LiverCirrhosis

AToolkitforPatients

Bringthisbooktoeveryappointment

Revised4292011

TableofContents

Welcomeandphonenumbers3
Aboutlivercirrhosis4

Toolkitsections:
MyPhysicians7
CurrentMedicationList8
MyAppointmentPlanner11
WeightLog13
ScheduleforBloodwork15

Referencesections:
Diet17
Medications20
Surgery20
Hospitalizations20
Screeningforlivercancer21
Vaccination21
Preventingbleedingfromesophagealvarices22
Managingascites23
Managinghepaticencephalopathy26

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Welcome

WelcometotheCirrhosisManagementProgramattheUniversityof
Michigan.Asyourhealthcareteam,wetakeprideindoingeverythingpossibleto
maximizeyourhealth.However,wecannotdothisalone.You,thepatient,can
makeanenormousdifferenceinyourhealthbyeatingright,takingyour
medicationsproperly,andtakingcontrolofyourdiseasemanagement.

Toscheduleanappointment,call:8882297408
Tospeakwithanurse,call:8003956431

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Aboutlivercirrhosis
Whensomethingattacksanddamagestheliver,livercellsarekilledandscartissueisformed.
Thisscarringprocessiscalledfibrosis(pronouncedfibrosis),andithappensslowlyover
manyyears.Whenthewholeliverisscarred,itshrinksandhardens.Thisiscalledcirrhosis,and
usuallythisdamagecannotbeundone.Anyillnessthataffectstheliveroveralongperiodof
timemayleadtofibrosisand,eventually,cirrhosis.Heavydrinkingandviruses(likehepatitisC
orB)arecommoncausesofcirrhosis.However,
thereareothercausesaswell.Cirrhosismaybe
causedbyabuildupoffatintheliverofpeople
whoareoverweightorhavediabetes.Some
peopleinheritgenesthatcauseliverdisease.
Othercausesincludecertainprescribedandover
thecountermedicines,environmentalpoisons,
andautoimmunehepatitis,aconditioninwhicha
personsownimmunesystemattackstheliveras
ifitwereaforeignbody.

Whathappenswhenyou
havecirrhosis?
Becausetheliverbecomeslumpyandstiffincirrhosis,bloodcannotflowthroughiteasily,so
pressurebuildsupinavein,calledtheportalvein,whichbringsbloodtotheliver.When
pressureishighintheportalvein,theconditioniscalledportalhypertension.Torelievethis
pressure,thebloodgoesaroundtheportalvein,throughotherveins.Someoftheseveins,
calledvarices,canbefoundinthepipethatcarriesfoodfromyourmouthtoyourstomach(the
esophagus)orinyourstomachitself.

Whenyouhavecirrhosis,thehighpressureintheportalveinbacks
upintoanotherorgancalledthespleen,whichthengetsbigand
destroysmoreplateletsthanusual.Plateletsarebloodcellsthat
helpinbloodclotting.Withcirrhosis,bloodisblockedfrom
enteringtheliverandtoxicsubstancesthatthelivernormallyfilters
escapesintogeneralbloodcirculation.

Asidefromtheproblemswithliverbloodflow,whencirrhosisis
advanced,therearentenoughhealthyworkercellstomakegood
substances,suchasalbumin(aprotein)andclottingfactorsthatthe
livernormallymakes.Livercancer,calledhepatocellularcarcinoma
(HCC)canalsooccurifsomeofthesicklivercellsstarttomultiply
outofcontrol.

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Whatarethesymptomsof
cirrhosis?Atfirst,youmayhavenosymptomsat
all(thisiscalledcompensatedcirrhosis).Infact,aperson
maylivemanyyearswithcirrhosiswithoutbeingaware
thathisorherliverisscarred.Thisisbecausethe
pressureintheportalveinisnotyettoohighandthere
arestillenoughhealthylivercellstokeepupwiththe
bodysneeds.Butifnothingisdoneaboutthecauseof
cirrhosis(ifyoucontinuetodrink,forexample,orifyour
hepatitisisnottreated),thepressureintheportalvein
getshigherandthefewremaininghealthyworkercells
becomeoverwhelmed.

Atthatpoint,youmaynoticesymptomslikelowenergy,poorappetite,weightloss,orlossof
musclemass.Youcanalsodevelopthefollowingseriousproblems:(1)internalbleedingfrom
largebloodvesselsintheesophagus,calledbleedingvarices;(2)abuildupoffluidinthebelly,
calledascites(pronouncedasightees);(3)confusionfromthebuildupoftoxinsintheblood,
calledencephalopathy(pronouncedensefalopathee);or(4)yellowingoftheeyesand
skin,calledjaundice.

Anotherseriouscomplicationofcirrhosisislivercancer,whichmayoccurinthecompensated
ordecompensatedstage.Theremaybenosignsoflivercanceruntilthecancerhasgrownvery
largeandcausespain.

Whatisdecompensatedcirrhosis?
Ifyouexperienceanyoftheseriousproblemsdescribed
below,yourdiseasehasprogressedfromcompensated
cirrhosistodecompensatedcirrhosis.Youarethenatriskof
dyingfromlifethreateningcomplicationsofliverdisease,
unlessyoursicklivercanbereplacedwithahealthyliver(liver
transplant).

1.Bleedingvarices(internalbleeding)
Largebloodvessels(varices)inthefoodtubegetbiggerandbiggerovertimeandcanburst
open.Whenthishappens,youmayvomitbloodornoticeyourstoolisblackandtarry.Ifeither
ofthesethingshappens,youshouldgototheemergencyroomimmediatelytogethelpand
stopthebleeding.

If you vomit blood or your stool turns black

and tarry, you should go to the emergency
room immediately. These are signs that
varices may have begun to bleed, and this can
be life threatening.

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2.Ascites(fluidinthebelly)
Anotherproblemcausedbyhighpressureintheveinsoftheliverisascites.Fluidleaksoutinto
thebellyandbeginstofillitup.Thiscanmaketheabdomenenlargelikeaballoonfilledwith
water.Thelegscangetswollentoo.Thiscanbeveryuncomfortable.Eatingcanbeaproblem
becausethereislessroomforfood.Evenbreathingcanbeaproblem,especiallywhenyouare
lyingdown.Butthemostdangerousproblemassociatedwithascitesis
infection,whichcanbelifethreatening.

If you have ascites and you suddenly get a

fever or new belly pain, you should go to the

emergency room immediately. These could

be signs of a serious infection that can be life

threatening.

3.Encephalopathy(confusion)
Apoorlyworkinglivermaynotbeabletogetridoftoxicsubstanceslike
ammonia(whichcomesfromtheintestines),anditmayallowthese
substancestogointothebrainandcauseconfusion.Besides
confusion,toxinsinthebraincausechangesinsleep,mood,
concentration,andmemory.Ifitgetsreallybad,thesetoxinscan
evencauseacoma.Thesechangesareallsymptomsofhepatic
encephalopathy.Ifyouhaveencephalopathy,youmayhave
problemsdriving,writing,calculating,andperformingother
activitiesofdailyliving.Signsofencephalopathyaretremblingand
handflapping.Encephalopathymayoccurwhenyouhaveaninfectionorwhenyouhave
internalbleeding,anditmayalsooccurifyouareconstipatedortaketoomanywaterpillsor
taketranquilizersorsleepingpills.

If you are not acting like yourself, if you are confused, or if

you are very sleepy, you should be taken to the emergency

room immediately. These symptoms could be a sign of a

serious medical problem. You should not drive when you

have these symptoms.

4.Jaundice(yellowingoftheeyesandskin)
Aliverthatisworkingpoorlycannotgetridofbilirubin,asubstancethatproducesayellowing
oftheeyesandskin,calledjaundice.Toomuchalcoholandsomemedicinescanalsoleadto
jaundice.Ifyouhavecirrhosisandnoticejaundiceforthefirsttime,itmaybeasignof
worseningofyourliverfunction,aninfection,orothernewproblems.

If you suddenly develop jaundice, you

should call your doctor immediately.

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MyPhysicians
PrimaryCarePhysician:
Name

Address

Telephone

NameandSpecialty

Address

Telephone

SpecialistPhysician(s):

HealthInsuranceInformation:

InsuranceCompany:

InsuredsName:

PatientsName:

Group#:
PharmacyPhone#:

PharmacyFax#:
Askyourdoctorfora3monthprescriptionifyoudoamailorder
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CurrentMedicationList
MedicationName Prescribing
physician

Strength
(ex:mg)

Frequency
(ex:3timesper
day)

Lastupdated:

Numbertaken
atatime(ex:2
tabs)

Dose
changed
on:

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MedicationName Prescribing
physician

Strength
(ex:mg)

Frequency
(ex:3timesper
day)

Numbertaken
atatime(ex:2
tabs)

Dose
changed
on:

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MedicationName Prescribing
physician

Strength
(ex:mg)

Frequency
(ex:3timesper
day)

Numbertaken
atatime(ex:2
tabs)

Dose
changed
on:

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MyAppointmentPlanner
Date

Time AppointmentType Appointment

Location

Refills
needed?

Driverneeded
for
appointment?

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

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Date

Time AppointmentType Appointment

Location

Refills
needed?

Driverneeded
for
appointment?

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

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WeightLog
Weight

Diuretic(waterpill)dose:

Date

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Weight

Diuretic(waterpill)dose:

Date

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ScheduleforBloodwork
Keeplabordersinattachedsleeve
HaveoutsidelabsfaxedtoUMat7347634574
Appointment

Location

Phone/Fax#oflab

Date

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Appointment

Location

Phone/Fax#oflab

Date

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Diet

Lowsodium(salt)

Alowsaltdietisimportantforpatientswithliverdisease,particularlythosewithleg
swellingorascites(fluidintheabdomen).Themoresaltyoueat,themorefluidbuildup
youwillexperience.

HowdoIwatchalowsaltdiet?

Readthelabelonallyourfoods,andtrytoeatlessthan2,000mgofsodiumperday.
Highsaltfoodsinclude:allfoodsinrestaurantsorfastfoodplaces,mostcannedfood,
pickles,tomatojuice,chipsandcrackers.Also,ifyouhaveawellwithawatersoftener,
thisaddslotsofsalttothewater.

HowcanImakefoodtastegoodwithoutsalt?

UseMrs.Dashorotherspices.Avoidsaltsubstitutesbecausetheycontaintoo
muchpotassium.Unfortunately,seasalthasjustasmuchsodiumasregularsalt.

Whataboutsugarandfat?

Thesewillnotharmtheliverwheneateninmoderation.However,youmayneedto
watchtheseifyouhavediabetes,heartdisease,orhighcholesterol.

WhatifIamtoldmysodiumlevelistoolow?

Thisisusuallyaresultoftoomuchwaterinthebody.Thisdoesnotmeanthatyou
shouldeatmoresalt!Seebelowaboutfluidrestriction.

DoIneedtolimitfluidintake?

Drinkinglotsoffluidwillnotmakeyourascitesorlegswellingworse;onlysaltwilldo
that.Mostpatientswithcirrhosisdonotneedtolimitfluidintake,unlessyoursodium
levelislessthan125mmol/L.Askyourhepatologist(UMliverspecialist)whetheryou
needtowatchyourfluidintake.

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LowSaltFoodChoices
GoodChoices

Avoid

MeatsandMeatAlternatives:

Freshbeef,pork,veal,lamb,poultry,fish
Eggs
Driedbeans,peas,lentils
Unsaltednuts,unsaltedpeanutbutter

Milk,Yogurt,Cheeses:

Milkoryogurt
Frozenyogurt,icecream
NaturalSwisscheese
Lowsodiumcheeses
Lowsodiumcottagecheeses

Breads,Cereal,Rice,andPasta:

Bread,rolls,breadstickswithoutsaltorcheese
Plaintacoshells,tortillas
Pasta,barley,ricecookedwithoutsalt
Unsaltedcookedcereal
Lowsodiumcrackers
Homemadesoupwithlowsodiumingredients

Vegetables:

Fresh/frozenvegetableswithoutsaltadded

Homemadetomatosauces

Processedmeats(bacon,sausage,
pepperoni,hotdogs,ham,luncheon/deli
meats,cornedbeef,anchovies,sardines,
caviar)

Meatalternatives/vegetarianentrees

Buttermilk,maltedmilk

Breads,rolls,breadsticksmadewith
garlic/onionsalt,orcheese

Stuffingmixes

Driedmeat,smokedfish
Saltednuts,saltedpeanutbutter
Microwave/frozenmeals

Processedcocoa
Processedcheese
Bleu,feta,andothersaltycheeses
Regularcottagecheese

Pastaorricewithseasoningpackets
Instanthotcereals,readytoeatcereals
Saltedcrackers
Regularcannedordrysoups,broths,
bouillons

Bakingmixessuchascakes,pancakes,
waffleormuffins

Cannedvegetables,vegetablejuices

Addingsalttofruits(suchasmelon)

Premadespaghetti/tomatosauces
Instantmashedpotatoes,boxed
Sauerkraut,olives,pickledvegetables

Fruits:

Anykindoffruitorfruitjuice,fresh,frozen,or
canned

Glazedorcrystallizedfruit

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Good
Snacks:

Freshfruitsandvegetables
Unsaltedpopcorn
Unsaltedpretzels
Unsaltednuts
Unsaltedcrackers

Beverages:

Water,fruitjuices
Milk
Coffee,decafcoffee,teas
Cocoamadewithmilk
Sodawithnosodium(limit24ozorlessperday)

Desserts:

Gelatindesserts
Homemadetapiocaorricepudding
Custardmadewithmilk
Hardcandy
Homemadecake,cookies,pie,sherbet,icecream
(limitto1servingorlessperday)

FatsandOils(usesparingly):

Vegetableoilandmayonnaise
Unsaltedbutterormargarine
Unsaltedorlowsodiumsaladdressing
Lowsodiumcream,nondairycreamers
Unsaltednuts
Avocado

SeasoningandCondiments:

Herbsandspiceswithoutsalt(Mrs.Dash)
Lemon
Freshgarlic,onion
Freshhorseradish
Lowsodiumketchup,lowsodiumhotsauce
Lowsodiumchilisauce

Avoid

Potatochips,cornchips,tacochips

Gatorade

Instantpuddingorotherprepackaged
dessertmix

Whippedtopping

Saltedspices(garlicandonionsalts,etc)

Cookingwine

Saladdressingscontainingsodium

Avoidsaltsubstituteasthiscontains
highlevelsofpotassium

Regularpopcorn
Regularpretzels
Regularnuts
Othersaltysnackfoods

Powerade
Vegetablejuices(V8)
Instantcocoamixes
Instantcappuccinomixes

Frozenpies
Mincedmeatpies

Soysauce,tartarsauce,teriyakisauce
Salsa,Worcestershiresauce,bouillon
Sweet&soursauces,steakandBBQsauce
Monosodiumglutamate(MSG)
Ketchup,relish,seasoning/coatingmix,
meattenderizers,flavoredvinegar

Baconandbaconfat
Gravymadewithmixesorbouillon
Snackdipsmadewithprocessedcheeseor
instantsoupmixes

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Medications(overthecounterandprescribedbyotherphysicians)

Patientswithcirrhosisshouldavoidpainmedicationscallednonsteroidalanti
inflammatories(NSAIDS).Theseincludeoverthecountermedicationssuchas
ibuprofen(Motrin,Advil),naprosyn(Aleve),aswellassomeprescription
medications.AskyourdoctorifanyofyourmedicationsareNSAIDS.

Formildtomoderateachesandpains,itissafetouseTylenol(acetaminophen)
atdosesof2,000mg/dayorless(nomorethan6regularstrengthornomore
than4extrastrengtheachdayANDnomorethan20regularstrengthornomore
than15extrastrengtheachweek).Somecoldmedicinesandprescriptionpain
medicinescontainacetaminophen,soreadthelabelsandmakesureyoudont
taketoomuchbymistake.

Mostotherprescriptionmedicationsaresafefortheliver.Youarenotat
increasedriskofsideeffectsjustbecauseyouhavecirrhosis.Inparticular,statins
suchasLipitorandZocorcanbeusedfortreatingcholesterolinpatientswith
liverdisease.Youwillrequirethesamemonitoringlikeotherpatientswithout
liverdisease.

Surgery
Surgerycanbequiteriskyinpatientswithcirrhosis.Ifyouareconsideringhaving
anytypeofsurgery,pleasebesuretoaskyourhepatologist(UMliverspecialist)if
thisissafeforyou.Ifthereareanyconcerns,pleaseaskyoursurgeontotalkto
yourhepatologist.

Hospitalizations
Itisveryimportantforustokeeptrackofanyhospitalizationsyouhave.Please
calltheLiverManagementNursesifyouareadmittedtoanoutsidehospital,and
callagainonceyouaredischarged.

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Screeningforlivercancer
Peoplewithcirrhosisareatincreasedriskforlivercancertheriskisabout1in
100peryear(eachyear,outof100patientswithcirrhosis,onewilldevelopliver
cancer).Allpatientswithcirrhosisshouldhaveanultrasoundandbloodtest
calledanalfafetoprotein(AFP)every6months.

Althoughthesetestsarenotperfect,theycanoftendetectthetumorwhenitis
small,beforepeopledevelopsymptoms.IftheultrasoundorAFPisabnormal,
thenextstepisMRIorCTscan.SinceMRIandCTscanhavegottensogood,in
manycasesabiopsyisnotneededtomakethediagnosis.

Vaccination
IfyouhaveneverbeenvaccinatedagainsthepatitisAorB,wewillchecktoseeif
youareimmune(alreadyhaveprotection).Ifnot,wewillrecommend
vaccination,whichcanbearrangedtobedonenearyourhome.Thescheduleis
shotsat0,1,and6months.

Theyearlyinfluenzavaccination(flushot)isalsorecommended.Itisimportant
thatyoureceivetheinactivatedvaccine(injection),nottheliveform(nasaldrop).

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PreventingbleedingfromEsophagealVarices

Esophagealvaricesareenlargedveinsthatoccurinthewallsof
theesophagus,becauseofbackupofbloodfromthescarred
liver.Theesophagusistheswallowingtubethatconnectsthe
throattothestomach.Thepressureinswollenveinsishigher
thannormal.Increasedpressurecancausetheveinstoburst,
leadingtosuddenandseverebleeding.

Unlessthevaricesbreakandbleed,
patientshavenosymptomsanddo
notknowtheyhavevarices.

Bleedingvaricescanbeverysevere,causingdeathif
nottreatedimmediately.Patientsusuallystartto
vomitlargeamountsoffreshbloodorclotsandshould
betakentoanemergencyroomimmediately.

Whatcanbedonetopreventserious
bleeding?Ifyouhaveliverdiseasethatcouldcause

varicestoform,yourdoctorwillusuallyrecommend
thatyouhaveanupperendoscopytest(EGD)todeterminethesizeofvarices,iftheyare
present.Thelargervaricesareahigherriskofbreakingandbleedingandthustreatmentwith
medicationsareusuallyprescribed.Ifvaricesdobleed,doctorsmayapplyrubberbandstothe
varicestoblockthem.Ifthesetechniquesdonotworktopreventbleeding,thenaninternal
tunnelinthelivercanbeconstructed(calledaTIPSortransjugularintrahepaticportosystemic
shunt)thatreducesbloodflowandpressureinvarices.

Medicationsusedtoreducebloodflowandpressureinvaricesaredrugscalledbetablockers.
Propranolol(Inderal):
Giventwiceaday
Nadolol(Corgard):
Givenonceaday
Carvedilol(Coreg):
Giventwiceaday

Yourdoctorwillgenerallystartyouonaverylowdoseofoneofthesedrugsandcheck

yourheartrate(pulse).Thegoaloftreatmentistogiveyouenoughofoneofthese
drugstoreduceyourheartrateby25%.Thedoseofmedicinewillbeincreasedslowly
untilthisgoalisreached.

Thesedrugsareusuallywelltoleratedeveninpatientswithlowbloodpressure.Tell
yourdoctorifyougetdizzyandlightheadedaftertakingthesemedicines.
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Managingascites
Ascitesistheabnormalcollectionoffluidinthe abdominalcavity,
mostoftenasaresultofchronicliverdisease.

AbdominalAnatomy
Theabdominalcavitycontainsthedigestiveorganssuchasthe
stomach,intestinesandliver.Normally,theabdominalcontents
aremoist,butcontainnofluid.Ascitesisamedicalconditionin
whichexcessfluidbeginstopuddlewithintheabdominalcavity.
Thisfluidisoutsideoftheintestinesandcollectsbetweenthe
abdominalwallandtheorganswithin.

CausesofAscites
Liverdiseaseisthemostcommoncauseofascites.Theword"cirrhosis"means"scartissue,"so

thisconditionisoftencalledcirrhosisoftheliver.Thisscartissuechangesthenormally
smoothliversurfacetoalumpysurfacethatblocksthebloodfromexitingtheliver.Iftheblood
cannotflowfreely,toomuchpressurebuildsupinthelivertissue.Thisiscalledportal
hypertension.Thiscausesthesurfaceoftheliverto"weep"fluidintotheabdominalcavity,
whichaccumulatesandcausesascites.Theliversendssignalstothekidneytoholdontosalt,
resultinginfluidretentioninthelegsorabdomen.

Symptoms
Inmildcases,thereareusuallynosymptoms.Asmorefluidcollects,theabdomenswells.There
maybealossofappetite,frequentheartburn,fullnessaftereating,orabdominalpain.
Eventually,thereisswellingoftheabdomenthatlookssimilartothelaterstagesofpregnancy.
Thismaycausebackpain,changesinbowelfunction,andfatigue.Duringtheday,gravitymay
carrysomeofthefluiddownintothescrotumorlegscausingswelling,oredema.Initially,the
swellingmaysubsideovernight.Astheconditionworsens,however,theswellingmayspread
upthelegandbepresentdayandnight.Asmorefluidbuildsup,itmayspreaduptothechest
andcausedifficultybreathing.

Treatment
Ascitesisnotactuallyadisease,butasymptom.Thepropertreatmentdependsuponthe
underlyingcause.Ifinfection,cancer,orheartfailureisthecause,thetreatmentisdirected
appropriatelytotheunderlyingproblem.However,inthemajorityofpatients,ascitesisasign
ofadvancedliverfailure,orcirrhosisoftheliver.Thebasisoftreatmentincludes:
Page|23

Avoidfurtherliverdamage
Patientswhodrinkalcoholmuststopallalcoholconsumption.

Lowsalt(sodium)diet
Itisnottoomuchwaterintakethatcausesthebuildupofasciticfluidinthe
abdomen,butitisactuallythebodythatiskeepingintoomuchsodium(salt).Thus,
itisimportanttocutdownonsaltintake,notwaterintake.Dietarysodiumintakeis
usuallyrestrictedtolessthan2000mgperday(about1teaspoon).Mostsaltina
personsdietcomesfromprocessedfoods,notfromthesaltshaker.

Diuretictherapy("WaterPills")
Thesemedicationshelpthebodygetridofextrasodiumandwaterthroughthe
kidneys.Commonmedicationsincludespironolactone(Aldactone),andfurosemide
(Lasix).Oneregimenbeginswith100mgofspironolactoneand40mgoffurosemide
everyAM.Ifthereisnoweightlossinthefirsttwoweeks,thedoseisgradually
increaseduptoamaximumof400mgofspironolactoneand160mgoffurosemide
daily.Responsetotreatmentvariesandfindingoutwhichtreatmentplanworksbest
foryou,thepatient,takestimeasthedoseofmedicationsisadjustedoveraperiod
ofweeksormonths.

Paracentesis(Tap)
Thisprocedureinvolvesdrainingfluidoutoftheabdomenwithaneedle.Itis
performedusinglocalanesthetic(lidocaine),andthefluidisalsosentfortesting.
Thisrapidlyrelievessymptomsofascites,butdoesnothingtocorrecttheunderlying
cause.Thefluideventuallyreturns.Strictsodiumrestrictionanddiuretictherapy
muststillbeusedtoslowdownthereaccumulationoffluid.
Removing5litersormoreatonetimecancauseadropinbloodpressure,
andkidneydamage.IValbumincanreducetheriskofthiscomplication.
Frequenttapscanincreasetheriskofinfection,electrolyte(sodiumand
potassium)imbalance,andworseningkidneyfunction

MonitorProgress
Duringtreatment,itisimportantthatpatientsundergocarefulmonitoringbytheir
doctorwithperiodicmeasurementsofbodyweightandbloodtests.Thisis
especiallytrueinpatientstakingdiuretics(whichmaycausereducedkidneyfunction
andchangesinthebloodlevelsofsodiumandpotassium).Thebestway,you,the
patient,canhelpthedoctorsmanageyourfluidproblemistokeepalogofyour
dailyweightandtokeeptrackofthedoseofyourwaterpills(diuretics)anddates
whenyouhavetaps(paracentesis).

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Spontaneousbacterialperitonitis
Thisconditionoccurswhentheascitesfluidbecomesinfected,andcanbelife
threatening.Symptomsincludefeverandabdominalpainbutthesesymptomsmay
beabsentduringtheearlystages.Ifyouhaveinfectionoftheascitesfluid,youwill
needtobeadmittedforIVantibiotics(givenintoyourvein).Onceyouhaveone
episodeofperitonitis,youwillhavetotakeanoralantibiotictopreventrecurrence
ofperitonitis.Ifyouarerequiringfrequentparacentesis,yourdoctormayprescribe
antibioticstopreventthisinfectionfromdeveloping.

Hepatorenalsyndrome
Thisreferstokidneyfailurethatsometimesdevelopsinpatientswithendstageliver
disease.Thismayhappensuddenlyorasaslowlyprogressiveprocess.Treatment
usuallyinvolvesstoppingdiuretictherapy,IVfluids,andasearchforareversible
causesuchasdehydrationorinfection.Rapidkidneyfailureincirrhoticpatientswith
ascitesisassociatedwitha90%chanceofdeathiflivertransplantisnotperformed.

Transjugularintrahepaticportosystemicshunt,orTIPSprocedure,involves
placementofashuntwithinthelivertoimprovebloodflow.ATIPSprocedureis
performedthroughtheveinsanddoesnotrequireabdominalsurgery.Thisisusually
donetocontrolbleedingfromvaricesifothersimplemeasuresfailandinsome
casestodecreasefluidbuildup(ascites).About30%ofpatientsdevelopincreased
mentalconfusionafterTIPS,andinsomecasestheshuntmustbeclosedbackdown
ifthisoccurs.Rarely,progressivejaundiceandliverfailuredevelopsafteraTIPS
procedure.

Livertransplant
Developmentofascitesasacomplicationofcirrhosisoftheliverisaconcerning
sign.Livertransplantisthetreatmentofchoiceinappropriatecandidates,but
unfortunately,notallpatientsarecandidatesforthisprocedure.Livertransplant
shouldbeconsideredinanyonehavingdecompensatedcirrhosis(seesectionon
Aboutlivercirrhosis).

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ManagingHepaticEncephalopathy
Patientswithcirrhosisoftendevelopdifficultythinkingandactingcalledhepatic
encephalopathy(HE).Thisisduetotoxinsfromthebowel(intestines)thatbypasstheliverand
reachthebrain.Hepaticencephalopathyisdiagnosedbyanexpertinliverdiseases,and
elevatedammoniaintheblooddoesnotnecessarilymeanyouhavethisdiagnosis.

ConsequencesofHepaticEncephalopathy:

Evenlowlevelsofhepaticencephalopathymaycauseproblemswithsafedriving.
Familymembersanddoctorsandpatientsshoulddiscussthisissueanddecideifthe
individualshouldbeallowedtocontinuedriving.Ifpatientshaveanyconfusionthey
shouldnotdrive.
Evenwhennotconfused,patientsmayhavedifficultywithnormalsleepingcyclesand
maybemoreirritable,crankyandforgetful.Theymayhaveworseninghandwriting
andmaynotbeabletocompletesimplearithmeticcorrectly.Familymembersshould
superviseortakeoverfinancialcalculations,billpaying,etc.
Infectionscanbringonorworsenhepaticencephalopathyquickly.Ifpatientsrapidly
becomeworsewithconfusion,thepatientshouldbebroughttoanemergencyroomto
evaluatethemforinfection,otherbloodproblems,dehydration.
Patientwithcirrhosisandevenearlyhepaticencephalopathyareverysensitivetodrugs
suchasnarcoticpainmedications,valiumlikedrugs(benzodiazepines)andother
sedatingdrugs.Ifthesemustbeused,thelowestpossibledoseshouldbeusedand
patientsshouldbewatchedforincreasedconfusion.

Treatmentforhepaticencephalopathyconsistsof:

1. Adietwheremostproteincomesfromvegetables.Patientswithhepatic
encephalopathyneedtolimittheirdiettoabout2smallservingsadayofanimal
protein,including:
Beef,steak,hamburger,ham,hotdogs,sausage,pork,chicken,
Fish,turkey,tunafish,shrimp,crab,etc.
Eggs
Patientscaneatasmuchvegetableprotein(driedbeansandpeas,soyproducts,peanut
butterandothers)astheylike.

*Aservingis23ouncesaday(about1/3ofacuporapieceaboutthesizeofaverylargeegg).

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2. Lactulosesyruptakendaily.Lactuloseisanartificialsugarthatcannotbedigestedby
thestomachorintestines.Itgoesintothelargebowel(colon).Inthecolon,itcauses
proteintoxinstobeheldinthebowel(notabsorbedinthebody)andexcretedinstool.
Lactuloseissometimesgivenasapowder(kristulose)whichismixedwithwateror
juice,thepowderformisnotsweetandmanypatientsfinditeasiertotake.Other
laxativeswillnotdothesamething.

*Patientsarestartedonlactulosesyrupat2ormoretablespoonsonceortwiceadayandthe
doseisgraduallyincreaseduntilthepatientishaving3loosestoolsaday.Lactuloseisoneof
theonlymedicineswhereitisuptothepatientandfamilytoadjustthedose.Increasethe
doseifyourstoolsarefirm,youarehavingfewerthan3stoolsperday,orondayswhenyouare
moreforgetfulorconfused.Decreasethedoseifyouarehavingmorethan3loosestoolsper
day.

3. Antibioticsthatworkonlyintheintestine.Theseincluderifaximin(Xifaxin)and
neomycin.Thesechangethetypeofbacteriaintheintestinetothekindthathelpget
ridoftoxins.

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