Treating cirrhosis

Treating cirrhosis

Treating cirrhosis

Once a diagnosis has been made, a doctor will recommend a treatment plan based on the determined underlying cause and severity of scarring to the liver. Primary goals of treatment involve slowing down the progression of tissue scarring (fibrosis), treating symptoms and preventing the onset of complications as much as possible. No case of liver cirrhosis can be repaired or reversed.

If cirrhosis is determined in the earlier stage (i.e. compensated cirrhosis), a doctor is likely to commence treatment by targeting the underlying cause, so as to prevent as much future damage as possible.

1. Treatment recommendations for slowing down fibrosis progression may involve:

  • Elimination of alcohol consumption: Any amount of alcohol consumption may be toxic for a cirrhotic liver. A doctor will recommend that alcohol consumption should be ceased. If a dependency makes it difficult to stop drinking, a treatment programme may be recommended for alcohol addiction.
  • Losing weight: Symptoms of an underlying cause determined as a non-alcoholic fatty liver disease can be alleviated by losing a little excess weight and taking in enough protein in order to achieve this. Healthier suggestions a doctor will make will also involve lifestyle adjustments which help to keep blood sugar levels balanced.
  • Medications: A doctor may recommend medications to treat an underlying cause, such as a hepatitis infection, or prescribe others which can help to reduce the progression of fibrosis. Medications may also be prescribed to alleviate specific symptoms such as fatigue, pain or skin itching. A doctor may also recommend supplements, particularly if there are signs of malnutrition as a result of liver damage, and also to prevent osteoporosis and weakening of the bones. Adequate protein intake and vitamin supplements may also come recommended to assist with alleviating blood clotting problems. If Wilson’s disease is found to be an underlying cause, medications may be prescribed to increase excretion of copper through urine and thereby diminish levels in the body. In this way, further damage to the liver is alleviated. Autoimmune hepatitis may also be treated with medications that suppress the immune system and thereby decrease inflammation in the liver.

2. Treatment recommendations for possible complications may involve:

  • Fluid build-up (fluid retention): A doctor will strongly recommend a low-sodium diet in combination with the use of a diuretic to alleviate fluid build-up causing swelling and ascites (fluid build-up in the abdomen). Pressure in the blood vessels typically forces fluid out and into surrounding tissues, where it is then retained. A doctor may recommend a diuretic (this encourages excretion of water via the kidneys in the form of urine) to assist with safely alleviating excess fluid (salt and water) from the body. This may mean that frequency of urination increases. Treatment with diuretics must be monitored as it can affect the function of the kidneys. Blood levels of BUN (blood urea nitrogen) and creatinine must be frequently measured to ensure that an excess of diuresis does not occur.

    Severe fluid retention may require fluid drainage procedures to assist with alleviating pressure. This may be done with a transjugular intrahepatic portosystemic shunt (TIPS / small flexible tube or catheter) which is inserted in the hepatic vein in the liver (normally by a radiologist) via the neck vein, and down the inferior vena cava (the largest vein in human body). A stent is then placed to alleviate fluid accumulation and reduce the blood pressure level within the organ and the portal vein by shunting blood around the liver.

    Another procedure is known as an abdominal paracentesis, whereby a catheter is inserted to drain large amounts of ascetic fluid directly from the abdomen and alleviate painful distention and breathing difficulties (due to limited diaphragm movement). Medications may also be prescribed to prevent fluid build-up. Fluid retention that results in an infection may require hospitalisation and treatment with intravenous (IV) antibiotics.

  • Infections: Signs of infection may be treated accordingly with prescribed medications, such as antibiotics and anti-viral drugs. A case of peritonitis (a potentially life-threatening inflammation of the abdominal wall lining) may be treated with intravenous antibiotics. Vaccinations for hepatitis, flu (influenza) and pneumonia may also be recommended.

  • Portal hypertension: Pressure in the portal vein may be treated with certain prescribed blood pressure medications (such as beta-blockers and nitrates), especially if there are varices (abnormal enlarged veins) present. This is to prevent an increased risk of severe bleeding in the veins which supplies the liver with blood. A doctor is likely to recommend periodic endoscopy procedures to check for potentially enlarged veins (varices) in the stomach and or / oesophagus, which typically rupture as a result of pressure and inflammation.

    An endoscopy band ligation may be recommended for those with an intolerance to medications as an alternative to treating varices or to stop any occurrence of bleeding. The procedure is done during an upper gastrointestinal endoscopy while under anaesthetic. Once sedated and the throat numbed, a scope is inserted into the mouth and down the oesophagus (throat) which connects to the stomach. Tiny elastic bands can then be placed around any enlarged veins or varices, restricting bleeding. This allows the varices to heal and in turn prevents any further bleeding. A transjugular intrahepatic portosystemic shunt can also be placed in the portal vein to assist with reducing bleeding (by alleviating blood pressure in the liver). Balloon inflation techniques may be successful in compressing a bleeding vein as well.

    Another procedure which can work during compensation stages is a distal splenorenal shunt / DSRS (the splenic vein is detached from the portal vein and is reattached to the renal vein allowing blood to be shunted from the spleen and around the liver). Bleeding varices will require hospitalisation as chances are high that a person’s condition can become life-threatening (30% to 50%). The majority of bleeding varices (up to 80% of the time) result in more than one occurrence and thus must be effectively monitored by a medical professional. If significant bleeding occurs, the affected person will be monitored closely in hospital until such time as bleeding is sufficiently controlled and circulation is restored to normal. Lost fluids will be replaced with IV lines and supplemental oxygen may be required. Some instances may require blood transfusions.

  • Hepatic encephalopathy: Medications, such as lactulose, may be prescribed to prevent a further build-up of toxins (ammonia) in the bloodstream (lactulose is used as an energy source by gut bacteria as opposed to protein, therefore producing less ammonia). The accumulation of toxins can lead to numerous other health complications such as personality or behavioural changes, anxiety, problems with clear thinking, poor concentration ability, confusion, memory difficulties, fatigue, lethargy, loss of small-hand movements and handwriting ability, impaired judgement, confused speech and a sweet or musty odour breath.

    Severe instances of this condition will require hospitalisation where oral lactulose (a non-absorbable sugar) will be given to assist with diminishing the amount of toxins present which can be absorbed into the intestinal tract. A low protein-diet will also be recommended as dietary protein is often a source of toxic compounds that can aggravate a person’s condition.

  • Risk of liver cancer: If there are reasons to suspect an increased risk of liver cancer, a doctor will request blood tests and imaging tests, such as an ultrasound, every few months to monitor a person’s condition and routinely check for possible signs requiring medical intervention. Liver cancer is rapidly progressive and can be life-threatening within a short space in time (sometimes months) if left untreated. If detected, liver cancer is usually treated by surgical means, sometimes involving a liver transplant.

  • Kidney failure (hepatorenal syndrome): Advanced liver disease (liver cirrhosis) can lead to severe kidney function failure. If this happens, a person’s condition is serious. Potentially fatal, rapid deterioration of kidney function is severely life-threatening. If caused by a deteriorating liver, a liver transplant may be the only treatment option to preserve a person’s life.

3. Treatment recommendations for decompensated / advanced cirrhosis may involve:

  • Liver transplant: Advanced stages of cirrhosis typically mean that liver function is severely diminished and may only be treatable with a liver transplant procedure. Jaundice, severe fluid retention, bleeding varices, kidney dysfunction, liver cancer and hepatic encephalopathy are just some of the severe complications which a doctor will take into serious consideration for a transplant. The objective of a liver transplant is to improve a person’s chances of long-term survival by removing the diseased organ completely and replacing it with that of a healthy one (from a deceased donor).

    Once the decision is made to undergo a liver transplant, extensive testing will then be required to determine overall state of health. This is to assess whether a person is fit enough to undergo surgery and determine how likely it may be that the outcome will be positive. Measures to curb further damage to the liver will be implemented ahead of surgery to enhance a person’s chances of a successful outcome. Effective supportive care following surgery also enhances a person’s overall success rate.

Advanced cirrhotic liver requiring a transplant.

4. Ongoing / follow-up care

Most major complications and advanced stages of liver cirrhosis generally require hospitalisation and very careful monitoring and administration of treatment.

Provided a person has no signs of infection, blood is clotting sufficiently (and any bleeds are able to be easily controlled), and they can hold down liquid and foodstuffs consumed, managing liver cirrhosis can be done at home.

All recommended follow-up medical appointments, which are likely to be ongoing, must be kept in order to ensure the best possible care.

5. Herbal alternatives

Some research (clinical trials) has been done with herbal compounds for the potential treatment of liver problems and scarring. Milk thistle (silymarin) is one that has been researched the most. Others include liquorice root (glycyrrhiza), astragalus and schisandra. To date, there have been no clinical trials that have conclusively recommended these herbal compounds as effective treatment options for liver cirrhosis. Medical professionals are likely to urge liver cirrhosis patients to avoid the use of herbal substances as there have been many reported cases of drug-induced injury to the liver.

Before introducing any natural substances into a treatment programme, a doctor should be consulted to ensure that the most up to date advice is given so as to avoid any potential adverse reactions which may cause irreversible damage to the liver.

6. Lifestyle adjustments

Changes which require ongoing care can greatly impact a person’s quality of life and will come highly recommended by a doctor at the point where treatment is to commence.

On the list of important considerations for the improved quality of life are:

  • Avoidance of alcohol consumption – this can help to slow down progression of the condition considerably.
  • Maintain a balanced, but low-sodium diet – salt may be replaced by flavoursome herbs and include a variety of fruits and vegetables, as well as lean protein (poultry, fish, legumes – avoid raw seafood) which provides the body with an adequate number of calories. Protein intake may need to be reduced if hepatic encephalopathy develops.
  • Preventative care – avoid infections where possible (by getting the appropriate vaccinations as per a doctor’s instructions) and practice good hygiene habits.
  • Over-the-counter medications should be used with caution and preferably under the supervision of the treating doctor (a cirrhotic liver has difficulty processing most medications. Non-steroidal anti-inflammatory medications such as ibuprofen, as well as aspirin should be avoided altogether).

Close-up of green apple, measuring tape and salad.

7. What is research aiming to accomplish?

Research teams and scientists are continually working to find feasible means to expand on treatment currently used for liver cirrhosis as a way to better preserve quality of life. There have been some successes, although these are regarded as limited thus far.

The number of potential causes and associated complications are so many that research teams require time to explore the various different avenues available. Existing medications, especially those involved in the treatment of complications due to cirrhosis, are also being studied to assess the possibility of improving survival rates and thus giving those with cirrhotic livers a better outcome. Existing treatments are constantly being developed, revised and tested by scientists.

Researchers are looking at determining the precise mechanism for scar formation to try and ascertain how the process of fibrosis may be interrupted (at the very least) or (at best) even reversed. 
Also on the table are ways and means that fibrosis can be dramatically halted or reversed altogether.

Once again, the myriad of causes needs to be explored further. Experimental treatments are being comprehensively researched as well, but are some way off from becoming available in the near future.

Thus far, comprehensive screening, medications, surgical interventions and a commitment to lifestyle changes have proved the most beneficial means of treatment for cirrhosis. Scientists are looking at ways to better enhance these treatment procedures and thereby improve the outcomes for those living with cirrhotic livers. As with most disorders, the earlier a condition is diagnosed, the better.

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