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Cirrhosis

What is Cirrhosis?
This is the permanent scarring or injury of the liver due to chronic diseases.  These diseases include infectious hepatitis, chronic alcoholism and underlying metabolic disturbances (eg. Wilson’s disease), inherited diseases, drugs, toxins and infections. The scar tissue can be extensive and affect the structure of the liver which in turns blocks blood flow.

Symptoms
As the disease is slow to display itself, there are no obvious symptoms in the early stages.  The first symptoms to be displayed can include anorexia, fatigue, loss of appetite, itching, nausea, vomiting, abdominal pain and distention.  As the disease progresses more serious symptoms such as jaundice become apparent.

Complications which can occur as a result of the disease include:

  • Bruising and bleeding – liver’s reduced ability to produce protein to aid blood clotting.
  • Edema and ascites – fluid collects in the legs (edema) and abdomen (ascites).
  • Gallstones – bile hardens as cirrhosis prevents it from flowing freely.
  • Hepatic encephalopathy – toxins accumulate in the brain as they can’t be removed by the liver. This leads to decreased mental function.
  • Insulin resistance and type 2 diabetes – cirrhosis causes resistance to insulin, thus the pancreas produces more.  Excess glucose then builds up in bloodstream leading to type 2 diabetes.
  • Liver Cancer – Hepatocellular carcinoma can occur in people with cirrhosis.
  • Esophageal varices and gastrophy – enlargement of the blood vessels in the esophagus and stomach resulting from portal hypertension.  This increases the likelihood of these vessels bursting.
  • Portal hypertension – slows the flow of blood through the portal vein, building pressure in this vein.
  • Sensitivity to medication – Cirrhosis slows the liver’s ability to filter medications from blood.
  • Splenomegaly – following Portal hypertension the spleen enlarges and retains white blood cells and platelets, restricting their availability to the blood.


Dietary Management
As malnutrition can be common in people with Cirrhosis, a healthy, nutritious diet is needed through all stages of the disease. Liquid supplements may be required in some cases to improve nutrition. Carbohydrate intake should be high to provide sufficient calories to avoid protein being used for energy. Some studies suggest intakes should be as high as between 300 and 400g per day.

Many people with Cirrhosis suffer from mal-absorption of fats. Fats can be replaced by medium-chain triglycerides for patients to reduce steatorrhea (excess fat in fecal matter).

High calorie-intake of between 35 and 50 kcal per kg is recommended. This may be difficult for those suffering anorexia and nausea.  In cases like these, dietary preferences should be considered and smaller more regular meals offered.

A sodium-restricted diet is recommended for people with ascites and edema. This may be prolonged to reduce fluid retention. This means that foods eaten also need to be low in sodium naturally eg. Milk intake is restricted. Liquid intake may also be restricted, based on the previous day’s urinary output. This will be balanced against the effectiveness of a sodium-restricted diet for those with edema and ascites.

In advanced cirrhosis, there may be a need to reduce the amount of fibre in the diet. This is due to the risk of hemorrhage from esophageal varices.

It is important to avoid raw shellfish as this may contain bacterium which can lead to infection.

Some patients with liver cirrhosis start to develop problems with their memory and concentration. In extreme cases patients become confused and disorientated and can fall into a coma. This condition is known as hepatic encephalopathy. Hepatic encephalopathy is likely to result from the accumulation of toxic substances which are formed from the breakdown of proteins. These toxins would normally be detoxified by the liver, however, where the liver is damaged the toxins start to accumulate in the bloodstream.

Traditional dietary management of liver cirrhosis involved the prescription of low protein diets, however, this is no longer deemed necessary in all cases. Some more recent research indicates that protein requirements are in fact higher in patients with cirrhosis. These studies have found high protein diets are well tolerated by patients with liver disease and that using these diets resulted in improvements in their mental capacity particularly when they were malnourished before diet therapy was commenced.  In view of these results the European Society for Parenteral and Enteral Nutrition recommended that traditional protein restriction should be abandoned in patients with hepatic encephalopathy.   


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