Compensated Vs Decompensated Cirrhosis: Know The Difference

Cirrhosis of the liver is a condition in which normal liver tissue is replaced by scar tissue, making it difficult for the liver to function properly. The progression of cirrhosis can occur over many years and can lead to serious complications if left untreated. It's important to understand the different stages of cirrhosis so that you can take the necessary steps to manage your condition and avoid serious health problems.

This article will explore the difference between compensated and decompensated cirrhosis and what you need to know about each stage. Understanding the progression of cirrhosis can help you take control of your health and improve your quality of life.

What is compensated and decompensated cirrhosis?

Cirrhosis is the end stage of any chronic liver disease. It involves fibrosis and the conversion of the normal architecture of the cells in the liver into abnormal nodules called regenerative nodules. The two types are differentiated based on severity.

Compensated cirrhosis

This is where biochemical, radiologic, and histologic findings are consistent with cirrhosis, but the liver synthetic function is preserved without complications related to portal hypertension, such as ascites, varices, or jaundice.

In short, people with compensated cirrhosis do not show symptoms, with a 10-year survival rate of more than 90%.¹

Decompensated cirrhosis

This is diagnosed when there is evidence of complications of liver dysfunction alongside reduced hepatic synthetic function and portal hypertension such as ascites, jaundice, variceal bleeding, or hepatic encephalopathy. People with decompensated cirrhosis have a median survival time of two years.²

Cirrhosis can develop from any chronic liver disease that damages the liver, causing it to become fibrotic. It can progress to the point of no return when the only way to save the life may be a liver transplant.

Other treatments involve lifestyle changes that reduce damage caused to your liver, such as losing weight, halting the consumption of alcohol, treating conditions such as diabetes or Wilson's disease that may be contributing, or treating hepatitis. 

Another adjunctive treatment is transjugular intrahepatic portosystemic shunt (TIPS) for patients not suitable for a liver transplant.

Symptoms of compensated vs. decompensated cirrhosis

Compensated cirrhosis

People with compensated cirrhosis may be asymptomatic or have nonspecific symptoms such as anorexia, weakness, and weight loss, but they will not have signs and symptoms associated with portal hypertension. Compensated cirrhosis can be elucidated via biopsy as well as biochemical and radiologic testing.

Decompensated cirrhosis

Decompensated cirrhosis is the stage of the disease defined by the onset of symptoms associated with complications related to portal hypertension and reduced hepatic synthetic function. This is the stage in which your liver struggles to complete its usual duties, and your systems start to slow.

Symptoms of decompensated cirrhosis include the following (depending on the underlying cause of the cirrhosis):

• Exhaustion

• Easy bruising

• Easy bleeding

• Hematemesis & melena (blood in vomitus and blood in stool)

• Yellowed skin and whites of eyes (jaundice)

• Itchiness

• Hand and nail features such as leukonychia, palmar erythema, and spider nevi

• Facial features such as telangiectasia, spider nevi, and jaundiced sclera

• Abdominal features (collateral circulation, distention, hepatosplenomegaly)

• Swollen ankles and legs due to fluid buildup

• Hepatic fetor

• Fluid buildup in the abdomen (ascites)

• Pain in the abdomen

• Nausea

• Fever

• Weight loss

• Loss of appetite

• Confusion, loss of memory, insomnia (hepatic encephalopathy)

• Variceal hemorrhage (life-threatening bleeding from abnormal veins in the esophagus)

Late-stage liver disease can also cause changes in stool, such as black tarry stools, due to blood passing through the gut. Contact a medical professional immediately if you experience blood in your stool or vomit.

Causes of cirrhosis

Cirrhosis is the process of the liver being damaged and trying to repair itself. In the repair process, scar tissue is formed, slowly hindering the liver's function more and more. It can be caused by a wide variety of conditions and diseases, including:

• Alcohol-related liver disease

• Chronic viral hepatitis (B (∓D), and C)

• Non-alcoholic fatty liver disease

• Excess of iron in the body (hemochromatosis)

• Cystic fibrosis

• Wilson disease

• Infection, e.g., syphilis, echinococcosis, or brucellosis

• Some medications, including methotrexate or amiodarone

• Autoimmune liver disease

• Problems with your bile ducts (biliary atresia or primary biliary cirrhosis)

• Alpha-1 antitrypsin deficiency

• Sugar metabolism disorders (galactosemia or glycogen storage disease) 

• Right-sided heart failure

Complications of decompensated cirrhosis

Several complications can happen as a result of decompensated cirrhosis. Some of these include:

Portal hypertension

Portal hypertension is high blood pressure in the veins that drain into the liver, mainly from the GI tract. The fibrosis caused by cirrhosis increases the resistance of the liver to the blood flow, building up pressure and causing enlarged veins in the esophagus and stomach. This puts you at a higher risk for bleeding. The liver's role in forming proteins that assist with coagulation may also be impaired, meaning continuous bleeding is also a risk. 

Portal hypertension can also cause changes to the spleen, including excess swelling and trapping of blood cells, termed hypersplenism. Measuring blood cell counts can be a good way to ensure appropriate management of cirrhosis.

Fractures (hepatic osteodystrophy)

Studies have demonstrated that patients with cirrhosis are more prone to fractures. However, the exact reason is yet to be elucidated but is hypothesized to be secondary to vitamin D metabolism.³

Liver cancer

People with cirrhosis are at risk for hepatocellular carcinoma, particularly those with hepatitis B, C, hemochromatosis, or nonalcoholic fatty liver disease.

Spontaneous bacterial peritonitis (infection of the abdominal lining)

The buildup of fluid in the peritoneum (ascites) can pose a high risk of infection, and cirrhosis, in general, can reduce your body's ability to fight them.

How are compensated and decompensated cirrhosis diagnosed?

Cirrhosis is usually diagnosed with clinical, laboratory, radiologic, elastographic, or biopsy findings. 

Diagnosis of compensated cirrhosis is more complex, as patients often lack overt and specific symptoms and must be diagnosed via biopsy, radiologic or biochemical testing. Decompensated cirrhosis diagnosis often involves patient history, laboratory findings, and physical examination, as these are much more obvious.

Risk factors for developing decompensated cirrhosis

Risk factors for developing cirrhosis include:

Drinking in excess

Abuse of alcohol is a huge contributing factor in the development of liver disease. It increases the amount of toxins your liver must process in your lifetime and can overload and damage it if regularly consumed in excess. 

Obesity

Obesity can contribute to diseases such as non-alcoholic fatty liver disease. Fatty liver disease is the buildup of excess fat in the liver cells. This can eventually lead to more serious conditions such as cirrhosis.

Chronic hepatitis (B or C)

Chronic viral hepatitis can cause damage to the liver and lead to cirrhosis. There are several ways you can reduce the risk of contracting this disease. The first is to get vaccinated. This arms your immune system in case you are exposed to the disease. Another way to defend yourself against hepatitis is to practice safe sex, as it can be transmitted between sexual partners. 

Treatment for compensated vs. decompensated cirrhosis

Treatment for both compensated and decompensated cirrhosis focuses on the root cause of the disease. For compensated cirrhosis, the complications and discomfort are much less and can often be managed well. In decompensated cirrhosis, the focus is on reducing symptoms and complications as much as possible and attempting to stop the disease from progressing. Treatment includes:

• Reducing alcohol consumption

• Weight loss

• Medication for hepatitis

• Medications for Wilson disease or primary biliary cholangitis

In severe cases, a TIPS procedure or liver transplant may be needed. 

How long can you live with decompensated cirrhosis?

Decompensated cirrhosis reduces your life expectancy dramatically. The average life expectancy without a transplant is difficult to predict. This depends on other factors such as age, complications, and overall health.

The prognosis for those who receive a liver transplant is very positive, with studies showing that 74.6% of people live at least five years after receiving one. Recipients often will live a healthy, normal life for more than 20 years.⁴

The lowdown

Decompensated cirrhosis is the more severe, more symptomatic version of compensated cirrhosis. The outlook for decompensated cirrhosis is much less positive than compensated. However, both can be managed by lifestyle changes and certain medications that treat the root cause of liver damage. 

If you have any concerning symptoms that you think may be due to either of these conditions, contact your doctor for further opinion. They will be able to guide you through diagnosis and treatment options for your personal situation. 

Frequently asked questions

Is compensated or decompensated cirrhosis worse?

Overall, decompensated cirrhosis has worse symptoms, complications, and outlook. Compensated cirrhosis is usually asymptomatic and sometimes reversible. If left untreated, it can progress to decompensation. If caught early, it is a less serious condition. Decompensated cirrhosis will most likely require a transplant. Without this, patients have very little chance of survival.

Does compensated cirrhosis always become decompensated?

No. If compensated cirrhosis is discovered early, and when little damage to the liver has been caused, it will not necessarily progress to decompensated cirrhosis. Treatment involves lifestyle changes that reduce toxins traveling through the liver or treatment of an underlying condition that is causing cirrhosis.

A study has shown that overall, 11% of patients will have compensated cirrhosis progress to decompensated cirrhosis annually. Bear in mind that this refers to cases where the cirrhosis has been identified before progressing — in some cases, this does not happen.⁵

Can decompensated cirrhosis be reversed?

Decompensated cirrhosis is a late-stage liver disease. At this stage, reversing the disease is difficult and usually impossible. This is because extensive scarring of the liver cannot be repaired. Often, the only way to properly ‘reverse’ the disease would be to entirely replace the liver via a liver transplant. The more urgently you require this, the more likely you will receive one.

Is decompensated cirrhosis terminal?

Patients with decompensated cirrhosis have a reduced life expectancy. However, treatment such as a liver transplant can prolong this. The disease can be terminal in some cases. It depends on complications, age, and overall health of each individual and their access to medical care such as liver transplants.