stage of liver scarring, also called fibrosis. While cirrhosis was once thought to be permanent, research has shown that some improvement is possible if the underlying cause is treated and further liver injury is prevented.

Where does cirrhosis occur?

Cirrhosis affects the entire liver. It is a diffuse condition, meaning that scarring and nodules are present throughout the organ rather than in one isolated area.

What causes cirrhosis?

The causes of cirrhosis vary around the world. Still, the most common causes include chronic viral hepatitis (especially hepatitis B and hepatitis C), alcohol-related liver disease, and nonalcoholic (metabolic-associated) fatty liver disease.

Other causes include inherited metabolic disorders such as hereditary hemochromatosis, alpha-1 antitrypsin deficiency, and Wilson’s disease. Immune-mediated conditions, including autoimmune hepatitis, primary biliary cholangitis, and primary sclerosing cholangitis, can also lead to cirrhosis. Long-standing bile duct obstruction and drug-induced liver injury are additional causes.

In some people, no clear cause is identified. This is called cryptogenic cirrhosis. Many cases of cryptogenic cirrhosis are now believed to represent advanced “burnt-out” fatty liver disease.

What happens in the liver in cirrhosis?

Cirrhosis develops gradually after long-standing liver injury. The liver normally has a remarkable ability to repair itself, but repeated damage overwhelms this capacity.

One of the earliest changes is fibrosis, which means scarring. Fibrosis occurs when liver support cells produce excessive amounts of collagen, a protein that forms scar tissue. Over time, these scars thicken and connect, forming large fibrous bands.

At the same time, surviving liver cells attempt to repair the damage by dividing and forming regenerative nodules. Although these nodules contain living liver cells, they are surrounded by scar tissue and are not organized normally. This abnormal structure disrupts blood flow and bile drainage through the liver.

Damage to small blood vessels also causes areas of liver tissue to die, a process known as parenchymal extinction. Together, scarring, abnormal regeneration, and blood flow disruption reduce the liver’s ability to perform essential tasks such as detoxifying the blood, producing proteins, and processing bile.

If the underlying cause of cirrhosis is successfully treated, inflammation may decrease, scar-producing cells may become inactive, and some scar tissue can be broken down. This is why cirrhosis is now considered potentially partially reversible in selected cases.

What are the symptoms of cirrhosis?

The symptoms of cirrhosis depend on how advanced the disease is and how well the liver is still functioning.

Early in the disease, symptoms are often vague. People may feel exhausted, have a poor appetite, or lose weight. These symptoms occur because the liver is less efficient at processing nutrients and toxins.

As cirrhosis progresses, symptoms become more specific. The liver normally produces proteins needed to keep fluid inside the bloodstream and help blood clot. When protein production decreases, fluid can leak into the abdomen (called ascites), bruising occurs more easily, and the nails may appear white.

Impaired bile flow can cause bile to build up in the body, leading to yellowing of the skin and eyes (jaundice) and intense itching. When the liver can no longer properly process nitrogen-containing waste products, toxins accumulate and affect the brain, causing confusion, sleep changes, or personality changes, a condition called hepatic encephalopathy.

The liver also plays a role in hormone metabolism. When this function is impaired, men may develop breast enlargement or testicular shrinkage, and both men and women may develop red palms or small spider-like blood vessels on the skin.

What complications can cirrhosis cause?

Cirrhosis can remain stable for years or become decompensated, meaning serious complications develop.

Scar tissue increases resistance to blood flow through the liver, causing portal hypertension. This can lead to fluid accumulation in the abdomen, enlargement of the spleen, and enlarged veins in the esophagus or stomach that can bleed.

Advanced cirrhosis can cause liver failure, resulting in clotting problems, severe encephalopathy, kidney failure (hepatorenal syndrome), and lung-related complications.

Cirrhosis is also the most important risk factor for hepatocellular carcinoma, the most common type of liver cancer. The yearly risk of developing this cancer in people with cirrhosis is approximately 2–8%, which is why regular imaging surveillance is recommended.

How is cirrhosis diagnosed?

Cirrhosis is diagnosed using a combination of imaging studies, blood tests, and sometimes a liver biopsy.

Imaging

Ultrasound, CT, or MRI can show a nodular liver surface, changes in liver size, enlargement of the spleen, and signs of portal hypertension. Elastography measures liver stiffness and helps estimate the degree of scarring.

Blood tests and clinical scoring systems

Blood tests help assess liver function and disease severity.

  • The Child-Pugh score combines blood tests and clinical findings to classify cirrhosis as mild, moderate, or severe.
  • The MELD score estimates short-term mortality risk and helps prioritize patients for liver transplantation.
  • The ALBI score uses albumin and bilirubin levels as an objective alternative to Child-Pugh scoring.

Microscopic features

When a liver biopsy from a person with cirrhosis is examined under the microscope, the pathologist sees widespread scarring and distortion of the normal liver structure. In a healthy liver, blood flows in an organized way from the portal tracts to the central veins. In cirrhosis, this normal arrangement is lost.

A key feature of cirrhosis is bridging fibrosis, in which thick bands of scar tissue connect different parts of the liver. These fibrous bands divide the liver into rounded areas called regenerative nodules, which are made of liver cells trying to repair damage. Although these nodules contain living liver cells, their abnormal organization prevents the liver from functioning normally.

Special stains

Pathologists use special stains to highlight scar tissue and liver architecture. Trichrome, Sirius red, and reticulin stains make fibrous bands easier to see and help confirm the diagnosis of cirrhosis.

Types of cirrhosis

Pathologists sometimes divide cirrhosis into different types based on what the liver looks like under the microscope and which part of the liver has been most affected by long-term injury. This classification does not change the diagnosis of cirrhosis, but it can provide helpful clues about the underlying cause of liver disease. The three broad patterns most commonly described are nonbiliary cirrhosis, biliary cirrhosis, and alcohol-related cirrhosis. Each type shows a slightly different pattern of scarring and nodule formation, reflecting how and where damage occurred in the liver over time.

Nonbiliary type cirrhosis

In nonbiliary cirrhosis, which includes causes such as viral hepatitis and fatty liver disease, microscopic examination often shows:

  • Diffuse disruption of the entire liver architecture, with loss of the normal relationship between portal tracts and central veins.

  • Broad fibrous bands that bridge different areas of the liver.

  • Rounded nodules of regenerating liver cells are separated by scar tissue.

This pattern reflects a long-standing injury that directly affects liver cells.

Biliary type cirrhosis

In biliary cirrhosis, which is caused by diseases that damage bile ducts, microscopic examination often shows:

  • Diffuse architectural distortion throughout the liver.

  • Bridging fibrosis similar to nonbiliary cirrhosis.

  • Irregularly shaped nodules, often described as having a “jigsaw puzzle” appearance rather than smooth, round contours.

The edges of these nodules often show a pale halo. This happens because bile cannot drain properly, leading to swelling, loose scar tissue, and chronic bile-related injury to liver cells near the fibrous bands. These cells may appear feathery due to bile accumulation.

Alcohol-related cirrhosis

In alcohol-related cirrhosis, microscopic examination often shows:

  • Micronodular cirrhosis, meaning the nodules are small and relatively uniform in size.

  • Fat accumulation within liver cells.

  • Mallory bodies, which are clumps of damaged protein inside liver cells caused by alcohol-related injury.

  • Scarring around individual liver cells and small veins, especially near central veins. Over time, these central veins may become partially or completely blocked by scar tissue.

Bridging fibrosis in alcohol-related cirrhosis often connects central veins to other central veins or to portal tracts. Inflammation is usually mild unless there is ongoing alcohol use or a superimposed hepatitis.

Laennec fibrosis scoring system

In some pathology reports, cirrhosis may be further classified using the Laennec fibrosis scoring system. This system divides cirrhosis into three substages based on the thickness and extent of the scar tissue.

  • Stage 4A (mild cirrhosis): The liver shows clear cirrhosis with fibrous bands and nodules, but most of the scar bands are thin. Only one broader band of scar tissue is allowed.

  • Stage 4B (moderate cirrhosis): There are at least two broad bands of scar tissue separating the nodules, indicating more advanced scarring.

  • Stage 4C (severe cirrhosis): The liver shows very broad bands of scar tissue or many tiny nodules, reflecting severe architectural distortion.

This scoring system is useful because it correlates with disease severity, including:

  • The degree of portal hypertension.

  • Child-Pugh score.

  • MELD score.

How is cirrhosis treated?

Treatment focuses on managing the underlying cause, preventing further liver injury, and treating complications. Avoiding alcohol, managing metabolic disease, and treating viral hepatitis are critical.

People with decompensated cirrhosis or a MELD score of 15 or higher should be referred to a liver transplant center. Regular imaging is recommended to screen for liver cancer.

What happens after the diagnosis?

After cirrhosis is diagnosed, the following steps focus on understanding the cause, assessing disease severity, and preventing complications. Your healthcare team will usually review blood tests, imaging studies, and biopsy findings together to confirm the diagnosis and determine the extent of the disease.

If the cause of cirrhosis has not already been identified, additional tests may be ordered to look for viral hepatitis, metabolic conditions, immune-mediated diseases, or genetic disorders. Identifying and treating the underlying cause is one of the most important steps, because stopping ongoing liver injury can slow progression and, in some cases, allow partial improvement in liver structure and function.

Your doctor will also assess whether the cirrhosis is compensated (the liver is still performing most of its functions) or decompensated (complications such as ascites, jaundice, bleeding varices, or hepatic encephalopathy have developed). This assessment often includes clinical scoring systems such as the Child-Pugh and MELD scores.

Regular follow-up is essential. People with cirrhosis usually require:

  • Ongoing blood tests to monitor liver function.

  • Imaging studies, typically ultrasound, are performed every six months to screen for hepatocellular carcinoma.

  • Evaluation for complications of portal hypertension, such as an endoscopy to look for esophageal varices.

Lifestyle and medication changes are often recommended. These may include avoiding alcohol, adjusting medications that can stress the liver, managing metabolic risk factors, and receiving vaccinations to prevent additional liver infections.

If cirrhosis becomes advanced or complications develop, referral to a liver transplant center may be appropriate. Early referral allows time for evaluation and planning, even if transplantation is not immediately needed.

Close monitoring, treatment of complications, and clear communication with your care team play a key role in maintaining quality of life and improving long-term outcomes after a diagnosis of cirrhosis.

What is the prognosis for a person with cirrhosis?

Prognosis depends on the cause, severity, and presence of complications. Many people with compensated cirrhosis live for years with proper care. Decompensated cirrhosis carries a higher risk of liver failure and death.

Early diagnosis, treatment of the underlying cause, and close follow-up can significantly improve outcomes.

Questions to ask your doctor

  • What caused my cirrhosis?
  • What is my Child-Pugh or MELD score?
  • What complications should I watch for?
  • Do I need screening for liver cancer?
  • Could my liver improve if the underlying cause is treated?
  • Should I be evaluated for liver transplantation?
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