Hey, I Have Questions About Cirrhosis And My Liver......
2013 - EASL: New Advances in The Management of Patients with
Q-Isn’t it true that the liver can regenerate and does this mean I can get better on my own?
A-Your body can replace old liver cells, called hepatocytes, with new ones. This means that your liver can recover from minor stresses and strains. However, over time damage can cause fibrous scar tissue. This changes the structure of the liver and cannot be repaired. This is why it is so important to spot liver problems before the damage builds up and becomes irreversible.
Q-When does a doctor think liver enzymes readings are cirrhosis? Wanted to see if anyone knew what liver enzyme reading ast/alt would concern a dr to the point to refer for a biopsy?
A-Doctors don't generally make a diagnosis of cirrhosis based solely on liver enzymes, which are not a reliable indicator of liver damage, i.e. a person can have end-stage liver disease and normal liver enzymes, or a healthy liver and elevated enzymes. While elevated liver enzymes indicate activity going on in the liver, they don't paint the whole picture, nor do they identify a specific liver problem, as many things can account for the elevation. Further, the doctor will also consider: How high are the enzymes? Was it a sudden one-time spike, or have they been up in the 100s over a period of time?
If elevated for a long time, have they remained steady around that level, or have they been steadily increasing? It's important to provide the doctor with a full (honest) history to determine whether there are risk factors for liver disease. Patient history, symptoms, and blood count are among the indicators (as well as enzymes & biopsy) that will help a physician assess liver damage. Liver biopsy remains the "gold standard" of evaluating the liver's condition. However, biopsy isn't always necessary, nor is it always 100% accurate, due to sampling error.
Generally, biopsy is only done to provide additional information that can't be assessed or confirmed through non-invasive measures - information that would help identify a specific liver disease or make a difference in determining a course of treatment. If non-invasive measures do suggest advanced disease (cirrhosis), the doctor may decide against doing a biopsy due to risk. So, in answer to your question, liver disease is complex, and assessing damage isn't as simple as a single test result, i.e. there isn't a liver enzyme level that prompts referral for biopsy, and biopsy isn't always needed to determine that someone has cirrhosis. .
Q-Do high liver enzymes indicate serious liver damage? .
A-Despite what one might expect, high levels of liver enzymes (transaminases - AST and ALT) in the blood don’t always reveal just how badly the liver is inflamed or damaged. This is an extremely important point to keep in mind. The normal ranges for AST and ALT are around 0 to 40 IU/L and 0 to 45 IU/L respectively. (IU/L stands for international units per liter and is the most commonly accepted way to measure these particular enzymes.) But someone who has an ALT level of 50 IU/L is not necessarily in better condition than someone with an ALT level of 250 IU/L! This is because these blood tests measure inflammation and damage to the liver at an isolated point in time. For instance, if the liver is inflamed on the day that blood was drawn—let’s say if a patient consumes an alcoholic drink a few hours prior to blood being drawn—the levels of the transaminases may be much higher than if the alcohol had not been consumed. Following the same reasoning, if the liver was damaged years before—by excessive alcohol use—the results of a blood test done today may be normal, but a damaged liver may still be present. .
Q-What About My Diet ? .
A- Cirrhosis refers to the replacement of damaged liver cells by scar tissue. Too much scarring prevents blood flow through the liver. This causes even more damage and loss of liver function. Cirrhosis can hinder the body's use of nutrients and can lead to malnutrition.
Many patients with cirrhosis tend to hold onto (or retain) water. This often is shown first by swelling in the ankles, particularly after walking. The swelling may move up the legs to the abdomen. Water buildup in the abdomen is called "ascites" (pronounced "ah-si-teez").
Sodium (salt)Too much sodium (or salt) in the diet can make the situation worse, because sodium encourages the body to retain water. Your doctor will tell you if you need to limit sodium in your diet. Usually this means restricting sodium intake to about 2,000 mg a day or less.
If you need to restrict sodium, here are some tips that can help:
Avoid salty foods, salt in cooking, and salt at the table. Anything that tastes salty (such as tomato sauce, salsa, soy sauce, canned soups) probably has too much salt. Spice things up with lemon juice or herbs, instead of salt. Fresh foods usually are a better bet than processed foods.
Read food labels when shopping. Check the amount of sodium in the foods you are buying.Avoid fast-food restaurants. Most fast foods are very high in sodium.
Go easy on meats, especially red meats, which are high in sodium. When possible, consider vegetarian (meat-free) alternatives.
A dietitian can inform you about other products, such as antacids, that also contain lots of sodium.
The more fluid you retain, the greater your need to avoid salt. Your doctor may prescribe diuretics ("water pills") to help you urinate more. But all the water pills in the world won't help if you eat salty foods, such as anchovy pizzas.
Calories and protein
People with cirrhosis may need more extra calories and protein. They may lose their appetite and experience nausea, vomiting, and severe weight loss. This can lead to shortage of the minerals calcium and magnesium (signs include muscle cramps, fatigue, weakness, nausea, and vomiting), or a shortage of zinc (signs include reduced ability to taste, changes in taste).
It can help to eat small, frequent meals (4 to 7 times a day), including an evening snack. Your doctor even may recommend high-nutritional supplement drinks, such as Ensure or Boost.
When the scarring from cirrhosis prevents blood from passing through the liver, pressure increases in the veins entering the liver. This is called portal hypertension. The body is forced to reroute the blood away from the liver and into the general blood circulation. This causes large blood vessels, called "varices," to form.
Because the rerouted blood bypasses the liver, it contains high levels of amino acids, ammonia, and toxins that normally would have been handled by the liver. When these substances reach the brain, they can cause confusion and temporary loss of memory (a condition called "hepatic encephalopathy").
Amino acids and ammonia come from protein in the diet. Some evidence shows that patients with cirrhosis do better when they get their protein from vegetables (such as beans, lentils, and tofu) and from dairy products (eggs, milk, yogurt) instead of from meats.
Doctors can prescribe a syrup called Lactulose to push food through the bowels more quickly. This way, less food is absorbed, the liver has less work to do, and fewer toxins make their way to the brain. Avoid eating raw oysters or other raw shellfish. Raw shellfish can harbor bacteria (Vibrio vulnificus) that cause severe infections in people with cirrhosis. .
Q-Can antidepressants raise liver enzymes? .
A-While SSRIs are considered to be safe for people with liver disease, they can increase liver-related blood tests. However, other causes of liver elevations need to be looked for as the SSRI may or may not be the cause, for example, thyroid disease can also sometimes cause elevations in liver enzymes.
Q-Can prescription medicines, common pharmacy medicines, herbal remedies and illegal drugs affect my liver disease?
A-Yes. Most drugs (whether prescription, legal or illegal) are processed and broken down by the liver. In people with liver disease where the liver is already under strain, the extra work in breaking down drugs can be dangerous. Make sure all the health professionals (such as your GP, dentist and pharmacist) know about your liver disease before you are given or buy medicines from them. Even common tablets such as aspirin can be dangerous to people with liver problems. Herbal remedies and illegal drugs are a particular risk, as they are not regulated and can contain impurities that cause liver damage. If in doubt, speak to your liver specialist before taking any medicines or drugs.
The following are some tips for managing your medication: ..
To avoid potentially life-threatening complications, you should talk to your doctor or pharmacist about all medications or supplements - pharmaceutical and herbal - that you are taking or thinking of taking.
Always read the instructions, and never take more than the recommended dose. Taking more than is recommended of any medication could potentially cause harm to the liver.
NEVER mix medication with alcohol. Alcohol only increases the risk of possible liver damage. Acetaminophen can be especially toxic when combined with alcohol.
Consult your doctor about acetaminophen if you have liver disease.
Avoid certain herbal supplements as well as certain vitamins in high doses as they have the potential to cause damage to the liver. Kava, kava kava, comfrey, chaparral, jin bu huan, kombucha tea, pennyroyal, skullcap and shou-wu-pian all may be toxic to the liver.
High doses of vitamins E, K - and especially vitamins A and D - also may be harmful.
Take acetaminophen and all other pain relievers only when really necessary. .
Q -What about using Milk Thistle ? .
A- Laboratory studies suggest that milk thistle may benefit the liver by protecting and promoting the growth of liver cells, fighting oxidation (a chemical process that can damage cells), and inhibiting inflammation. Study results from small clinical trials on milk thistle for liver diseases have been mixed; however, most of these studies have not been rigorously designed, or they have looked at various types of liver diseases—not just hepatitis C. High-quality, well-designed clinical trials have not proven that milk thistle or silymarin is beneficial for treating hepatitis C. The HALT-C study mentioned above found that silymarin use by hepatitis C patients was associated with fewer and milder symptoms of liver disease and somewhat better quality of life, but there was no change in virus activity or liver inflammation.
2013 - Dietary Supplements for Hepatitis C? Not So Fast
Q-Can I use supplements? .
A- In general it is important to keep in mind that excessive doses of iron , vitamin A and niacin have been found to be toxic to the liver. Thus, individuals with liver disease are generally advised to avoid these supplements. And, since osteoporosis ( a disease characterized by reduced bone mass resulting in an increased risk for bone fractures), is common to many liver diseases, it is a good idea for all people with chronic liver disease to take a calcium supplement. Calcium supplementation should be limited to no more than 1000 to 2000 milligrams per day and should be taken with a vitamin D supplement ( which is usually included in the calcium tablet). Since stomach acid is needed to properly absorb calcium, antacids, such as Tums, which reduce stomach acid, are poor sources of calcium. Finally. individuals suffering from ascites- a complication of cirrhosis resulting in an abnormal accumulation of fluid in the abdomen, need to limit their intake of sodium. For every gram of sodium consumed, the accumulation of 200 milliliters of fluid results. The lower the consumption of sodium in the diet, the better controlled this excessive fluid accumulation is. For people with ascites, sodium intake should be restricted to under 1,000 milligrams per day and preferably under 500 milligrams. This goal is difficult, yet attainable. .. Iron and Hepatitis C :The liver plays an important role in the metabolism of iron since it is the primary organ in the body that stores this metal. The average American diet contains about 10- 20 mg of iron. Only about 10% of this iron is eliminated from the body. Patients with chronic hepatitis C sometimes have difficulty excreting iron from the body. This can result in an overload of iron in the liver, blood, and other organs. Excess iron can be very damaging to the liver. Studies suggest that high iron levels reduce the response rate of patients with hepatitis C to interferon. Thus, patients with chronic hepatitis C whose serum iron level is elevated, or who have cirrhosis, should avoid taking iron supplementation. In addition, one should restrict the amounts of iron rich foods in their diet, such as red meats, liver, and cereals fortified with iron, and should avoid cooking with iron coated utensils. .
Q-I have cirrhosis what can I take for joint pain ?
A-Acetaminophen is the recommended medication for relieving minor aches, pains, and headaches in people with liver disease. In small doses (less than 4 grams per day, or eight pills taken over a twenty-four hour period of time) acetaminophen is quite safe for the liver—unless combined with alcoholic beverages. (Note: each acetaminophen tablet or pill typically contains 500 milligrams of acetaminophen.) Be careful about mixing Tylenol® with other products that contain acetaminophen. By taking more than one pain reliever at a time, you may accidentally take more acetaminophen than is safe.
Q-What is acetaminophen? .
A: Acetaminophen (pronounced: a∙seet·aminofen), is an active ingredient found in many OTC and prescription medicines to help relieve pain and reduce fever. It is also found in combination with other active ingredients, called combination medicines, which treat conditions such as:
symptoms of colds and flu
Medicines containing acetaminophen are available in many forms, including drops, syrups, capsules, and pills. Many people call OTC acetaminophen by a brand name, Tylenol. Others may know Percocet or Vicodin, which are prescription brand names that contain acetaminophen and other active ingredients to help relieve pain.You might see acetaminophen abbreviated as “APAP” on prescription medicines. In other countries, acetaminophen may have a different name. For example, acetaminophen is known as paracetamol in the United Kingdom.
AASLD-What Patients Need to Know about Acetaminophen
Hepatitis C Review - Acetaminophen -Tylenol
Q-Can liver cysts cause abdominal pain?
A-Simple liver cysts — fluid-filled cavities in the liver — usually cause no signs or symptoms and need no treatment. However, they may enlarge enough to cause pain or discomfort in the upper right part of the abdomen.
Most liver cysts can be detected on ultrasound or computerized tomography (CT) scans. When needed, treatment may include drainage or removal of the cyst.
The cause of simple liver cysts isn't known, but they may be present at birth (congenital). Rarely, liver cysts may indicate a serious, underlying condition such as:
Polycystic liver disease, an inherited disorder
Echinococcus infection, a parasitic infection
Q- What is a hemangioma ?
A- Hemangioma (he-man-jee-O-muh) is a noncancerous (benign) mass that occurs in the liver. A liver hemangioma is made up of a tangle of poorly formed blood vessels. Liver hemangioma is sometimes called hepatic hemangioma or cavernous hemangioma.
Most cases of liver hemangioma are discovered during a test or procedure for some other condition. Most people who have a liver hemangioma never experience signs and symptoms and never need treatment. While it may be unsettling to know you have a mass in your liver, even if it's a benign mass, there's no evidence that an untreated liver hemangioma can lead to liver cancer. ,
Q-What is the most common benign liver tumors?
A-Hemangiomas are the most common benign tumors of the liver.The name hemangioma derives from the fact that these tumors are filled with heme (blood). They have no malignant potential and may occur in a person with or without underlying liver disease. Hemangiomas occur in the liver in approximately 10 percent of the population, and are usually detected by chance during a sonogram or CT scan performed for the evaluation of an unrelated medical condition. Hemangiomas are more common in women, but can also be found in men, and can occur at any age. Typically, an individual who harbors a liver hemangioma will not even be aware of it, as these tumors are usually asymptomatic. Some researchers believe that excess estrogen can cause hemangiomas to grow. In fact, growth of hemangiomas has been observed in some women during pregnancy, and in others while taking birth control pills. Furthermore, these people may be at increased risk for rupture. Although the effect of estrogen on hemangiomas is not conclusive, it is advisable for people with hemangiomas to stay off birth control pills and all other forms of estrogen replacement.
In the United States, metastatic tumors are the most common malignancies that occur in the liver. A metastatic liver tumor is a cancer that originally started in an organ other than the liver (known as the primary organ), and then spread to the liver. .
Q-Why does my liver hurt ?.
A-When diagnosed with hepatitis, patients often expect to feel pain over the liver. And, in fact, many people with chronic hepatitis do experience abdominal pain or discomfort over the liver. Others state that although they do not actually experience pain, they do feel a vague sense of “fullness”, or an “awareness”, of the liver. However, patients who report these symptoms to the doctor, will likely be informed that the liver itself does not typically cause pain or discomfort. Abdominal pain and/or pain over the liver (known as right upper quadrant pain), in people with liver disease may have many causes. This type of pain should not automatically be attributed to a liver disorder – other causes should be investigated. In fact, abdominal and right upper quadrant pain is rarely due to chronic liver disease.Right upper quadrant pain, when due to the liver, occurs most commonly in the acute stages of liver disease, (inflammation of the liver that lasts less than six months), or during a flare - up of a chronic liver disease. In these circumstances, the cause of this pain is due to acute inflammation, irritation, and distention of the liver’s surface. Otherwise, the liver is rarely tender. Gallstones often occur in individuals with liver disease, especially those with cirrhosis. Other risk factors for gallstones include female gender, obesity, a family history of gallstones, multiple pregnancies, rapid weight loss, and biliary tract narrowing (known as biliary strictures). The typical pain from gallstones is a right upper quadrant discomfort that usually lasts from a half hour to six hours before abating. Pain is usually severe and usually recurs. This pain often radiates to the shoulder or back, and is usually accompanied by nausea and vomiting. Diagnosis of gallstones is typically made by obtaining an abdominal sonogram.Liver cancer may also cause abdominal or right upper quadrant pain. People with a history of chronic hepatitis B or C, and those with cirrhosis due to any chronic liver disease are at risk for developing liver cancer, (also known as hepatocellular carcinoma, (HCC) or hepatoma). HCC is one of the most common cancers in the world, with its greatest frequency occurring in Asia and Africa. Although its rate of occurrence has been rising over the past twenty years in the United States, it is still uncommon, accounting for only 0.5 to 2 percent of all cancers. The cause of this rise has been linked to the prevalence of chronic hepatitis C in the United States. Stomach disorders, such as peptic ulcer disease (PUD) and gastritis (inflammation of the stomach lining) often cause abdominal pain in people with liver disease. An upper endoscopy (a procedure wherein a flexible tube with a light at the end is inserted down the esophagus into the stomach and first part of the small intestine) is typically performed in order to diagnose these stomach disorders. During an upper endoscopy, a biopsy is usually taken of the lining of the stomach for Helicobacter pylori, a bacteria which may cause gastritis and ulcers. These stomach ailments are readily treatable with medications known as proton-pump inhibitors, such as Prevacid, Nexium, Protonix or Aciphex, either alone, or in combination with antibiotics, depending upon the precise diagnosis. Other causes of abdominal and right upper quadrant pain which should be investigated in people with liver disease, include inflammation of the pancreas a condition known as pancreatitis, which may occur with increased frequency in those who drink excessive alcohol, and scar tissue from prior abdominal surgery known as adhesions.
If one experiences abdominal pain along with distention and swelling of the abdomen, ascites must be considered as a cause. Ascites is characterized by accumulation of fluid in the peritoneal cavity – the space between the abdominal organs and the skin, and is the most common complication of cirrhosis. When this is accompanied by a fever and severe abdominal pain, an infection of this fluid should be suspected. This is a serious medical condition known as spontaneous bacterial peritonitis (SBP), and requires immediate hospitalization and treatment.
However, abdominal distention and pain occurring in patients with liver disease may be due to less serious ailments than ascites. For example, abdominal distention and discomfort can result when the digestive tract fills with gas. When this happens, one may experience the sensation of being bloated. This type of abdominal distention may be due to impaired or inadequate absorption known as malabsorption or digestion, known as maldigestion, of certain foods which can be associated with certain liver disorders. This is a controllable condition, and may be treated by the avoidance of specific foods, for example milk-products or wheat (gluten) products
Q- Why does my spleen hurt?
A- Spleen is an important organ of the lymphatic system. It is found on the left upper side of the abdomen, between the 9th and 12th rib. The primary function of the spleen is to produce lymphocytes and plasma cells, which are used in humoral and cellular immune defense. Approximately half of the body’s monocytes are stored in this organ. These cells can easily transform into macrophages and dendritic cells, and assist in wound repair. Additionally, the spleen filters the blood and removes all the unwanted materials like cell debris and microorganisms as bacteria, viruses and fungi. Furthermore, it monitors the red blood cells, eliminating those that are abnormal, damaged or too old to function properly. It also serves as a storehouse for various elements of the blood like platelets and white blood cells. In the absence of the spleen, the body becomes susceptible to diseases caused by bacteria and protozoa, and responsiveness to certain vaccines also decreases.
Whenever the normal functioning of the body is hampered by disorders like cancer, anemia, malaria, tuberculosis, amyloidosis, cirrhosis, hepatitis and the like, the spleen becomes hyperactive, and starts entrapping and storing a large number of blood cells and platelets. As the result, the platelet and blood cell count in the bloodstream begins to fall dramatically. Due to entrapment, the spleen grows in size, and as it grows, it traps in more and more blood cells and platelets. Eventually the overgrown spleen starts capturing and destroying the normal blood cells together with the abnormal ones. These blood cells and platelets clog the spleen and interfere with its normal function.
The characteristic symptom of spleen enlargement is severe pain in the abdomen and back. At times, the pain shoots up to the left shoulder. This happens when certain parts of the spleen begin to bleed and die due to inadequate supply of blood. The enlarged spleen also starts pressing the stomach, which leads to the feeling of fullness after eating a small amount of food or even without eating anything. Furthermore, as too many blood cells and platelets have been removed from the bloodstream, the body’s immune response begins to dwindle, symptoms of anemia emerge, and normal blood clotting process is also slows down.
Q-What is cirrhosis ?
A-Cirrhosis is a description of the extent of scarring of the liver. With cirrhosis, scarring or fibrosis has advanced to the extent that the structure of the liver is altered: the usual smooth texture of the liver starts to become nodular and lumpy. Nodules are areas of liver cells that have become cut off from the rest of the liver by circular bands of scarring with liver cells unsuccessfully trying to regenerate inside the bands. The free flow of blood throughout the liver starts to be compromised.
Also See : News/Cirrhosis
Q-What are some symptoms of early cirrhosis? .
A-Many people with cirrhosis have no symptoms in the early stages of the disease. However, as the disease progresses, a person may experience the following symptoms:
loss of appetite
abdominal pain and bloating when fluid accumulates in the abdomen
spiderlike blood vessels on the skin
Q- What is compensated cirrhosis ?
A-Compensated cirrhosis means that the liver is still able to cope with or compensate for the damage and carry out most (sometimes all) of its functions. Cirrhosis, as with fibrosis, ranges from mild (at the beginning) to moderate and severe. Severe cirrhosis can then progress to decompensated cirrhosis.
** For people with Hepatitis C it is important to remember the disease progression is not linear; that is, the process speeds up so it is critical for people to take the necessary steps to make sure that they are receiving the appropriate medical care, which may include HCV therapy to help slow down or stop the disease progression process.
Q-What is decompensated cirrhosis ?
A- Decompensated cirrhosis means that the liver is extensively scarred and unable to function properly. People with decompensated cirrhosis eventually develop many symptoms and complications that can be life threatening.
Management of patients with complications of cirrhosis
Q- When does the liver stop working ?
A-The liver can still function with up to 80 percent deterioration. According to the Hepatitis C Trust, 80 to 90 percent of the liver becomes permanently damaged before decompensated occurs.
Q-Can a person have ascities and not have decompensated cirrhosis?
A- While the presence of ascites usually stems from decompensated cirrhosis, there are other causes of ascites, unrelated to liver disease - such as kidney failure, heart failure or ovarian cancer. Veno-occlusive disease can also cause ascites in people who do not have decompensated cirrhosis. In this disease, the hepatic vein becomes clogged, blocking off the blood supply to the liver resulting in ascites. The pyrrolizidine alkaloids which are ingredients of some herbal teas, such as Comfrey tea have been associated with veno-occlusive disorder. Many herbal preparations that contain a mixture of herbs include comfrey, but due to the lack of labeling regulations of herbal products, comfrey may or may not be listed as an ingredient on these products. .
Q-Why is my urine a dark color ? .
A-Brown urine can be a danger sign of liver disease, according to the University of Maryland Medical Center. Jaundice is often the first sign of liver disease, causing dark urine and yellowed eyes and skin. Cirrhosis, hepatitis, pancreatic cancer, pancreatitis, bile duct cancer and alcoholic liver disease all cause dark urine. Other symptoms of liver disease include an enlarged abdomen, disorientation, easy bruising or bleeding, nausea, loss of appetite and fatigue. Liver disease is a life-threatening disorder. .
Q- What happens as liver function decreases?
A-As liver function decreases, fewer proteins such as albumin are produced resulting in fluid accumulation in the legs (edema) or abdomen (ascites). Individuals with cirrhosis may bleed and bruise easily due to a decrease in proteins required for blood clotting. Some people may even experience intense itching due to products that are deposited in the skin.
Q-What problems are associated with the later stages of cirrhosis, or in decompensated cirrhosis?
A-Complications can include:
• Hardening of the Liver due to dying liver cells can be felt on examination.
• As liver disease progresses there is bone mass and density loss.
• A damaged liver is unable to regulate the production and breakdown of some female and male hormones. In women this can cause menstrual irregularities, and in men, gynecomastia (breast enlargement).
• Impaired Mental Status is due to many factors. Toxic substances that are usually filtered by the liver reach the brain. Symptoms of encephalopathy include personality changes, changes in sleep patterns, sluggish movements, drowsiness, confusion, stupor, and coma.
• Itching (pruritus) can develop that can be debilitating. The cause of pruritus is believed to be caused by impairment or failure of bile flow complicated by jaundice.
• Kidney function deteriorates in someone with decompensated cirrhosis, contributing to fluid retention(ascites, edema) and various kidney disorders.
• People with hepatitis C who develop cirrhosis are at risk for liver cancer.
• Muscle wasting can result from the liver’s inability to metabolize proteins, which can make a person with cirrhosis more prone to bone fractures.
• A combination of factors such as portal hypertension,low albumin levels and kidney dysfunction produce an accumulation of fluid in the body. Ascites is the accumulation of fluid in the abdominal cavity. Edema is the accumulation of fluid in the extremities, especially the feet and legs
• Bleeding problems (coagulopathy) develop as the liver
• The spleen stores red and white blood cells and platelets. An enlarged spleen develops due to blood being forced into it when portal hypertension develops. An enlarged spleen loses its ability to store red and white blood cells, and platelets.
• Scar tissue in the liver restricts the flow of blood and leads to portal hypertension resulting in complications such as ascites, spontaneous bacterial peritonitis, varices and other potentially life-threatening complications.
• Spontaneous Bacterial Peritonitis is a condition caused when the body’s natural bacteria enters the ascites fluid causing severe infection.
• The veins in the stomach, esophagus and rectum become so stretched and dilated (due to portal hypertension) that a condition called varices develops which can lead to internal bleeding.
Q-What is hepatic encephalopathy?
A-Hepatic encephalopathy (HE) is a disorder of mental activity, neuromuscular function and consciousness that occurs as a result of either chronic or acute liver failure. This complex neuropsychiatric syndrome is primarily caused by metabolic abnormalities. The syndrome may occur spontaneously or be induced by some precipitating factor and may be reversible, either by improvement in liver function, correction of the precipitating factors or the administration of therapy. However, HE can eventually lead to coma and especially in acute liver failure, may be fatal.
Also See: Staging Cirrhosis
Q-What are the different types of hepatic encephalopathy?
A-Acute or subacute encephalopathy - is generally rapidly progressive over the short course and is a complication of acute liver disease. This type of HE most often occurs in patients with acute fulminant viral hepatitis, toxic hepatitis and Reye's syndrome and is a sign of terminal liver failure.
Acute or subacute recurrent encephalopathy - more than one episode of HE in a patient with chronic disease with cirrhosis, with periods in between without any observable HE.
Specific precipitating factors can usually be identified in association with the recurrent episodes. Even though coma may develop, it is rarely fatal. Chronic recurrent encephalopathy - multiple recurrences of observable HE, requiring continuous therapy to decrease or prevent the development of symptoms during intervening periods.
Usually this type of HE is found in patients who are cirrhotic with an extensive portal collateral circulation with shunts either surgical or spontaneously evolving.
Chronic permanent encephalopathy or myelopathy - permanent neurological abnormalities unresponsive to therapy and forming part of the spectrum of acquired hepatocerebral degeneration and may include a myelopathy. This condition is very rare.
Q-What are the symptoms of hepatic encephalopathy?
A-There are four different stages of symptoms that can occur. The abnormalities that reflect mental and personality changes are distinguished from those reflecting neuromuscular functions.
In Stage 1, the symptoms include mild confusion, short attention span, nightmares and poor night time sleep with daytime sleepiness, restlessness, depression, aimless wandering, anxiety and irritability.
In Stage 2, the mental and personality changes include obvious drowsiness, obvious personalty change, gross impairment of ability to do mental tasks, slow response, disobedience, sullenness and disorientation for time and place.
In Stage 3, the symptoms include bizarre behaviour, occasional fits of rage, confusion, speech that is incomprehensible, paranoia and anger.
In Stage 4, coma is either responsive or unresponsive.
Q-How is hepatic encephalopathy diagnosed?
A-The diagnosis of HE is made primarily by recognition of neuropsychiatric changes occurring in a patient with known liver disease. In a patient with cirrhosis, whose liver disease has been followed for some time, the diagnosis becomes readily apparent with development of several of the symptoms mentioned above. When confronted with a patient who presents with an encephalopathy or a patient known to have a history of previous or current liver disease and who has neurological impairment, it is very important that attention should be paid to neurological symptoms such as personality changes, hypersomnia, reversal of sleep pattern, presence of precipitating factors such as gastrointestinal bleeding, use of sedative hypnotic drugs, etc. The presence of a flapping tremor is also an important physical finding in a patient with HE. There is no specific diagnostic test, improvement with treatment is the usual method of diagnosis.
Q-What is the treatment for hepatic encephalopathy?
A-The most important aspect of management is the prompt recognition and correction of precipitating factors, when possible. These factors include kidney failure, use of sedatives or narcotics, GI bleeding, hypokalemia/alkalosis, dietary protein increase, infection, constipation and exacerbation of liver disease. The importance of recognizing and correcting any precipitating factors in patients with HE cannot be overemphasized. Every patient with alcoholic cirrhosis and presumed HE should receive thiamine upon admission to hospital.
Additional therapeutic measures include dietary protein restriction and lactulose and occasionally additional neomycin or metronidazole therapy. The use of L-Dopa or bromocriptine is reserved for patients who do not respond to more conventional therapies, even though, in general, these two therapies are not effective in most patients.
Patients with chronic encephalopathy are encouraged to eat vegetable rather than animal protein. Branched-chain amino acid (BCAA) therapy, administered either orally or intravenously, remains the most controversial treatment. Available data about BCAA are conflicting and do not support its routine use. Newer therapies include lactilol, a disaccharide compound quite similar to lactulose. It is reported to be as effective as lactulose or neomycin but is associated with a decreased incidence of severe diarrhea and other side effects. In many patients with chronic liver disease, liver transplantation entirely reverses HE. Thus, liver transplantation may be considered in some patients with hepatic encephalopathy.
Q-What treatments are used to fight liver cirrhosis?
A-Treatments of cirrhosis are aimed at stopping or delaying the disease progress, minimizing liver cell damage and reducing complications. When cirrhosis is caused by alcohol, the patient must stop drinking to halt the progression of the disease. Cirrhosis caused by viral hepatitis may be treated with antiviral drugs to reduce liver cell injury. Medications can be given to control the symptoms of cirrhosis. For example, drugs called "diuretics" are used to remove excess fluid and to prevent edema and ascites from recurring. Combined diet and drug therapy can improve altered mental function. For instance, decreasing dietary protein results in less toxin formation in the digestive tract. Laxatives, such as lactulose, may be given to help absorb toxins and speed their removal from the intestines. A serious consequence of cirrhosis may be bleeding as a result of portal hypertension. Medications, such as beta blockers, may be prescribed to reduce portal hypertension.
Even when complications develop, they can usually be treated. If the patient bleeds from the varices of the stomach or esophagus, the doctor can inject these veins with a sclerosing (hardening) agent administered through a flexible tube (endoscope) that is inserted through the mouth and esophagus. Rubber bands can also be placed around the veins through the endoscope. In critical cases, a liver transplant or a portacaval shunt, which relieves the pressure in the portal vein and varices, may be necessary.
Q-What are varices?
A-Normally, blood from the intestines and spleen is brought to the liver through the portal vein. In people with severe liver damage (cirrhosis) however, the normal flow of blood through the liver is blocked. This can lead to swelling of the liver and potentially the spleen. Blood from the intestines is then rerouted around the liver through small vessels primarily in the stomach and esophagus. Some of these blood vessels become quite large and swollen (varices). These varices may rupture due to high blood pressure (portal hypertension) and thin vessel walls, causing bleeding in the upper stomach or esophagus.
EASL 2013: Watch - NEW PATHS FOR CIRRHOSIS TREATMENT
Q-What is a portal systemic shunt?
A-In cases where severe bleeding occurs, surgical shunt procedures may be used to improve the flow of blood through the varices and to stop bleeding and relieve pressure in these swollen blood vessels.
Introduced in 1945, the portal shunt (portal systemic shunt) was the first definitive form of therapy used for patients who had bled from varices. The procedure involves the surgical joining of two veins, the portal vein and the inferior vena cava, to relieve pressure in the portal vein that carries blood into the liver.
Q-Who qualifies for this procedure?
A-Elective portal shunt surgery is performed in only a relatively small number of patients who bleed from esophageal varices. About one-fourth have severe, uncontrollable bleeding requiring emergency surgery.
Q-Is the portal systemic shunt still performed? .
A-The shunt operation virtually eliminated recurrent bleeding from varices but its use declined in the 1970's for two major reasons. One was the frequency of encephalopathy (dysfunction of the brain) as a complication. The other was the failure of controlled clinical trials to establish a statistically significant advantage in survival for patients treated with shunts, over those treated with nonsurgical therapy. The failure of portal shunts to enhance survival, reflected the associated complications of encephalopathy and post shunt failure.
Q-What is a distal splenorenal shunt (DSRS)?
A-This operation was devised to preserve the flow of blood through the portal vein to the liver, while decompressing varices in the stomach and esophagus by joining the splenic vein to the left kidney vein. Studies comparing portal systematic shunts with DSRS, found similar rates of overall mortality and cumulative survival. DSRS had a higher operative mortality but a lower rate of encephalopathy afterwards. Also, patients with alcoholic cirrhosis do poorly with DSRS compared to nonalcoholic cirrhotic patients.
Q-What is endoscopic therapy?
A-Endoscopic therapy is a way of reducing variceal bleeding without surgery. In one procedure called endoscopic sclerotherapy, a flexible endoscope is used to inject diluted mixtures of sclerosing (hardening) solutions into the esophageal varices. Another technique called variceal banding, involves placing rubber bands around the veins through the endoscope.
What are the relative advantages and disadvantages of endoscopic therapy over surgical shunts?
The major merit of endoscopic therapy is that it is relatively easy to apply and can be administered at many primary care hospitals. It is commonly used in the initial management of patients with cirrhosis and variceal bleeding. However, patients experiencing gastric (stomach) variceal bleeding, hypertensive gastritis bleeding or repeated esophageal variceal bleeding following endoscopic therapy, should be treated surgically. In this combination, initial endoscopic therapy and selective shunt surgery may significantly improve survival in patients with variceal bleeding. .
Q-What is a transjugular intrahepatic portal-systemic shunt (TIPS)?
. A-An important recent advance has been the development of the transjugular intrahepatic portal-systemic shunt (TIPS). TIPS is performed by radiologists using only a local anesthetic and a sedative. A long needle is inserted via the jugular vein in the neck, advanced into a hepatic vein and then into a large branch of the portal vein in the liver. Using an inflatable balloon-tipped catheter tube, the section between the portal vein branch and the hepatic vein is widened and then kept open (stented) with a cylindrical wire-mesh stent.
Q-What are the advantages and disadvantages of TIPS?
A-The major advantages of TIPS are that it dispenses with the need for a general anesthetic and a major surgical procedure, both of which are often poorly tolerated by patients with cirrhosis. Another advantage of TIPS is that it reduces ascites (accumulation of fluid in the abdomen) while the DSRS does not. It has been used successfully to treat severe ascites that no longer respond to the use of drugs (diuretic) to reduce the amount of fluid. TIPS is a valuable innovation but it is not without its hazards. Although the direct mortality from TIPS complications is relatively low (less than 5%), this is true only in the hands of experienced radiologists in specialized centres. Approximately one quarter of patients develop encephalopathy after TIPS and these shunts frequently narrow or block up, requiring additional interventional procedures. In the setting of life-threatening bleeding that cannot be controlled by endoscopic therapy, TIPS is probably the ideal shunt procedure if it is readily available. In patients with portal hypertension who have failed treatment with endoscopic therapy and are candidates for liver transplantation in the near future, TIPS is not the preferred type of shunt. The presence of a surgical shunt makes transplant surgery more difficult and may therefore result in an increased risk of complications following liver transplantation. In patients who have recurrent bleeding in spite of endoscopic therapy and whose liver function is good, DSRS may be preferable in the elective or non-emergency setting. Appropriate clinical comparisons between TIPS, DSRS and endoscopic therapy are not yet available and will help to further clarify the place of TIPS in the management of variceal bleeding.
Q-What is ascites and what causes it? .
A-When fluid accumulates in the abdominal cavity, it is called ascites. Cirrhosis of the liver is the most common cause of ascites but other conditions such as heart failure, kidney failure, infection or cancer can also cause ascites.
Q-How common is ascites in people with cirrhosis? .
A-Ascites is common in people with cirrhosis and it usually develops when the liver is starting to fail. In general, the development of ascites indicates evidence of advanced liver disease and patients should be referred for consideration of liver transplantation.
Q-What causes ascites in patients with cirrhosis?
A-Ascites is caused by a combination of elevated pressure in the veins running through the liver (portal hypertension) and a decrease in liver function caused by scarring of the liver.
Q-What are the symptoms of ascites?
A-Most patients who develop ascites notice abdominal distension and rapid weight gain. Some people also develop swelling of ankles and shortness of breath.
Q-How is ascites diagnosed?
A-Depending on how much fluid is present in the abdomen, ascites may be diagnosed by your doctor on physical examination but is usually confirmed by tests such as ultrasound or CT scan of the abdomen. In the majority of patients, your doctor will recommend that a small needle be inserted through the abdominal wall (after local anesthesia) to remove fluid to be examined in the laboratory. This test is called a paracentesis. The fluid removed will be examined for signs of infection or cancer and to determine the cause for the fluid accumulation.
Q-Is ascites a dangerous sign?
A-Yes. The development of ascites generally suggests that the liver is not working well. The survival rate 5 years after ascites develops is only 30-40% and it is important that you and your doctor discuss a referral to a liver specialist and a liver transplant center.
Q-What are the complications of ascites?
A-Abdominal pain, discomfort and difficulty breathing: These may occur when too much fluid accumulates in the abdominal cavity. This may limit your ability to eat, ambulate and perform activities of daily living.
Infection: This is called spontaneous bacterial peritonitis (SBP) and it usually causes abdominal pain, tenderness, fever or nausea. If this is not promptly diagnosed or treated, a patient may develop kidney failure, severe infection in the blood stream or mental confusion. The diagnosis is generally made by taking a sample of the fluid from your abdominal cavity as described above. This infection can be treated with intravenous antibiotics, and after recovery, patients will require long term treatment with antibiotics to prevent SBP from recurring.
Ascites related hernias: Elevated intra-abdominal pressure can lead to the development of umbilical (around the bellybutton) and inguinal (groin) hernias that can cause abdominal discomfort. Surgical repair is generally avoided unless there is severe pain suggesting the intestines or tissue may be pinched or twisted along with a persistent bulge from the hernia. Surgeons who have experience in treating patients with cirrhosis should perform the operation.
Fluid may get into the chest: This is called hepatic hydrothorax and abdominal fluid fills your lung cavities (mostly on your right side).
Q-How best to treat ascites?
A-The most important step to treat ascites is to strictly reduce your salt intake. Your doctor may advise you to limit your salt intake to 4-5 grams per day (2,000 mg of sodium) or less. As it can be difficult to determine the salt content of various foods, it is generally recommended that a patient with ascites see a nutritionist (dietician) for advice about various foods to avoid. Patients may use salt substitute but it is essential to choose one without potassium because the potassium levels can increase with certain medications to treat ascites. It is important to discuss with your doctor or the dietician which salt substitute you are planning to use.
Most often, patients will require water pills (diuretics) to treat ascites. Your doctor will choose appropriate doses of water pills such as spironolactone (Aldactone) and/or furosemide (Lasix). As these water pills can cause problems with your electrolytes (levels of sodium, potassium, chloride, and bicarbonate in the blood stream), your doctor will need to monitor your blood levels closely. It is important to realize that taking water pills is not a substitute for reducing your salt intake, as water pills will work only when they are taken together with restricted salt intake.
Checking your body weight daily on a scale and contacting your physician whenever there is a gain of more than 10 lbs (or greater than 2 lbs per day for 3 consecutive days) is a good strategy for better management of ascites.
When fluid accumulation cannot be treated optimally with water pills and salt restricted diet, patients may require a large amount of fluid be removed (paracentesis) for relief of symptoms. Your doctors may also discuss with you other procedures such as having a radiologist place a shunt within the liver (called TIPS) to prevent significant fluid accumulation from ascites. As mentioned, patients with ascites have a serious health risk and are often evaluated for liver transplantation. Source
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