Limit damage to liver

Symptomatic relief:

• high ammonia levels (Hepatic encephalopathy):  There are two strategies to addressing high ammonia:  trap and remove ammonia and reduce ammonia production that is outside of the liver (e.g. by bacteria within the digestive system).  Dietary agents (e.g. lactulose)  can be used to trap and expel excess ammonia, as ammonia is water-soluble and lactulose osmotically pulls water into GI tract for defecation.  Antibiotics (in oral form) are used to reduce the number of bacteria which reside in the GI tract: by reducing their number.  Therefore there will be less ammonia produced and thus less work for the liver to try to convert ammonia to urea.   Similarly, a diet lower in protein will give the liver a break from having to process amino acids which generate ammonia. A dietician can recommend liver-friendly diets.
• portal hypertension and varices:  although the cause of portal hypertension is irreversible (fibrotic tissue is laid inside the liver), blood pressure medications can be used to help lower the pressure in the varices and portal vein. This should also reduce the risk of varices rupture. If portal hypertension can’t be managed pharmacologically, a physical shunt can be surgically implanted to bypass the liver tissue by connecting the portal vein directly to the hepatic vein.
• swelling and ascites:  as there is excess fluid in tissues and peritoneal space, fluid needs to be removed physically or through diuretics. Diuretics are useful in promoting fluid loss from peripheral tissues – assuming that kidneys are functional.  However, if ascites is severe, physical removal using a needle (paracentesis) .
• nutritional deficiencies:  as cirrhosis affects its storage and activation of hormones, dietary supplementation might be helpful.  Iron, Vitamin D & K supplements would be helpful to address the anemia and fatigue.  Consultation with a dietician would result in a dietary plan that will help give the liver a rest and address the nutritional deficiencies.
• poor clotting (coagulopathy):  depending on the degree of the coagulopathy, lifestyle changes can be initiated to minimize accidental traumas.  For example, using an electric razor instead of a manual razor may minimize cuts during shaving. The patient can also be educated on signs of bleeds in the GI tract from bleeding from esophageal or rectal varices.  However, if the bleeding is problematic, a discussion with a health care provider about clotting factor/platelet transfusion might be helpful.

Section Summary

Because the liver is irreversibly damaged in cirrhosis, the only cure is a liver transplant WITH addressing the original cause of the liver damage.  Until a transplant can be arranged, symptoms of cirrhosis can be managed with lifestyle choices, medications, and if needed – medical intervention.  Portal hypertension can be managed pharmacologically with select anti-hypertensives or surgically with a shunt that connects the portal vein to the hepatic vein.   Ascites and swelling can be managed pharmacologically with diuretics or with physical removal of fluid with a needle (i.e. paracentesis).  Patients should be educated on their likelihood to bleed and watch out for signs of GI bleed if esophageal or rectal varices rupture.  A dietician should be involved in the care to address nutritional deficiencies and liver-friendly diet.

Lifestyle changes will also be encouraged to limit further damage to the cirrhotic liver.  A review of toxin and medication ingestion can be done as well as dietary changes to protein intake to reduce the amount of ammonia produced.

Review Questions