WHAT LIFESTYLE FACTORS CAN HELP MANAGE CIRRHOSIS?

A healthy lifestyle is particularly important for people with cirrhosis.
Dietary Factors
Healthy Foods. Because important antioxidant vitamins are depleted in the
cirrhotic liver, cirrhosis patients should maintain a diet rich in fresh fruits,
vegetables, and whole grains.

Antioxidant Supplements. There is some preliminary laboratory evidence that
various antioxidant supplements including vitamin E, selenium, and
S-adenosylmethionine (SAMe) may help protect against liver damage and cirrhosis.
Supplements, however, are not recommended for people with liver disease except
with the advice of a physician. Some vitamins, such as vitamins D and A, are
metabolized in the liver and can be toxic.

Iron Restrictions. Elevated iron levels have been associated with cirrhosis from
many causes. Patients should avoid iron-rich foods, such as red meats, liver,
and iron-fortified cereals and should avoid cooking with iron-coated cookware
and utensils.

Supplemental Nutritional Products. Supplemental nutritional beverages may be
helpful, particularly for patients with both alcoholism and cirrhosis. In one
study, patients with both alcoholism and cirrhosis drank Ensure every day as a
supplement to their regular diet. After six months they showed significant
improvement in many signs of overall health compared to those who didn't consume
the beverage.

Vitamin B1 (Thiamine). Thiamine binds to iron and helps reduce iron load in the
liver. One small study suggested it may be helpful for patients with chronic
hepatitis B. It is not known if it has any benefit for cirrhosis. Pork is high
in the vitamin, but more healthful sources include dried fortified cereals,
oatmeal, corn, nuts, cauliflower, sunflower seeds and vitamin pills.

Omega-3 Fatty Acids. Some research suggests that supplements of omega-3 fatty
acids (found in fish oil and evening primrose oil) may help protect the diseased
liver.

Protein and Soy. High-quality dietary protein may be especially helpful for
patients with ascites and for repairing muscle mass, but excessive protein loads
may trigger encephalopathy. Protein solutions have been devised that provide
beneficial amino acids without including those that increase this risk. There is
no limit on vegetable proteins, such as those from soy.

Salt Restriction. Restricting salt consumption to less than 2,000 mg a day is
particularly important for patients with ascites. The less salt the better.

Zinc. In some studies, taking zinc supplements have lowered ammonia levels in
some patients who were zinc-deficient, a common problem in cirrhosis. Zinc
replacement may reduce frequency and severity of muscle cramps and may even help
protect against encephalopathy.
Limiting Fluids
Fluid restriction is not usually necessary, but patients with severe ascites
should discuss limiting fluid with their physicians.
Exercise
Exercise increases the risk for portal pressure and variceal bleeding. One study
reported that taking a beta-blocker may reduce this risk, although patients
should discuss this with their physician.
Preventing Influenza and Infections
Infections can have a severe impact on the liver. Although most respiratory
infections generally affect only the lungs, one small study suggested influenza
may directly affect the liver in patients with cirrhosis and exacerbate the
disease process. Researchers in the study advise annual flu shots for people
with cirrhosis. Furthermore, they advise that patients who get the flu be
treated immediately with rimantadine, but not a similar treatment called
amantadine.
Treating Chronic Fatigue
A 2000 study of 15 patients with chronic liver disease concluded that
methylphenidate (Ritalin) improves chronic fatigue symptoms in patients with
cirrhosis and chronic hepatitis. All patients reported some improvement in
fatigue, and no side effects were severe enough to warrant withdrawal from the
study. The researchers recommended that treatment for chronic fatigue in
patients with liver disease combine methylphenidate with physical therapy and
nutritional counseling. Results of the study need to be confirmed in a
randomized prospective trial.
Alternative Remedies
Among the natural substances being investigated for liver disease are ginseng,
glycyrrhizin (a compound in licorice), catechin (found in green tea), SAMe, and
silymarin (found in milk thistle). Two natural substances that may have some
benefits for people with cirrhosis are discussed in the following paragraphs:

Silymarin. A 2001 review analyzed studies on 10 herbal remedies used for liver
disease. None showed any benefits except silymarin. Furthermore, an analysis of
five studies on cirrhosis patients reported an association between silymarin and
a 7% reduced mortality rates from liver-related diseases. Known side effects
from silymarin include rare reports of gastrointestinal problems and allergic
skin rashes.

S-adenosylmethionine (SAMe). S-adenosylmethionine (SAMe) is a chemical found in
all parts of the body, which declines with age. It has been investigated for
years in Europe for arthritis, depression, and liver disease. Some preliminary
studies suggest it may provide some protection against liver damage and scarring
and may improve survival rates in alcoholic patients with cirrhosis. It is very
expensive, however, and as with all unregulated products, long-term side
effects, drug interactions, and other factors are not fully known.

It should be strongly noted that herbal remedies are not necessarily harmless
simply because they are natural (or marketed as natural), and their quality is
not regulated except in clinical studies. [See Box Warnings on Alternative and
So-Called Natural Remedies.]
Warnings on Alternative and So-Called Natural Remedies
It should be strongly noted that alternative or natural remedies are not
regulated and their quality is not publicly controlled. In addition, any
substance that can affect the body's chemistry can, like any drug, produce side
effects that may be harmful. Even if studies report positive benefits from
herbal remedies, the compounds used in such studies are, in most cases, not what
are being marketed to the public.

There have been a number of reported cases of serious and even lethal side
effects from herbal products. In addition, some so-called natural remedies were
found to contain standard prescription medication.

The following warnings are of particular importance for people with liver
disease:

Kava kava (an herb used for anxiety and tension) can be toxic to the liver
and cause severe hepatitis and even liver failure if taken excessively.
Black licorice (not red) can increase blood pressure and may be harmful in
people with hypertension.

The following website is building a database of natural remedy brands that it
tests and rates. Not all are available yet. http://www.ConsumerLab.com

The Food and Drug Administration has a program called MEDWATCH for people to
report adverse reactions to untested substances, such as herbal remedies and
vitamins (call 800-332-1088).


HOW ARE ABDOMINAL INFECTIONS MANAGED IN CIRRHOSIS?

Antibiotics are administered when fluid examination and tests for ascites
indicate infection. For a first episode, the antibiotic cefotaxime is typically
administered intravenously, requiring hospitalization. Treatment usually lasts
10 days but research indicates that five days may be sufficient for certain
patients. Some research indicates that the oral antibiotic ofloxacin may be as
effective and is without complications, allowing patients to be treated at home.
Preventing Infections in Advanced CirrhosisIn advanced cirrhosis, the risk for
serious abdominal infection is high and the antibiotic norfloxacin is often
prescribed preventively against specific organisms that infect the abdominal
cavity. One study found that preventive antibiotics were very cost effective in
high-risk patients. Another study reported, however, that patients who took
norfloxacin became susceptible to Staphylococcal infections, which are not
ordinarily a problem in cirrhosis, and their survival rates were similar to
patients who did not take the antibiotic. Long-term treatments with norfloxacin
or similar antibiotics may increase the risk for fungal infections after liver
transplantation. More research is needed.

HOW IS ENCEPHALOPATHY MANAGED IN CIRRHOSIS?

The first step in managing encephalopathy (damage to the brain) is to treat any
precipitating cause, if known, such as:

High ammonia levels.
Bleeding.
Low oxygen.
Dehydration.
Infection.
Use of sedatives.

Some studies indicate that manganese poisoning may be partially responsible for
encephalopathy in cirrhosis. Studies are needed to determine if drugs that
remove manganese improve this complication.
Eliminating Ammonia
Ammonia is the leading toxin in causing encephalopathy related to cirrhosis.
Mild encephalopathy is managed by directing therapy toward eliminating ammonia
in the intestine:

The first step is to restrict animal protein, substituting meats and dairy
products with vegetable protein, such as soy, and amino acid supplements.
Enemas, which clean out the intestine, may be effective.
Lactulose (Cephulac, Chronulac, Constulose, Duphalac, Enulose) and lactitol,
known as disaccharides, help lower blood ammonia levels and may be beneficial in
mild encephalopathy.
Antibiotics, such as metronidazole, rifamycin, or neomycin, are effective in
reducing levels of ammonia-producing bacteria in the intestine, although
long-term use of these drugs can cause toxic side effects.
Adding non-ammonia producing bacteria to the intestine, including L.
acidophilus and E. faecium, is showing promise as a safe and effective
treatment.
Investigative Agents. Certain drugs, such as flumazenil (Mazicon, Romazicon),
are under investigation for treating encephalopathy. Flumazenil is typically
administered to counteract the effects of sedatives.



Sandra Tara Balduf (Ane)

Frontline Hepatitis Awareness

Support for patients and educational materials

http://frontline-hepatitis-awareness.com

1-866-Hep-GoGo 866-437-4646




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