Cirrhosis is scar tissue replacing working liver. It accumulates for years without symptoms, which is why the National Institute of Diabetes and Digestive and Kidney Diseases says most people are not aware they have it until the liver is badly damaged. About 1 in 400 US adults have cirrhosis. The two biggest drivers, chronic viral hepatitis and metabolic fatty liver disease, are now curable, controllable, or modifiable. Timing of the diagnosis decides the outcome.
Compensated and decompensated: the two stages that decide everything
The liver scars in response to injury. Early scarring is called fibrosis. When enough accumulates that the organ is rebuilt around the scar, that is cirrhosis. NIDDK describes cirrhosis as permanent damage, and that is the honest bar: an established cirrhotic liver does not return to normal.
What does change is the trajectory. Clinicians split cirrhosis into two stages. Compensated cirrhosis means the liver is scarred but still doing its job, and people live there for years with nothing more than fatigue, itching, or a poor appetite. Decompensated cirrhosis means the liver has stopped keeping up: fluid in the abdomen, yellowing eyes, confusion, bleeding from swollen veins. Everything worth doing about cirrhosis is done in the compensated stage.
Removing the cause moves people in the right direction, sometimes dramatically. In a five-year open-label follow-up, 348 people with chronic hepatitis B had liver biopsies before and after long-term tenofovir. Of the 96 who had cirrhosis on the first biopsy, 71 no longer met the biopsy definition of cirrhosis after five years of viral suppression.
The causes worth knowing by name
Hepatitis C. A chronic infection that scars the liver quietly for decades, and it is now curable. MedlinePlus states plainly that antiviral medicines for hepatitis C "can cure the disease in most cases." The drugs are direct-acting antivirals, they are pills, and a course is finite. Our full guide covers what the diagnosis and the cure look like in practice: hepatitis C in Black adults.
Hepatitis B. Not curable, but controllable. Daily antiviral pills suppress the virus, and the tenofovir biopsy data above is what suppression can buy. Hepatitis B also causes liver cancer directly, without waiting for cirrhosis, so your status matters even if your liver looks fine today.
MASLD and MASH. In 2023 a multisociety Delphi panel of 236 experts from 56 countries retired the terms NAFLD and NASH as imprecise and stigmatizing. Fat in the liver driven by metabolic factors is now metabolic dysfunction-associated steatotic liver disease (MASLD), and its inflammatory form is MASH. It is the most common liver disease in the country: national elastography data put MASLD at 25.6% of US adults and liver fibrosis at 11.3%.
Alcohol. NIDDK lists alcohol-associated liver disease alongside fatty liver and viral hepatitis as one of the most common causes of cirrhosis. Cutting back is the one intervention that is free and available today.
The fatty liver nuance to get right
MASLD is less common among Black adults. In the national elastography survey of 13,538 adults, both MASLD and fibrosis were inversely associated with non-Hispanic Black race and ethnicity after adjustment. Any article telling you the opposite has it backwards.
That is not protection you can bank on, and it changes the risk in one specific way: a clinician who has internalized "fatty liver is uncommon in Black patients" is less likely to look. Under-suspicion is its own hazard. MASH scars whoever has it regardless of the population average, and the fibrosis score below costs nothing to run.
Two screening tests every adult should have once
Hepatitis C, once. The US Preventive Services Task Force recommends screening every adult aged 18 to 79 for hepatitis C infection, a B recommendation, meaning insurers generally cover it with no cost sharing. It applies to asymptomatic adults with no known liver disease. You do not need a risk factor and you do not need to explain yourself.
Hepatitis B, once. In 2023 the CDC expanded hepatitis B screening from a risk-based approach to all adults aged 18 and older, at least once in a lifetime, using a triple panel: HBsAg, antibody to HBsAg, and total antibody to hepatitis B core antigen. The CDC's stated reasoning includes reducing health disparities by removing the need to disclose stigmatizing risk factors. Anyone who requests the test should receive it, disclosure or not.
What happens without that screening shows up in the cancer data. Researchers at one New York City institution reviewed 4,400 liver cancer cases and identified 33 patients estimated to be African immigrants with hepatitis B-related liver cancer. Median age at diagnosis was 48. Among those with a recorded hepatitis B diagnosis date, 71% did not know they carried the virus until they presented with cancer. Not one was found through routine screening, and 64% were already ineligible for surgery or transplant. The sample is small and immigrant status was inferred from surnames, so read it as a signal about screening failure, not a national rate.
Ask for a FIB-4 score, then elastography
You do not need a biopsy to learn whether your liver is scarred. FIB-4 is a fibrosis score calculated from four values already on standard bloodwork: age, AST, ALT, and platelet count. No extra draw, no extra cost. AASLD guidance uses it as the first step. A FIB-4 below 1.3 makes advanced fibrosis unlikely and means primary care can keep following you. Above 1.3 is the trigger for the next test.
That next test is elastography, usually vibration-controlled transient elastography, sold as FibroScan. A probe on the right side of the ribcage measures liver stiffness in kilopascals. Stiffer means more scar. Minutes, no needle, and a number you can track.
Two sentences to bring to your next appointment: "Can you calculate my FIB-4 from my last labs?" and "If it is above 1.3, can I get a FibroScan?" If you have type 2 diabetes, obesity, a family history of cirrhosis, or you drink more than lightly, that request is squarely within guideline.
Where Black patients actually lose ground: treatment, not testing
A cure that nobody prescribes is not a cure. At one urban academic medical center, 4,345 people had a positive hepatitis C RNA test between 2018 and 2023. Only 1,150 of them, 26.5%, were ever prescribed a direct-acting antiviral. Black patients, people experiencing homelessness, and people on Medicaid or uninsured were among the least likely to get one. The untreated then turned up in the hospital and the emergency department at several times the rate of the treated.
The same pattern holds further down the line. A national registry analysis found Black patients have unequal access to being listed for a liver transplant, before the waiting list even starts counting. An analysis of 717,580 hospital admissions for decompensated cirrhosis from 2009 to 2018 found that by the end of that decade Black patients were still not receiving TIPS (a shunt that relieves the pressure driving fluid buildup and variceal bleeding) or transplant at equal rates, and their odds of dying in the hospital had not converged.
With cirrhosis, an ultrasound every 6 months is not optional
Cirrhosis of any cause raises liver cancer risk enough that AASLD recommends surveillance for every adult who has it: abdominal ultrasound plus an alpha-fetoprotein blood test at roughly six-month intervals. Six months is short enough to find a tumor while it can still be removed, ablated, or transplanted around. Our guide to liver cancer in Black adults covers what happens after a spot is found.
Almost nobody gets it. A meta-analysis of 29 studies covering 118,799 patients with cirrhosis found pooled surveillance use of 24.0%, and 8.8% in population-based cohorts outside specialty liver clinics. Reminder systems and outreach raised it every time they were tried. If you have cirrhosis and no one has scheduled your next ultrasound, that is the highest-value thing to fix at your next visit.
How to get care
Start with one visit and three asks: screen me once for hepatitis C, screen me once for hepatitis B with the triple panel, and calculate my FIB-4. A primary care clinician can do all three. If FIB-4 comes back above 1.3, ask for elastography and a hepatology or gastroenterology referral, and do not let that referral sit.
If you want a clinician who takes the ask seriously the first time, find a Black gastroenterologist or primary care doctor in our directory. Bring your last complete blood count and metabolic panel. Those are the labs FIB-4 is built from.
Frequently asked questions
Can cirrhosis be reversed? ▼
NIDDK describes cirrhosis as permanent scarring, and established cirrhosis does not return to a normal liver. But it is not fixed in place either. In a five-year study of people with chronic hepatitis B on tenofovir, 71 of the 96 who had cirrhosis on the first biopsy no longer met the biopsy definition after five years of viral suppression. Removing the cause is what makes that possible, and it lowers complication and cancer risk even when the scarring stays.
What is a FIB-4 score and how do I get one? ▼
FIB-4 is a fibrosis estimate calculated from your age, AST, ALT, and platelet count, all of which appear on routine bloodwork. There is no separate test to order and no additional blood draw. AASLD guidance uses it as the first step: below 1.3 makes advanced fibrosis unlikely, above 1.3 is the trigger for elastography. Ask your clinician to calculate it from your most recent labs.
Is hepatitis C really curable? ▼
Yes. MedlinePlus states that antiviral medicines for hepatitis C can cure the disease in most cases. The current drugs are direct-acting antivirals taken as pills for a defined course. The obstacle is not the medicine, it is getting prescribed it: in one health system only 26.5% of people with active hepatitis C between 2018 and 2023 ever received a prescription.
Is fatty liver disease more common in Black adults? ▼
No. In national elastography data, both MASLD (formerly called NAFLD) and liver fibrosis were inversely associated with non-Hispanic Black race and ethnicity. The practical risk runs opposite to what people assume: lower average prevalence makes clinicians less likely to look, so ask for the fibrosis check on your own terms if you have diabetes, obesity, or a family history of liver disease.
How often do I need a liver ultrasound if I have cirrhosis? ▼
Every six months. AASLD recommends abdominal ultrasound plus an alpha-fetoprotein blood test at roughly six-month intervals for every adult with cirrhosis, whatever the cause. Only about 24% of patients with cirrhosis actually receive it, so treat scheduling the next one as your job.
