Cirrhosis

A normal liver is able to filter a large amount of blood. A liver with cirrhosis is stiffer and has
trouble filtering blood properly, which builds up pressure. The extra pressure causes fluid to
build up inside your belly, in the space around your liver, stomach, intestine and other organs.
This fluid in the belly is called ascites. It can cause your belly to stretch out like a balloon filled
with water, and cause your legs to get swollen too.

Large amounts of fluid can be painful and cause you to have low appetite, nausea or
constipation. It can also make your breathing more difficult, especially when you lie down.
Ascites can be controlled by keeping a low salt diet and by using medications prescribed by your doctor to pee out extra water. These are called diuretics, or water pills, like Spironolactone and Lasix©(furosemide). If the ascites is severe, a small needle can be used to drain the fluid out from the belly (paracentesis, or tap).

Bacteria are part of the normal digestive tract. Cirrhosis can cause bacteria to leak out of the
intestines and infect the fluid in your belly (ascites). This is called spontaneous bacterial
peritonitis, or SBP for short. SBP can be silent (no symptoms) or may cause you to develop a
fever, nausea, vomiting, decreased appetite, belly pain, and/or confusion. It can be life
threatening if not treated.

If you suspect you have this infection, seek medical attention right away. Your doctor(s) can
confirm if there is an infection by using a small needle to take a sample of the fluid in your belly
(diagnostic paracentesis). SBP can be treated with antibiotics. If you have had this infection, you will be asked to take antibiotics as long as you have fluid in your belly (ascites) to prevent
infection from coming back.

The same pressure buildup that causes ascites can also lead to stretching out of blood vessels in other places, like the lining of your esophagus (the tube that connects the mouth to the
stomach) and/or stomach.

The stretched blood vessels (varices) do not cause any pain, or problems with swallowing or
digestion. They can threaten your life if they start to bleed (see below). The only way to find out
if you have varices is to look with a camera scope (see “endoscopy”). It is important to take
regular looks because varices can develop over time, even if you did not previously have them.

If you have varices, tell your doctor if you are planning to fly anywhere.

When too much pressure builds up in varices, they can burst and cause you to lose a lot of blood very quickly – this is life threatening if not treated immediately. If this happens, you might vomit large amounts of blood, have dark mushy poops (like tar) called melena, feel weak and
dizzy, or any combination of those things. When the gut breaks down blood in people with cirrhosis, it can cause confusion. New or worsening confusion can be a sign of slow bleeding and should be investigated by your doctor. 

Bleeding of varices can be prevented in a few ways. It is important to regularly look for varices with endoscopy, and tie them off with banding, or variceal ligation (refer to page 14) to make them disappear. If the varices are small, taking a medication (beta blocker, e.g. nadolol) helps decrease the pressure in the varices and can help prevent bleeding. There is also a special procedure called TIPS (refer to page 14) that can help get rid of varices.

The liver is responsible for getting rid of toxins in the body, such as ammonia. When the liver is
working poorly, these toxins can build up in the blood stream and affect the brain causing
confusion. The degree of confusion varies and it can present itself in different ways. It is
important to recognize the symptoms of confusion to treat it before it becomes severe as it can
lead to coma and death.

Symptoms of hepatic encephalopathy include: 

• • Difficulty thinking clearly (“fogginess”) 
  • Forgetfulness 
  • Personality or mood changes 
  • Bizarre behaviour 
  • Shortened attention span 
  • Drowsiness during the day 
  • Trouble sleeping at night 
  • Slurred speech 
  • Poor judgment 
  • Anxiety 
  • Slow reaction time 
  • Worsening of fine motor movements, e.g. handwriting

• • Drinking alcohol 
  • Medications – avoid sleeping pills or other sedatives, like benzodiazepines (e.g. Ativan) 
  • Having an infection anywhere in the body 
  • Constipation – you should aim to have 2-3 bowel movements every day 
  • Being dehydrated 
  • Bleeding inside your digestive tract – this is why regular exams for varices are important 
  • Problems with other organs in your body 
  • Surgeries 

“Hepato” means liver, and “renal” means kidney. Hepatorenal syndrome (HRS) is what happens
when the balance between the liver and kidneys gets out of sorts – the kidneys do not receive
enough blood to filter from the liver, and they begin to shut down. If this is not caught early, it
can result in complete kidney failure and/or death. HRS can be triggered by many things, but
the most common are infections and being dehydrated.

There can be very few symptoms of HRS. You should watch for a sudden decrease in the amount of pee you make each day, nausea, drowsiness and confusion. If you have these symptoms or are worried, you should seek medical attention right away.

Hepatocellular carcinoma (HCC) is a type of liver cancer. It can happen when sick liver cells start to multiply abnormally. The risk is about 1 in 100 per year. Because anyone with cirrhosis is at risk of HCC at any point in their disease, it is important to get screened regularly. There may be no signs of this cancer until it grows very large and causes pain. Your liver specialist will talk to you about screening which involves taking images of your liver every 6 months to look for early signs of cancer.

HCC screening
You should have imaging of your liver every 6 months to look for early signs of HCC. Typically,
this is done with an ultrasound, but there may be reasons your doctor chooses CT or MRI.
Remember, it is easier to cure a small cancer – regular screening is very important.