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Cirrhosis Treatment And Recommendations

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Cirrhosis

Currently there is no treatment or cure for cirrhosis, nor is there a treatment that can heal the liver damage already done. However, treatment can sometimes prevent or delay further liver damage.

The main components of cirrhosis treatment include:

  • Treating the cause of cirrhosis, if possible, to prevent further deterioration;
  • Avoid substances that can aggravate liver damage, especially alcohol and NSAIDs (Non-steroidal anti-inflammatory drugs);
  • Preventing and treating symptoms and complications or cirrhosis;
  • Liver transplant, if severe liver damage and if the cirrhosis patient is included on the transplant waiting list and a compatible donor is found.

Treatment

Initial cirrhosis treatment

When cirrhosis is diagnosed, it is recommended to:

  • Stop any kind of alcohol intake! Alcohol consumption of any kind or quantity is not allowed;
  • Avoid the use of NSAIDs such as Ibuprofen or Naproxen and other drugs that can affect the liver;
  • Initiate a diet that is low in salt, if fluid retention occurs. Reducing salt consumption may prevent the accumulation of fluid in the abdomen (ascites) or chest;

Start immunization (if not already immune) against hepatitis A and B, influenza and Streptococcus pneumoniae(pneumococcus).

Following these steps prevents further complications and liver damage and also help alleviate symptoms. Initial treatment of cirrhosis also includes the treatment of already present complications. Depending on complications, cirrhosis patients may need drug therapy, surgery or other treatments.

Ongoing treatment of cirrhosis

Accumulation of fluid in the abdominal cavity, or ascites, is one of the most common complications of patients with cirrhosis and can become life threatening if not treated. A diet low in salt usually helps reduce fluid in the abdominal cavity. However, the following may also be required:

  • Diuretics, such as Spironolactone and Furosemide, which help reduce fluid in the abdominal cavity and in other parts of the body. These drugs help prevent and treat ascites. They may be prescribed for long-term administration;
  • Paracentesis with or without infusion of protein (albumin). Paracentesis is a procedure that involves inserting a needle through the abdominal wall in order to extract the liquid ascites. It can be used to treat severe cases of ascites that cause symptoms and do not respond to standard treatment with diuretics and low salt diet;
  • Antibiotics, such as Cefotaxime, in case the patient develops a bacterial infection in the abdominal fluid (spontaneous bacterial peritonitis), as a complication of ascites;
  • Transjugular intrahepatic portosystemic shunt (TIPS) or another type of surgery. These procedures can divert fluid from the abdominal cavity. It is used to treat ascites that are unresponsive to other forms of treatment.

Digestive tract bleeding varices (variceal bleeding) is another common complication and can be life-threatening for people with cirrhosis. Patients with variceal bleeding or at risk of bleeding should avoid taking Aspirin and other non-steroidal anti-inflammatory drugs. The following may be necessary:

Cirrhosis Medication

Cirrhosis Medication

  • Beta blockers, such as Propranolol or Nadolol. These drugs decrease the risk of variceal bleeding caused by portal hypertension. Beta blockers also help reduce blood pressure in the portal vein, thereby reducing the risk of a first variceal bleeding episode. These drugs are also used to reduce the risk of recurrent variceal bleeding;
  • Vasoconstrictor agents. These drugs are used to treat acute variceal bleeding episodes. They also reduce blood flow through the portal vein by narrowing the blood vessels. Somatostatin and Vapreotide are the most frequently used;
  • Endoscopic variceal heeling or sclerotherapy. These techniques can also be used in the treatment and prevention of bleeding esophageal varices;
  • Balloon tamponade using a Sengstaken-Blakemore tube. The Sengstaken-Blakemore tube insertion is only a temporary variceal bleeding treatment. It helps stabilize the patient’s condition before the use of other forms of treatment or if the patient requires movement to a hospital unit where he will undergo a different treatment. It is used also when no other form of treatment is effective in stopping the variceal bleeding;
Cirrhosis Liver

Cirrhosis Liver

Hepatic encephalopathy may also complicate cirrhosis when the liver is no longer effective in removing toxins from the bloodstream, especially substances produced by intestinal bacteria. These toxins accumulate in the bloodstream and affect the cerebral functions. For treatment and prevention of this complication the following might be necessary:

  • Lactulose, a drug that reduces the accumulation of ammonia and other natural toxins in the intestine;
  • Low protein diet. If liver damage is severe, the body becomes unable to properly use proteins, and that contributes to the accumulation of toxins;
  • Avoidance of sedative drugs, sleeping pills and medications such as anxiolytics (anti-anxiety). These can aggravate the symptoms of encephalopathy;
  • Regular medical appointments to monitor the disease are very important, especially because symptoms may be absent until the disease becomes severe. In addition to these, regular monitoring is needed for varicose veins and hepatocellular carcinoma.

American College of Gastroenterology (ACG) recommends the screening (monitoring) of varicose veins by endoscopy in individuals suffering from cirrhosis. If initial screening does not detect varicose veins, endoscopic re-evaluation is recommended every 1-2 years after the first endoscopy. If the initial assessment detects large varicose veins or if there was an episode of variceal bleeding, frequent endoscopic reassessment is recommended along with beta blockers therapy in order to prevent further bleeding episodes.
Screening for liver cancer (hepatocellular carcinoma) should be done every 6 months or 1 year, using a technique that uses both alpha-fetoprotein blood levels and liver ultrasound. Cirrhosis is a progressive disease. We recommend the consideration of possibilities for further treatment before the disease becomes severe. In particular, the following should be discussed:

  • The possibility of being a good candidate for a liver transplant when cirrhosis becomes severe. The steps that must be followed in order to increase the chances of being a good candidate must be discussed;
  • The level of medical interventions that the patient is willing to undergo when health conditions deteriorate. Some patients might want to undergo any medical treatment possible to keep them alive while others may prefer measures which creates more comfort, without prolonging their life;
  • Severe liver cirrhosis can affect brain function, so all this talk makes sense, if done when the patient is able to make and communicate decisions.
Cirrhosis Liver

Cirrhosis Liver

Treatment if medical condition worsens

Receiving a liver from an organ donor (liver transplant) is the only treatment that restores normal liver function and cures portal hypertension. Liver transplant is considered, usually only when liver damage is severe and life-threatening. Most patients who were transplanted were in final stages of liver cirrhosis and portal hypertension had severe complications. Liver transplant surgery is very expensive and waiting for a transplant is likely to be very long as very few organs are available.
Even if liver transplant is done, it may not be successful. Considering these factors, the physician must decide which patients may benefit from liver transplant. Liver transplant is an option for patients with end-stage cirrhosis who are good candidates for surgery. Good candidates for liver transplantation are:

  • Those who did not abuse alcohol or illegal drugs in the past 6 months;
  • Those who have good family support;
  • Those who resist the complicated drug regime that needs to be followed in order to prevent post-transplant liver rejection;
  • Liver transplant is not a good option for those who suffer serious concomitant other diseases (such as heart or lung diseases), which can reduce the chance of survival after surgery and can reduce life expectancy even if liver transplant is done.

End-stage liver cirrhosis

If the patient hasn’t yet made a decision regarding issues of this stage, it is recommended that he does so now. Many people find it helpful to put their choices regarding health care in writing, while they are still capable to decide and communicate the decisions of others. It also recommended to appoint a physician to carry out the decisions if the patient is unable to speak for himself.
If certain decisions were taken early in the course of the disease, there is the possibility that the patient will want to review them with the family and the doctor in order to make sure that is still what he wants. There comes a time in which the purpose of treatment is no longer to treat or cure the disease but to maintain the comfort and dignity of the patient. Your doctor may ask questions about maintaining comfort when cure is no longer an option. Doctors at hospices and palliative care centers can ensure a comfortable environment for people in final stages of cirrhosis.

Recommendations

No Alcohol

No Alcohol

Abandonment of alcohol!
Consumption of excessive amounts of alcohol is the leading cause of cirrhosis. If diagnosed with cirrhosis, it is extremely important to completely renounce alcohol, even if alcohol consumption is not the cause of liver cirrhosis. If the patient doesn’t give up alcohol consumption, liver disease progresses more rapidly.

Diet modification
If the body retains fluid, the most important change in diet is to reduce the amount of sodium intake by reducing the amount of salt in your diet. People with liver damage tend to retain sodium. This may contribute to accumulation of fluid in the abdominal cavity (ascites), the most common complication of cirrhosis.
If the patient is at risk of developing hepatic encephalopathy (altered mental function) due to advanced liver disease, the doctor may recommend a temporary reduction of daily protein intake. However, protein is necessary in one’s diet in order to be well fed, but it is recommended that the majority of proteins should be of vegetable provenience. It also recommended to avoid eating large amounts of protein at one meal.

Avoidance of harmful drugs
Certain medications, including acetaminophen (Paracetamol) and NSAIDs (Ibuprofen, Naproxen) may accelerate liver damage in patients suffering from cirrhosis. They also increase the risk of variceal bleeding in patients who have varicose veins in the digestive tract. Consult your doctor for safe alternatives.
Certain prescription drugs that are meant to treat other conditions can be harmful to patients suffering from cirrhosis. The gastroenterologist who has cirrhotic patients under observation should be informed about all the medication that his patients use.