Information Chronic Liver Disease and Cirrhosis
Introduction
Patients who suffer from chronic liver disease may develop cirrhosis after years of disease. Cirrhosis of the liver is a serious condition characterized by severe scarring. Not everyone with hepatitis or liver disease develops cirrhosis. If your doctor has told you that you have chronic liver disease and/or cirrhosis, there are important precautions that you should take to prevent further damage to your liver.
Can I drink alcohol?
No, you should not drink alcohol.
Alcohol damages liver cells. A healthy liver is able to replace most liver cells that are injured by alcohol. However, in individuals with cirrhosis, the liver is unable to replace the damaged liver cells. Drinking any alcohol, not just hard liquor, but also beer or wine will speed up the process of liver destruction and may counteract any treatments prescribed by your doctor.
Sensitive to medications
Cirrhosis slows the liver's ability to filter medications from the blood. Because the liver does not remove drugs from the blood at the usual rate, they act longer than expected and build up in the body. This causes a person to be more sensitive to medications and their side-effects.
Is it safe to take acetaminophen (Tylenol ®)?
Patients with cirrhosis can safely receive between 2 grams (2000 mg) and 3 grams of acetaminophen daily for longer than two weeks, and individuals with and without cirrhosis using alcohol regularly can safely receive up to 4 grams on a short-term basis, according to Mayo Clinic researchers
(Mayo Clin Proc2010;85:451-458).
Acetaminophen is the main ingredient in Tylenol ®, but it is also found in many non-prescription products for headaches, the flu, sinus problems, arthritis or general aches and pains. In 1993, an FDA Advisory Committee recommended that all over-the-counter pain relievers contain an alcohol warning. Tylenol and some other pain relievers have included such an alcohol warning on their labeling. But, not all over-the-counter pain relief products have complied with the FDA recommendation. There have been some reports that chronic heavy alcohol users may be at increased risk of liver toxicity from excessive acetaminophen use.
Pay particular attention to products labeled "aspirin-free"; because some prescription medications also contain acetaminophen, so be sure to ask your doctor about use of pain relievers.
Some Acetaminophen Containing Medicines
Pay particular attention to products labeled "aspirin-free"; because some prescription medications also contain acetaminophen, so be sure to ask your doctor about use of pain relievers.
Some Acetaminophen Containing Medicines
People with alcoholic liver disease or cirrhosis should use no more than 4 tablets (2 grams or 2000 mg) a day. If there is any uncertainty, always check with your physician.
Tylenol ® 325 mg/tablet
Tylenol Extra Strength ® 500 mg/tablet
Tylenol Adult Liquid ® 500 mg/tablespoon
Tylenol Extended Relief ® 650 mg/tablet
Aspirin Free Excedrin ® 500 mg/tablet
Excedrin Extra-Strength ® 250 mg/tablet
Excedrin P.M. ® 500 mg/tablet
Midrin ® 325 mg/capsule
Actifed Cold & Sinus ® 500 mg/tablet
Sinutab Sinus Allergy ® 500 mg/tablet
Sudafed Cold & Cough ® 500 mg/tablet
What other medications should I avoid?
You may need to avoid iron supplements. Too much iron can damage liver cells or aggravate liver damage caused by some viruses. Most adults do not need to take iron supplements unless there is a history of obvious blood loss or a known deficiency of iron. Unless your doctor prescribes iron supplements for you, do not take any iron supplements or even multivitamins that contain iron.
What foods should I avoid?
Sewage runoff can infect edible sea organisms (clams, oysters, crustaceans and fish) with both bacteria and viruses. Contamination of seafood may be undetectable by smell or taste. Clams and oysters are especially susceptible to sewage contamination and should never be eaten raw.
Vibrio vulnificus is a bacteria that is found in contaminated oysters and other seafood. In healthy people, it rarely causes serious infection, but in individuals with cirrhosis it can cause death in 48 to 72 hours.
Hepatitis A is a virus that can be found in clams and oysters. Infection with hepatitis A can cause even healthy persons to become very sick. Individuals with cirrhosis are especially vulnerable to a life-threatening infection caused by this virus.
If you have open sores on your skin, you should avoid exposure to sea water during the warm summer months. Harmful organisms can enter the blood stream through these sores and cause serious infection.
Are vaccines important?
Yes. Ask your doctor if you would benefit from one or more of the following vaccines:
Hepatitis A Vaccine:
Used to prevent hepatitis A, which can be severe in individuals with cirrhosis. It consists of a series of two injections given six months apart.
Tylenol ® 325 mg/tablet
Tylenol Extra Strength ® 500 mg/tablet
Tylenol Adult Liquid ® 500 mg/tablespoon
Tylenol Extended Relief ® 650 mg/tablet
Aspirin Free Excedrin ® 500 mg/tablet
Excedrin Extra-Strength ® 250 mg/tablet
Excedrin P.M. ® 500 mg/tablet
Midrin ® 325 mg/capsule
Actifed Cold & Sinus ® 500 mg/tablet
Sinutab Sinus Allergy ® 500 mg/tablet
Sudafed Cold & Cough ® 500 mg/tablet
What other medications should I avoid?
You may need to avoid iron supplements. Too much iron can damage liver cells or aggravate liver damage caused by some viruses. Most adults do not need to take iron supplements unless there is a history of obvious blood loss or a known deficiency of iron. Unless your doctor prescribes iron supplements for you, do not take any iron supplements or even multivitamins that contain iron.
What foods should I avoid?
Sewage runoff can infect edible sea organisms (clams, oysters, crustaceans and fish) with both bacteria and viruses. Contamination of seafood may be undetectable by smell or taste. Clams and oysters are especially susceptible to sewage contamination and should never be eaten raw.
Vibrio vulnificus is a bacteria that is found in contaminated oysters and other seafood. In healthy people, it rarely causes serious infection, but in individuals with cirrhosis it can cause death in 48 to 72 hours.
Hepatitis A is a virus that can be found in clams and oysters. Infection with hepatitis A can cause even healthy persons to become very sick. Individuals with cirrhosis are especially vulnerable to a life-threatening infection caused by this virus.
If you have open sores on your skin, you should avoid exposure to sea water during the warm summer months. Harmful organisms can enter the blood stream through these sores and cause serious infection.
Are vaccines important?
Yes. Ask your doctor if you would benefit from one or more of the following vaccines:
Hepatitis A Vaccine:
Used to prevent hepatitis A, which can be severe in individuals with cirrhosis. It consists of a series of two injections given six months apart.
Hepatitis B Vaccine:
Used to prevent hepatitis B, another type of viral hepatitis. It consists of a series of three injections. The second and third injections are given one and six months after the initial injection.
Pneumococcal vaccine:
Used to prevent a kind of pneumonia caused by a bacteria called Streptococcus pneumoniae. It consists of only one injection, and should be repeated in five years.
Flu Shot:
Used to prevent influenza, a cause of severe upper respiratory infection and pneumonia. It is a single injection given yearly, usually in the Fall, just prior to the flu season.
Are there any natural herbs that can heal my liver?
Many causes of cirrhosis do not have any treatment available. For this reason, many individuals resort to the use of "health foods" and "natural herbs or supplements" to improve the liver. There is no scientific proof that any of these products are of benefit to the liver. Most of them are safe, but liver damage caused by herbal products has been reported. There are several herbal remedies that are known to cause liver damage. Be sure to tell your doctor before you begin any herbal products so that he or she may better monitor your condition.
CIRRHOSIS SYMPTOMS
People with cirrhosis may or may not have symptoms early in the course of the disease. Some of the more common symptoms include:
Used to prevent influenza, a cause of severe upper respiratory infection and pneumonia. It is a single injection given yearly, usually in the Fall, just prior to the flu season.
Are there any natural herbs that can heal my liver?
Many causes of cirrhosis do not have any treatment available. For this reason, many individuals resort to the use of "health foods" and "natural herbs or supplements" to improve the liver. There is no scientific proof that any of these products are of benefit to the liver. Most of them are safe, but liver damage caused by herbal products has been reported. There are several herbal remedies that are known to cause liver damage. Be sure to tell your doctor before you begin any herbal products so that he or she may better monitor your condition.
CIRRHOSIS SYMPTOMS
People with cirrhosis may or may not have symptoms early in the course of the disease. Some of the more common symptoms include:
Normally, blood from the intestines and spleen is carried to the liver through the portal vein. But cirrhosis slows the normal flow of blood, which increases the pressure in the portal vein. This condition is called portal hypertension. When portal hypertension occurs, the spleen frequently enlarges and holds white blood cells and platelets, reducing the numbers of these cells in the blood. A low platelet count may be the first evidence that a person has developed cirrhosis.
Scarring makes it difficult for blood to flow through the liver. As a result, veins in other areas outside of the liver become abnormally expanded. Abnormally expanded blood vessels are referred to as varices.
When the liver slows or stops production of the proteins needed for blood clotting in patients with cirrhosis they have easy bruising and bleeding. Once bleeding starts (such as with variceal bleeding), it can be severe.
One place where varices are commonly found is in the esophagus, the swallowing tube connecting the mouth with the stomach (figure 2).
When the pressure in the varices reaches a certain level, the varices can burst, which can cause massive bleeding (known as variceal bleeding).
( figure 2)
Cirrhosis can cause the blood vessels around the esophagus to swell. This is called "esophageal varices". In severe cases, these blood vessels can burst and cause internal bleeding.
Body fluids accumulate as a result of liver scarring and a decreased ability to manufacture blood proteins. Fluid is typically seen in the legs (edema) and abdomen (ascites) and sometimes in the lung (pleural effusion).
EDEMA SYMPTOMS
Symptoms of edema depend upon the cause, but may include:
Swelling or puffiness of the skin, causing it to appear stretched and shiny. This is typically seen in the lower legs (called peripheral edema) or lower back (called sacral edema, frequently seen in those with edema who have been in bed for long periods). Swelling is often worst after sitting or standing for a period of time (due to gravity), and may be worse at the end of the day. Pushing on the swollen area for a few seconds will leave a dimple in the skin
(picture 1)
EDEMA SYMPTOMS
Symptoms of edema depend upon the cause, but may include:
Swelling or puffiness of the skin, causing it to appear stretched and shiny. This is typically seen in the lower legs (called peripheral edema) or lower back (called sacral edema, frequently seen in those with edema who have been in bed for long periods). Swelling is often worst after sitting or standing for a period of time (due to gravity), and may be worse at the end of the day. Pushing on the swollen area for a few seconds will leave a dimple in the skin
(picture 1)
.
Treatment of edema includes several components: reducing the amount of salt (sodium) in your diet, and in many cases, use of a medication, called a diuretic, to eliminate excess fluid. (additional information below)
Ascites causes the abdomen to enlarge as fluid accumulates, which can cause shortness of breath and a feeling of fullness. The fluid provides an environment where bacteria can grow, increasing the risk of infection.
Patients with cirrhosis have a weakened immune system and are at increased risk of infections.
Spontaneous bacterial peritonitis is an infectious form of peritonitis (inflammation of the abdominal cavity) that affects 10 to 30 percent of people hospitalized with ascites.
Spontaneous bacterial peritonitis can cause:
Spontaneous bacterial peritonitis is an infectious form of peritonitis (inflammation of the abdominal cavity) that affects 10 to 30 percent of people hospitalized with ascites.
Spontaneous bacterial peritonitis can cause:
· rapid acceleration of liver disease
· other complications
· sepsis (whole body infection)
· death
A dangerous result of fluid buildup in the abdomen, spontaneous bacterial peritonitis is the most common infection in patients with ascites from cirrhosis, and it strikes without any identifiable external source of infection.
Hepatic encephalopathy is a condition that develops when the liver is unable to break down toxins normally found in the bloodstream, such as ammonia. In this condition, confusion or even coma are caused by toxins that build up in the blood. In the early stages, there may be mild symptoms, such as difficulty sleeping or sleeping too much. Advanced hepatic encephalopathy can cause confusion, delirium, and even coma. Hepatic encephalopathy can develop suddenly and may become a medical emergency.
Hepatic encephalopathy is a condition that develops when the liver is unable to break down toxins normally found in the bloodstream, such as ammonia. In this condition, confusion or even coma are caused by toxins that build up in the blood. In the early stages, there may be mild symptoms, such as difficulty sleeping or sleeping too much. Advanced hepatic encephalopathy can cause confusion, delirium, and even coma. Hepatic encephalopathy can develop suddenly and may become a medical emergency.
Malnutrition is common in patients with cirrhosis a damaged liver cannot properly metabolize many of the nutrients that an individual consumes in his or her diet. Patients are often malnourished for any of a number of reasons (eg, ongoing ethanol use, chronic nausea, anorexia, fat malabsorption, meal-induced abdominal discomfort, dietary protein restriction).
Malnutrition can lead to proximal muscle wasting, hypoalbuminemia with worsening of ascites, neutropenia with decreased resistance to bacterial infections, and weak cough with predisposition to pneumonia. Weakened connective tissue may predispose to variceal hemorrhage, umbilical hernia, and other complications. Because of these concerns, adequacy of the diet should be a major focus in the cirrhotic patient.
Aside from sodium restriction in patients with ascites, physicians try to not restrict the diet of patients with cirrhosis, even in the setting of hepatic encephalopathy. Routine supplementation with thiamine, folate, calcium, and a therapeutic multivitamin is appropriate. Some authorities recommend avoiding supplemental iron because excess absorption may contribute to liver injury.
Many people with advanced cirrhosis have jaundice (yellowed skin or whites of the eyes).
People with cirrhosis are at increased risk for developing liver cancer (hepatocellular carcinoma).
Cirrhosis can cause fatigue and in some cases itching.
Cirrhosis can cause fatigue and in some cases itching.
Signs Of Compensated Liver disease
In hepatitis C infection about 20 percent of people develop cirrhosis. Once your liver has reached this stage cirrhosis commonly occurs in two stages, compensated and decompensated. In the first stage of liver damage, the liver still has the ability to function normally or compensate for the damage. When extensive damage occurs and the liver can no longer function normally, decompensation occurs. According to the Hepatitis C Trust, up to 80 to 90 percent of the liver becomes permanently damaged before decompensated occurs.
The signs of compensated cirrhosis include a large, hardened liver, small, star-shaped vessels (spider angiomata) on the skin of the upper torso, blotchy redness on the palms (palmar erythema), whitened nails, thin silky hair, loss of body hair, prominent veins on the abdomen (abdominal collateral veins), irregular or absent menstruation in pre-menopausal women, and small testes and enlarged, sometimes painful breasts (gynecomastia) in men.
Signs Of Decompensated Cirrhosis
The signs of decompensated cirrhosis include all the above except that the liver may be shrunken and there may be swelling of the legs (edema), accumulation of fluid in the abdomen (ascites), bleeding from veins in the esophagus (varices), and mental confusion (hepatic encephalopathy) and jaundice.
Most chronic liver disease damages the liver over time by forming scar in the liver that replaces normal liver tissue. When there is enough scar, we call this cirrhosis. Cirrhosis is an advanced form of scarring or liver damage. However, even a cirrhotic or badly scarred liver can often still perform all the functions that a liver needs to do and in fact, it often continue to perform these functions quite well even for decades. This is because we are all given excess liver capacity which allows the liver to function well even if a significant amount of the liver is damaged.
When a liver is diseased or cirrhotic but is still functioning well we say this is compensated liver disease. This is a critical distinction because many people with hepatitis C will have cirrhosis but have no signs of liver failure. We call this compensated cirrhosis. Many of these people will be stable for years and many will be candidates for therapy. They typically do not have to be considered for liver transplant unless the liver starts to fail or their disease “decompensates”.
However, when the liver starts to fail with chronic liver disease, it almost never happens suddenly, unless some one is drinking heavily or gets another insult to the liver like hepatitis A.
People with chronic liver disease feel because they feel fine one day and then be close to death the next , that they quickly went into liver failure. This is not the way things work. In fact, typically, liver specialists can start to see signs of liver failure in tests months or years before the patients themselves notice them.
General Health With Cirrhosis
General health in patients with cirrhosis should not be neglected. For example, dental care is important to correct periodontal disease that may lead to abscesses. Diabetes mellitus occurs with increased frequency in patients with hepatitis C or hemochromatosis, and complications of diabetes may add to the risk of liver transplantation. Many patients who have cirrhosis smoke cigarettes, which increases the risk for atherosclerotic disease and chronic lung disease, lung cancer, and squamous cell cancers of the head, neck, and esophagus, patients should be strongly encouraged to quit smoking.
Certain classes of medications have the potential to aggravate complications of cirrhosis and are best avoided or used with caution. These include aminoglycosides, which increase nephrotoxicity; angiotensin-converting enzyme inhibitors, which can cause hypotension; nonsteroidal anti-inflammatory drugs, which promote renal sodium retention; and sedative and narcotic agents, which precipitate hepatic encephalopathy.
Drugs that are eliminated by the liver must be used in low doses in patients who have cirrhosis. This is particularly true of drugs that undergo high first-pass hepatic clearance, because portosystemic shunting greatly increases their bioavailability. Potentially hepatotoxic medications present a difficult problem.
In patients with cirrhosis the early signs of hepatotoxicity can be difficult to identify. The consequences of hepatotoxicity superimposed on cirrhosis can be devastating.
Dietary Factors
Healthy Foods. Because important antioxidant vitamins are depleted in the cirrhotic liver, cirrhosis patients should maintain a diet rich in fresh fruits, vegetables, and whole grains.
Healthy Foods. Because important antioxidant vitamins are depleted in the cirrhotic liver, cirrhosis patients should maintain a diet rich in fresh fruits, vegetables, and whole grains.
Antioxidant Supplements.
There is some preliminary laboratory evidence that various antioxidant supplements including vitamin E, selenium, and S-adenosylmethionine (SAMe) may help protect against liver damage and cirrhosis. Supplements, however, are not recommended for people with liver disease except with the advice of a physician. Some vitamins, such as vitamins D and A, are metabolized in the liver and can be toxic.
Iron Restrictions.
Elevated iron levels have been associated with cirrhosis from many causes. Patients should avoid iron-rich foods, such as red meats, liver, and iron-fortified cereals and should avoid cooking with iron-coated cookware and utensils.
Supplemental Nutritional Products.
Supplemental nutritional beverages may be helpful, particularly for patients with both alcoholism and cirrhosis. In one study, patients with both alcoholism and cirrhosis drank Ensure every day as a supplement to their regular diet. After six months they showed significant improvement in many signs of overall health compared to those who didn't consume the beverage. Vitamin B1 (Thiamine). Thiamine binds to iron and helps reduce iron load in the liver. One small study suggested it may be helpful for patients with chronic hepatitis B. It is not known if it has any benefit for cirrhosis. Pork is high in the vitamin, but more healthful sources include dried fortified cereals, oatmeal, corn, nuts, cauliflower, sunflower seeds and vitamin pills.
Omega-3 Fatty Acids.
Some research suggests that supplements of omega-3 fatty acids (found in fish oil and evening primrose oil) may help protect the diseased liver. Protein and Soy. High-quality dietary protein may be especially helpful for patients with ascites and for repairing muscle mass, but excessive protein loads may trigger encephalopathy. Protein solutions have been devised that provide beneficial amino acids without including those that increase this risk. There is no limit on vegetable proteins, such as those from soy.
Salt Restriction.
Restricting salt consumption to less than 2,000 mg a day is particularly important for patients with ascites. The less salt the better. Zinc. In some studies, taking zinc supplements have lowered ammonia levels in some patients who were zinc-deficient, a common problem in cirrhosis. Zinc replacement may reduce frequency and severity of muscle cramps and may even help protect against encephalopathy.
Also See: Chronic Liver Disease: The Salt Scenario
Limiting Fluids
Fluid restriction is not usually necessary, but patients with severe ascites should discuss limiting fluid with their physicians.
Fluid restriction is not usually necessary, but patients with severe ascites should discuss limiting fluid with their physicians.
Exercise
Exercise increases the risk for portal pressure and variceal bleeding. One study reported that taking a beta-blocker may reduce this risk, although patients should discuss this with their physician.
Exercise increases the risk for portal pressure and variceal bleeding. One study reported that taking a beta-blocker may reduce this risk, although patients should discuss this with their physician.
Preventing Influenza and Infections
Infections can have a severe impact on the liver. Although most respiratory infections generally affect only the lungs, one small study suggested influenza may directly affect the liver in patients with cirrhosis and exacerbate the disease process. Researchers in the study advise annual flu shots for people with cirrhosis. Furthermore, they advise that patients who get the flu be treated immediately with rimantadine, but not a similar treatment called amantadine.
Infections can have a severe impact on the liver. Although most respiratory infections generally affect only the lungs, one small study suggested influenza may directly affect the liver in patients with cirrhosis and exacerbate the disease process. Researchers in the study advise annual flu shots for people with cirrhosis. Furthermore, they advise that patients who get the flu be treated immediately with rimantadine, but not a similar treatment called amantadine.
Compiled From :
No comments:
Post a Comment