Transplant hepatologist Sumera Ilyas, M.B.B.S. answers the most frequently asked questions about cirrhosis.
Hi, I'm Dr. Sumera Ilyas, a transplant hepatologist at Mayo Clinic, and I'm here to answer some of the important questions you may have about cirrhosis.
No amount of alcohol is considered safe in patients with cirrhosis. They should avoid all alcohol use.
Well some pain medications are safe to take in certain doses, and some are not. For instance, nonsteroidal anti-inflammatory drugs such as ibuprofen and naproxen, they should be avoided in patients with cirrhosis, because when the liver is scarred, there's a greater chance of hurting the kidneys with these types of medications. Narcotics such as oxycodone are not a good idea either as they can be quite problematic with certain complications of cirrhosis. Acetaminophen, on the other hand, is safe to take, but at smaller doses. For pain relief in cirrhosis, we recommend taking acetaminophen up to two grams a day. So that's four extra strength tablets within a 24-hour period.
So it's important to eat an overall healthy diet that is balanced and full of fruits and vegetables. It's important to have protein intake, and that can be from lean sources of protein such as beans or lentils. And salt restriction is also very important. Limit the amount of salt in your diet to less than two grams of total intake a day.
Although certain herbal supplements such as milk thistle have been tried in liver disease, there's no evidence to suggest that herbal supplements or any other alternative therapies can effectively treat cirrhosis. However, there is a chance of herbal supplements causing harm to the liver, sometimes to the point of liver failure requiring a liver transplant. So we recommend avoiding any and all herbal supplements.
Well vaccinations are an important preventive measure in patients with cirrhosis. Because when the liver is scarred, patients are at higher risk of complications from certain infections. For patients with cirrhosis, we recommend vaccination against hepatitis A and B. We also recommend the pneumococcal vaccine, which is commonly referred to as the pneumonia vaccine for all adult patients with cirrhosis. And patients with cirrhosis should also get the annual flu shot.
There are instances when damage to the liver can be slowed, although complete reversal generally does not happen. For example, if a patient has cirrhosis due to alcohol use, we know that completely abstaining from alcohol can improve the function of the liver. Similarly, weight loss can help improve fatty liver disease. And cirrhosis from hepatitis C was a major reason patients required liver transplants. But we now have medications - antiviral drugs that are very effective at curing it. There's evidence to suggest that getting rid of the hepatitis C can slow or maybe even help reverse some of the damage done. But there are instances when the liver disease is too advanced and medical interventions cannot reverse the process. And that's when we consider liver transplantation.
We know that this is tough for our patients and their loved ones. And we want to do everything we can to make the process seamless for our patients. It's helpful for us if we have as much information about your condition as possible. Any prior medical therapies, any new symptoms or signs, any medications, herbal supplements, or any other medical conditions that you may have. Collect all of this information and share it with your liver team. Be open and transparent with your team. Never hesitate to ask your medical team any questions or concerns you have. Being informed makes all the difference. Thanks for your time, and we wish you well.
A liver biopsy is a procedure to remove a small sample of liver tissue for laboratory testing. A liver biopsy is commonly performed by inserting a thin needle through your skin and into your liver.
People with early-stage cirrhosis of the liver usually don't have symptoms. Often, cirrhosis is first detected through a routine blood test or checkup. To help confirm a diagnosis, a combination of laboratory and imaging tests is usually done.
Your doctor may order one or more tests that may suggest a problem with your liver, including:
Laboratory tests. Your doctor may order blood tests to check for signs of liver malfunction, such as excess bilirubin, as well as for certain enzymes that may indicate liver damage. To assess kidney function, your blood is checked for creatinine. You'll be screened for the hepatitis viruses. Your international normalized ratio (INR) is also checked for your blood's ability to clot.
Based on the blood test results, your doctor may be able to diagnose the underlying cause of cirrhosis. He or she can also use blood tests to help identify how serious your cirrhosis is.
- Imaging tests. Magnetic resonance elastography (MRE) may be recommended. This noninvasive advanced imaging test detects hardening or stiffening of the liver. Other imaging tests, such as MRI, CT and ultrasound, may also be done.
- Biopsy. A tissue sample (biopsy) is not necessarily needed for diagnosis. However, your doctor may use it to identify the severity, extent and cause of liver damage.
If you have cirrhosis, your doctor is likely to recommend regular diagnostic tests to monitor for signs of disease progression or complications, especially esophageal varices and liver cancer. Noninvasive tests are becoming more widely available for monitoring.
Treatment for cirrhosis depends on the cause and extent of your liver damage. The goals of treatment are to slow the progression of scar tissue in the liver and to prevent or treat symptoms and complications of cirrhosis. You may need to be hospitalized if you have severe liver damage.
Treatment for the underlying cause of cirrhosis
In early cirrhosis, it may be possible to minimize damage to the liver by treating the underlying cause. The options include:
- Treatment for alcohol dependency. People with cirrhosis caused by excessive alcohol use should try to stop drinking. If stopping alcohol use is difficult, your doctor may recommend a treatment program for alcohol addiction. If you have cirrhosis, it is critical to stop drinking since any amount of alcohol is toxic to the liver.
- Weight loss. People with cirrhosis caused by nonalcoholic fatty liver disease may become healthier if they lose weight and control their blood sugar levels.
- Medications to control hepatitis. Medications may limit further damage to liver cells caused by hepatitis B or C through specific treatment of these viruses.
- Medications to control other causes and symptoms of cirrhosis. Medications may slow the progression of certain types of liver cirrhosis. For example, for people with primary biliary cirrhosis that is diagnosed early, medication may significantly delay progression to cirrhosis.
Other medications can relieve certain symptoms, such as itching, fatigue and pain. Nutritional supplements may be prescribed to counter malnutrition associated with cirrhosis and to prevent weak bones (osteoporosis).
Treatment for complications of cirrhosis
Your doctor will work to treat any complications of cirrhosis, including:
- Excess fluid in your body. A low-sodium diet and medication to prevent fluid buildup in the body may help control ascites and swelling. More-severe fluid buildup may require procedures to drain the fluid or surgery to relieve pressure.
Portal hypertension. Certain blood pressure medications may control increased pressure in the veins that supply the liver (portal hypertension) and prevent severe bleeding. Your doctor will perform an upper endoscopy at regular intervals to look for enlarged veins in the esophagus or stomach (varices) that may bleed.
If you develop varices, you likely will need medication to reduce the risk of bleeding. If you have signs that the varices are bleeding or are likely to bleed, you may need a procedure (band ligation) to stop the bleeding or reduce the risk of further bleeding. In severe cases, you may need a small tube — a transjugular intrahepatic portosystemic shunt — placed in your vein to reduce blood pressure in your liver.
- Infections. You may receive antibiotics or other treatments for infections. Your doctor also is likely to recommend vaccinations for influenza, pneumonia and hepatitis.
- Increased liver cancer risk. Your doctor will likely recommend periodic blood tests and ultrasound exams to look for signs of liver cancer.
- Hepatic encephalopathy. You may be prescribed medications to help reduce the buildup of toxins in your blood due to poor liver function.
Liver transplant surgery
In advanced cases of cirrhosis, when the liver ceases to function, a liver transplant may be the only treatment option. A liver transplant is a procedure to replace your liver with a healthy liver from a deceased donor or with part of a liver from a living donor. Cirrhosis is one of the most common reasons for a liver transplant. Candidates for liver transplant have extensive testing to determine whether they are healthy enough to have a good outcome following surgery.
Historically, those with alcoholic cirrhosis have not been liver transplant candidates because of the risk that they will return to harmful drinking after transplant. Recent studies, however, suggest that carefully selected people with severe alcoholic cirrhosis have post-transplant survival rates similar to those of liver transplant recipients with other types of liver disease.
For transplant to be an option if you have alcoholic cirrhosis, you would need:
- To find a program that works with people who have alcoholic cirrhosis
- To meet the requirements of the program, which would include lifelong commitment to alcohol abstinence as well as other requirements of the specific transplant center
Potential future treatments
Scientists are working to expand current treatments for cirrhosis, but success has been limited. Because cirrhosis has numerous causes and complications, there are many potential avenues of approach. A combination of increased screening, lifestyle changes and new medications may improve outcomes for people with liver damage, if started early.
Researchers are working on therapies that will specifically target liver cells, helping to slow or even reverse the fibrosis that leads to cirrhosis. While no targeted therapy is quite ready, the framework for developing such treatments is in place, and progress is accelerating.
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Lifestyle and home remedies
If you have cirrhosis, be careful to limit additional liver damage:
- Don't drink alcohol. Whether your cirrhosis was caused by chronic alcohol use or another disease, avoid alcohol. Drinking alcohol may cause further liver damage.
- Eat a low-sodium diet. Excess salt can cause your body to retain fluids, worsening swelling in your abdomen and legs. Use herbs for seasoning your food, rather than salt. Choose prepared foods that are low in sodium.
- Eat a healthy diet. People with cirrhosis can experience malnutrition. Combat this with a healthy plant-based diet that includes a variety of fruits and vegetables. Choose lean protein, such as legumes, poultry or fish. Avoid raw seafood.
- Avoid infections. Cirrhosis makes it more difficult for you to fight off infections. Protect yourself by avoiding people who are sick and washing your hands frequently. Get vaccinated for hepatitis A and B, influenza, and pneumonia.
- Use over-the-counter medications carefully. Cirrhosis makes it more difficult for your liver to process drugs. For this reason, ask your doctor before taking any medications, including nonprescription drugs. Avoid drugs such as aspirin and ibuprofen (Advil, Motrin IB, others). If you have liver damage, your doctor may recommend you avoid acetaminophen (Tylenol, others) or take it in low doses for pain relief.
A number of alternative medicines have been used to treat liver diseases. Milk thistle (silymarin) is the most widely used and best studied.
However, there is not enough evidence of benefit from clinical trials to recommend use of any herbal products to treat liver cirrhosis. In addition, some alternative medications may harm the liver. Talk with your doctor if you're interested in trying alternative medicine to help you cope with cirrhosis.
Preparing for your appointment
If you have cirrhosis, you may be referred to a doctor who specializes in the digestive system (gastroenterologist) or the liver (hepatologist).
Here's some information to help you get ready for your appointment and what to expect from your doctor.
What you can do
- Be aware of any pre-appointment restrictions, such as diet restrictions on the day before your appointment.
- Write down your symptoms, including when they started and how they may have changed or worsened over time.
- Take a list of all your medications, as well as any vitamins or supplements.
- Write down your key medical information, including other diagnosed conditions.
- Bring results of medical tests done so far, including digital copies of CT, MRI or ultrasound images and biopsy slides if a liver biopsy has been done.
- Write down key personal information, including any recent changes or stressors in your life.
- Take a family member or friend along to help you remember things.
- Write down questions to ask your doctor.
Questions to ask your doctor
Preparing a list of questions can help you make the most of your time. Some basic questions to ask your doctor include:
- What is most likely causing my cirrhosis?
- Is there a way to slow or stop my liver damage?
- What are my treatment options?
- Are there medications or supplements that can hurt my liver?
- What signs and symptoms of complications should I watch for?
- I have other health conditions. How can I best manage them together?
Don't hesitate to ask additional questions during your appointment.
What to expect from your doctor
Be prepared to answer questions your doctor is likely to ask, including:
- When did you first begin experiencing symptoms?
- Have your symptoms been continuous or occasional?
- How severe are your symptoms?
- What, if anything, seems to improve your symptoms?
- What, if anything, appears to worsen your symptoms?
- How often do you drink alcohol?
- Have you been exposed to or taken toxic drugs?
- Do you have a family history of liver disease, hemochromatosis or obesity?
- Have you ever had viral hepatitis?
- Have you ever had jaundice?
- Have you ever had a blood transfusion or used injection drugs?
- Do you have any tattoos?
Feb. 06, 2021