Common Questions and Answers for Patients with or At Risk for Cirrhosis

GENERAL QUESTIONS ABOUT CIRRHOSIS

What is cirrhosis of the liver? How is it diagnosed?
Cirrhosis is a condition where the liver becomes scarred (or fibrotic), and this can occur as a result of
alcohol, viral hepatitis, fatty liver disease, or many other types of chronic liver disease. Cirrhosis can
often be diagnosed by imaging tests (such as a CT scan, ultrasound, elastography or MRI) based on a
nodular or shrunken appearance to the liver or special scores. If there is fluid in the abdomen (ascites),
or an enlarged spleen, these can also be clues to the presence of cirrhosis. A low platelet count or
abnormal liver enzyme pattern or liver function tests can diagnose or suggest cirrhosis. Cirrhosis can
also be diagnosed by liver biopsy, although this is not always necessary.
Is cirrhosis reversible?
In most cases, cirrhosis is not felt to be fully reversible. However, the progression of liver scarring can be
slowed or halted with appropriate treatment and in many cases can reverse by 1-3 stages and signs of
liver failure can disappear. There may also be some patients who show evidence of complete reversal of
fibrosis over a long period of time when the underlying cause of their liver disease is corrected or cured.
For example, a patient with hepatitis C, or hepatitis B virus (HBV)-related cirrhosis that is started on
antiviral medications to suppress the virus or hemochromatosis when iron is removed. Over a period of
years, this patient may have some improvement in their cirrhosis that may appear to be completely
reversed on labs or imaging yet a liver biopsy will continue to show changes in the liver structure forever
in almost all patients.
What are the symptoms of cirrhosis?
Many patients with cirrhosis have no associated clear or specific symptoms. This is why cirrhosis is often
diagnosed when the late-stage complications of advanced liver disease develop. Fatigue is common
with early cirrhosis, but is also common in the general population. When patients begin to develop more
advanced cirrhosis, they may have evidence of muscle loss, jaundice, edema, mental confusion or fluid
build-up in the abdomen called ascites. Memory problems or sleep disorders are often early signs of
cirrhosis and blood shunting around or through the liver.
What is portal hypertension?
Portal hypertension most often occurs in patients with advanced cirrhosis, and it is defined by excessive
pooling of blood upstream (below the liver in the abdomen) of the cirrhotic liver. The liver receives
approximately 25% of all blood pumped (directly or indirectly) from the heart. A large portion of this
blood volume comes from the gastrointestinal (GI) tract and drains into the main vein feeding the liver
called the portal vein. This vein also receives drainage from the spleen as well. When the liver is
cirrhotic, blood flow through the liver is sluggish and can pool and back-up into the portal vein, and all
the upstream veins that feed into the portal vein. This can lead to congestion within the spleen, causing
an enlarged spleen (and low platelet levelsthese are filtered by the spleen). Blood can also pool in
veins that drain from the esophagus, stomach, and rectum, leading to esophageal, gastric, or rectal
varices (these look like large hemorrhoids).

What are esophageal varices?

Esophageal varices are enlarged veins within the esophagus (the food pipe that connects mouth to
stomach). If these veins become too large, they can rupture and cause life-threatening bleeding. Most
patients with a variceal bleed will vomit blood, but some will suddenly begin having dark purple, black
bowel movements that appear like tar. This bleeding may be accompanied by abdominal cramping,
lightheadedness or dizziness, and confusion. A variceal bleed, or suspicion of one, is always an
emergency and requires a visit to the closest E.R. or a call to 9-1-1. Esophageal varices are diagnosed by
performing an upper endoscopy called an esophagogastroduodenoscopy (EGD). If varices are found,
they may be treated by a procedure called banding, where a tiny rubber band is placed around the
varices to prevent bleeding and induce scarring. These varices may also be seen on CT, MR or
ultrasound exams.
How often should I have an upper endoscopy done?
This depends on what the previous findings were during each endoscopy. If you have cirrhosis and have
never had an upper endoscopy, you should have one performed now for initial screening for varices. If
no varices are seen, you may not need another endoscopy for several years. If varices are found, or if
you already have known varices, you should be enrolled in a regular screening program. The exact
frequency will be determined by the gastroenterologist performing your endoscopies. Varices can be
banded and sequential banding can decease the size of varices and decrease risk of bleeding.
What is hepatic encephalopathy?
Hepatic encephalopathy, or H.E., is a reversible syndrome of impaired brain function which can lead to
forgetfulness, inattention, drowsiness, reversal of sleep-wake cycle (i.e. awake all night and sleeps all
day), somnolence, and can even lead to a reversible coma. H.E. can typically be diagnosed by an
experienced provider and is first treated with a medication called lactulose or better yet, miralax, which
has less side effects when complared to lactulose. 1/3 of patients with cirrhosis have diarrhea and do
not need a medicine to increase their bowel movement number. Rifaximin is now considered a first line
therapy for HE and is used with miralax or lactulose (used to prevent constipation and ideally will be
used to keep patients at 1-2 BM per day). Together these medications work to reduce ammonia, short
chain fatty acids, benzodiazepine like compounds levels in the blood, and reduce the bacteria or change
the bacteria (biome) in the gut which produce ammonia, endotoxins, and other toxic byproducts in the
first place. There are many triggers for H.E. including infection, inflammation, dehydration, GI bleeding,
medications, medication non-compliance, kidney impairment, electrolyte disturbances especially a low
sodium and a buildup of renal toxins. Probiotics have recently been added to the tools we use to
manage HE and a supplement called VSL#3 can be used as 2 capsules twice a day to help decrease or
control HE.

Why is lactulose to be used cautiously?

In patients with hepatic encephalopathy (H.E.), lactulose helps by removing ammonia from the
gastrointestinal tract by causing a change in the acid environment and also bowel movement frequency.
Unfortunately, up to 1/3 of patients have diarrhea or loose BMs at the time they present with HE.
Lactulose itself is a non-absorbable sugar that is broken down by gut bacteria into substances that
irritate the lining of the GI tract causing diarrhea. Lactulose may cause bloating, gas, nausea, electrolyte
abnormalities, fungal infections, dehydration and diarrhea and is associated with high rates of
noncompliance. The correct dose of lactulose is however much causes the patient to have 1-2 soft
bowel movements daily. The patient can feel free to adjust their dose accordingly to achieve this bowel
movement goal to they are not constipated. In the hospital setting or in some cases outpatient
treatment can be supplement with PEG preparation similar to what is used for colonoscopy preps.
My doctor says my ammonia level is high. What can I do for this?
The ammonia level is a test that is still frequently done but not clinically reliable due to inaccuracies of
the test itself, how the blood is drawn and stored, etc. It is intended to screen for a complication of
cirrhosis called hepatic encephalopathy (H.E.), but the best way to assess for this is through a full
history, physical exam, and/or cognitive testing. Ammonia levels should not be used to screen for H.E.,
and they do not need to be followed on serial lab draws. Medications should not be adjusted based on
ammonia levels.

Other Treatments and MEDICATIONS

What can I take for mild-moderate pain?
Contrary to popular belief, Tylenol (or acetaminophen) is okay to take with liver disease, so long as you
take less than 2 grams (or 2,000mg) per day. This is the equivalent of 6 regular strength (325mg)
tablets, or 4 extra-strength (500mg) tablets. Non-steroidal anti-inflammatory drugs (NSAIDs) should be
avoided in patients with cirrhosis and/or kidney disease. Patients with a prior history of ulcers should
also avoid NSAIDs. Patients with cirrhosis should avoid NSAIDs as they may increase the risk of bleeding,
kidney injury, etc. There are many NSAIDs available and these include ibuprofen, naproxen, diclofenac,
etodolac, indomethacin, ketorolac, Aleve, Advil, Motrin, Naprosyn, Toradol, and Voltaren.
What can I take for sleep?
In patients with cirrhosis, particularly those with hepatic encephalopathy, we generally recommend
against certain classes of sleep aids which are broken down and cleared by the liver. Medications which
are safe any may be taken include Benadryl (diphenhydramine), melatonin, Atarax (hydroxyzine), and
trazodone. These medications to avoid include hypnotic-type agents such as Ambien or Ambien CR
(zolpidem), Restoril (temazepam), Lunesta (eszopiclone), Sonata (zaleplon), and any form of
benzodiazepine (e.g. valium, diazepam, Ativan, lorazepam).
Are there any herbals or supplements that may help?
Coffee is safe as is green tea and these probably are the best plant derived sources of liver health and
can decrease inflammation and may block scar tissue development and prevent or decrease the risk of
cancer. There are no other herbal supplements or medications that are proven to help with cirrhosis.
Many people take milk thistle (silymarin) based on Internet reading, but theres no proof that it helps in
cirrhotic patients or any type of liver disease. On the contrary, many herbal medications are linked to

cases of drug-induced liver injury. In general, we advise against these types of supplements other than
coffee or green tea. A regular daily multivitamin is safe.

FOOD & DIET and exercise

What kind of diet should I be on?
In general, cirrhotic patients need to be on a healthy, low-salt, high-protein diet. Protein consumption
should not be avoided in cirrhotic patients, and excellent sources of protein include vegetable sources of
protein (legumes and other beans), lean white meats (chicken, fish), dairy, nuts, etc. Try to consume at
least 80-100 grams of protein daily. Meals should be eaten in smaller quantity and more spread
throughout the day. Patients with muscle loss should consume a nutritional supplement before sleep,
such as a can of Ensure or Boost, to help keep the tank full while you are sleeping and the body is
repairing itself. Alcohol is strictly forbidden. We also advise against raw shellfish (i.e. oysters) because
there is an increased risk of fatal food poisoning from Vibrio vulnificans.
I have a lot of edema and swelling. Should I restrict my fluid intake?
There are some circumstances where fluid restriction is needed, but this is limited to patients with
severely low serum sodium levels. Most cirrhotic patients have mildly low sodium levels and this is
normal. For edema or ascites, however, fluid restriction is incorrectthe best treatment is aggressive
sodium (salt) restriction. The maximum daily limit is 2 grams of sodium per day, which is less than half
the average daily intake by most Americans. Foods high in salt that should be avoided include:
microwave dinners, pre-prepared or canned foods, soups, soy sauce, Gatorade, tomato juice, pickle
juice, etc.
What about coffee consumption and liver disease?
There are dozens of scientific studies showing the benefits of coffee consumption and the reduced risk
of developing liver cancer. This effect is not solely from caffeine, as the same effect is not seen in teadrinkers or people who drink soda pop.

PREVENTATIVE MEASURES
How do I get screened and undergo regular testing (surveillance) for liver cancer?
The most common form of liver cancer in patients with cirrhosis is hepatocellular carcinoma (HCC). This
cancer can be diagnosed in non-cirrhotics, but is most common in patients with cirrhosis and chronic
liver disease, and your risk of developing HCC increases the longer you have cirrhosis. Screening for HCC
involves a blood test called an alpha-fetoprotein (AFP), as well as some form of liver imaging
(ultrasound, CT or MRI). Screening ought to be done every 6-12 months at minimum. If a lesion is seen,
this may prompt additional testing such as further imaging, or potentially a biopsy in rare cases.
My surgeon cancelled my surgery because I have cirrhosis. Why is that?
Patients with cirrhosis have a higher risk of surgical complications and mortality due to their liver
disease. Your individual surgical risk depends on the type of surgery being performed, and how
advanced your liver disease is. Simple procedures such as mole removals, dental work, podiatry
procedures and ophthalmology procedures typically may be done without problems. Other surgeries,
especially any type of major surgery or abdominal surgery, are more dangerous to a cirrhotic patient.
Any upcoming surgery should be discussed with your surgeon and hepatology team first.
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What vaccines should I get?

Patients with chronic liver disease should be immunized against hepatitis A virus (HAV) and hepatitis B
virus (HBV). There is no vaccine against hepatitis C. If you have been immunized against HAV or HBV in
the past, your provider can ensure you remain immune with a simple blood test. Occasionally your
immunity and antibody levels can wane over time. The inactivated (injected) influenza vaccine is
recommended annually. The Pneumovax (pneumonia) vaccine is also recommended for adults over age
60. Other vaccines should be discussed with your provider in clinic.
Discuss what vaccines if patient has had a splenectomy
What warning signs should prompt me to visit the ER or call my physician?
Anything that worries you is a reason to call your physician or healthcare provider. Signs of a possible
emergency include fever greater than 100.4 (38.0 C), new or worsening jaundice, GI bleeding (either
vomiting blood, black material, or passing bloody or black bowel movements), low BP, falling episodes,
severe abdominal pain, tense ascites, shortness of breath, chest pain, or new changes in mental status
such as confusion or delirium.
Is there a good website with additional information on liver disease?
American Liver Foundation (www.liverfoundation.org)
Robertgish.com