Your liver does hundreds of jobs quietly every day.
It processes nutrients, helps remove waste from the blood, produces proteins needed for blood clotting and helps regulate many of the body’s essential functions.
The difficulty is that your liver can continue working even after it has been damaged.
This means someone can have significant liver disease and still feel relatively well.
So how do you know when your liver is beginning to struggle?
First: liver damage and liver failure are not the same thing
Having fatty liver, abnormal liver enzymes or even cirrhosis does not automatically mean that your liver is failing.
Liver disease can progress over time.
A simplified pathway may look like:
Even people with cirrhosis may remain relatively stable for a period of time. Doctors often refer to this as compensated cirrhosis.
The more serious turning point is when complications begin to appear because the liver can no longer compensate adequately.
This is known as decompensated cirrhosis. Ascites, hepatic encephalopathy and bleeding from enlarged veins in the digestive tract are among the major signs of decompensation.
1. Your eyes or skin are becoming yellow
One of the most recognisable signs of serious liver dysfunction is jaundice.
You may first notice that the whites of your eyes look yellow. The skin can also develop a yellow colour, although this may be less obvious on darker skin tones.
Jaundice happens when bilirubin — a yellow pigment produced as red blood cells break down — builds up in the body instead of being processed and removed normally.
Jaundice has several possible causes and does not always mean liver failure.
But new or worsening jaundice should always be medically assessed, particularly in someone with known liver disease.
2. Your stomach is becoming swollen
A stomach that becomes noticeably larger is not always weight gain.
Advanced liver disease can cause fluid to collect inside the abdomen. This is called ascites.
People may describe:
- a rapidly increasing waistline
- a tight or heavy abdomen
- difficulty fitting into clothes
- feeling full after eating only a small amount
- discomfort or shortness of breath as the swelling increases
Fluid may also collect around the ankles, feet and lower legs.
Ascites is an important development in someone with cirrhosis. AASLD identifies it as one of the main events that marks liver disease becoming decompensated, and patients with clinically significant ascites should be considered for specialist assessment, including transplant evaluation when appropriate.
3. You are becoming confused, forgetful or unusually sleepy
This is one of the warning signs families often notice before the patient does.
A person with advanced liver disease may begin to:
- struggle to concentrate
- become unusually forgetful
- reverse their sleep pattern
- appear confused
- behave differently
- become very sleepy
- have difficulty carrying out familiar tasks
This can happen because a badly damaged liver is less able to remove certain toxins from the blood.
When those substances affect the brain, the condition is called hepatic encephalopathy.
It can range from subtle concentration or sleep problems to severe confusion and reduced consciousness.
Sudden or significant confusion in someone with liver disease requires urgent medical attention.
4. You are bruising or bleeding more easily
Your liver makes several proteins needed for normal blood clotting.
As liver function deteriorates, the body’s ability to control bleeding can be affected.
You may notice:
- bruises appearing more easily
- bleeding that takes longer to stop
- frequent nosebleeds
- bleeding from the gums
However, bruising has many possible causes, including medicines and blood disorders, so it should not be used on its own to diagnose liver failure.
When it occurs together with jaundice, swelling or known advanced liver disease, it deserves further investigation.
5. You vomit blood or pass black stools
This is different from simply bruising easily.
Advanced cirrhosis can cause increased pressure in the veins carrying blood through the liver. This is known as portal hypertension.
As that pressure rises, enlarged veins called varices can develop in the oesophagus or stomach.
If they rupture, they can cause serious internal bleeding.
A person may:
- vomit fresh blood
- vomit material that resembles coffee grounds
- pass very dark or black stools
- become faint, weak or dizzy
Vomiting blood or passing black, bloody stools is a medical emergency. Go to hospital immediately.
6. You are becoming increasingly weak, losing weight or losing your appetite
Tiredness alone does not mean your liver is failing.
Fatigue is extremely common and has many possible causes.
But persistent fatigue combined with other changes may be significant.
People with worsening chronic liver disease can develop:
- severe tiredness
- weakness
- loss of appetite
- nausea
- unintentional weight loss
- loss of muscle mass
Muscle loss can sometimes be overlooked because a person’s abdomen may simultaneously become larger from fluid.
Early cirrhosis can also cause tiredness, appetite loss, nausea, weight loss and discomfort around the upper-right abdomen.
The key is not one symptom in isolation.
It is the pattern of symptoms and how they are changing over time.
7. Your urine becomes very dark or your stools unusually pale
Changes in urine and stool colour can sometimes occur when the liver or bile system is not processing and excreting bilirubin normally.
Dark urine can accompany jaundice, while stools may become lighter or pale.
Some people with liver disease also develop significant itching.
These symptoms have several possible causes — including conditions involving the gallbladder or bile ducts — so they do not automatically mean liver failure.
But unexplained changes, particularly when accompanied by yellow eyes or skin, should be investigated.
Can my liver be badly damaged even if I feel fine?
Yes.
This is one of the most important things to understand about chronic liver disease.
Cirrhosis can be present without obvious symptoms, particularly in its earlier stages. Symptoms may only become noticeable once the liver is significantly damaged.
That is why people with known risk factors should not rely only on how they feel.
These risk factors can include:
- fatty liver disease
- long-term heavy alcohol use
- hepatitis B or C
- autoimmune liver disease
- certain inherited or metabolic liver diseases
- previously diagnosed liver fibrosis or cirrhosis
Regular medical monitoring can identify deterioration before dramatic symptoms appear.
My liver enzymes are normal. Does that mean my liver is fine?
Not necessarily.
This is a common misunderstanding.
Tests such as ALT and AST can help doctors identify liver-cell injury, but abnormal results do not always tell doctors how badly the liver is functioning.
Importantly, liver blood tests may sometimes be relatively normal even in advanced liver disease.
Doctors therefore interpret blood tests together with your symptoms, history, physical examination and imaging.
How do doctors know whether the liver is failing?
There isn’t one single test that answers the question.
Doctors may assess several things together.
Blood tests
These can include tests that look at:
Bilirubin — how effectively bilirubin is being processed and removed.
Albumin — an important protein produced by the liver.
INR or clotting tests — which can help assess the liver’s ability to produce proteins needed for blood clotting.
Other blood tests can help doctors assess kidney function, infection, blood-cell counts and possible causes of liver disease.
Imaging
Ultrasound, CT, MRI or liver elastography may be used depending on the patient’s condition.
Clinical examination
Signs such as jaundice, ascites, swelling, muscle loss, confusion or evidence of bleeding can provide important information.
Doctors may also use validated scoring systems to assess the severity of advanced liver disease and whether transplant assessment should be considered.
Diagnosis of cirrhosis and advanced liver disease is therefore based on the whole clinical picture, not simply one abnormal liver result.
Can a failing liver recover?
It depends on why the liver is failing and how advanced the damage has become.
Some liver injuries can improve when the underlying cause is identified and treated early.
But advanced cirrhosis causes permanent scarring.
Treatment may then focus on controlling the cause of the liver disease, managing complications and preventing further deterioration.
When liver function becomes severely impaired despite treatment, liver transplantation may need to be considered.
This does not mean every patient with cirrhosis needs a transplant.
The decision depends on the severity of disease, complications, overall health and detailed specialist assessment.
When should you seek urgent medical help?
Seek urgent medical attention if someone with known or suspected liver disease develops:
- Vomiting blood
- Black or bloody stools
- New or worsening confusion
- Marked drowsiness or difficulty waking
- Rapidly increasing abdominal swelling
- Significant new jaundice accompanied by deterioration
These can represent serious complications of advanced liver disease and should not wait for a routine appointment.
Frequently Asked Questions
What are the first signs that your liver is struggling?
Early symptoms can be vague and may include persistent tiredness, reduced appetite, nausea, unexplained weight loss, itching or discomfort in the upper-right abdomen. However, some people with significant liver disease have no early symptoms at all.
What are the most serious signs of liver failure?
Jaundice, fluid accumulation in the abdomen, confusion, significant bleeding and vomiting blood or passing black stools can indicate advanced liver disease or its complications and require medical assessment.
Can you have liver failure without knowing it?
Chronic liver disease can progress for years with few symptoms. However, once true liver failure or decompensation develops, complications such as jaundice, ascites, encephalopathy or bleeding commonly begin to appear.
Does fatty liver mean my liver is failing?
No. Fatty liver means excess fat has accumulated in the liver. Many people with fatty liver do not have liver failure. The concern is whether inflammation and fibrosis have developed and whether liver function has become impaired.
Does cirrhosis mean my liver has failed?
Not necessarily. A person may have cirrhosis while the liver is still compensating adequately. Liver disease becomes much more serious when complications such as ascites, encephalopathy or variceal bleeding develop.
Can normal liver tests rule out advanced liver disease?
No. Some liver blood tests may remain normal despite advanced liver disease, which is why doctors interpret laboratory results alongside medical history, examination and imaging.
What happens when the liver starts failing?
As liver function deteriorates, the body may have increasing difficulty processing bilirubin and toxins, maintaining normal fluid balance and producing proteins involved in blood clotting. This can contribute to jaundice, swelling, confusion and bleeding.
When should someone with liver disease see a transplant specialist?
Transplant evaluation may be considered when advanced liver disease begins causing significant complications or when liver function continues to deteriorate despite appropriate treatment. The decision requires specialist assessment rather than one symptom or test result alone. AASLD specifically recommends considering transplant evaluation when patients with cirrhosis develop clinically significant ascites and related complications.
About Prof. Thamara Perera
Medical References
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) — Cirrhosis: Symptoms, Diagnosis and Treatment.
- American Association for the Study of Liver Diseases (AASLD) — Guidance on cirrhosis, ascites and hepatic decompensation.
- NHS — Cirrhosis and advanced liver-disease symptoms.
This article provides general health information and is not a substitute for individual medical assessment.