Dr. Lee was born in Shanghai, China, and received his college and medical training in the United States. He is fluent in English and three Chinese dialects. He graduated with chemistry departmental honors from Harvey Mudd College. He was appointed president of AOA society at UCLA School of Medicine. He underwent internal medicine residency and gastroenterology fellowship training at Cedars Sinai Medical Center.
Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
Treatment of cirrhosis includes 1) preventing further damage to the liver, 2)
treating the complications of cirrhosis, 3) preventing liver cancer or detecting
it early, and 4) liver transplantation.
Preventing further damage to the liver
Consume a balanced diet and one multivitamin daily.
Patients with PBC with impaired absorption of fat soluble vitamins may need additional vitamins D and
K.
Avoid drugs (including alcohol) that cause liver
damage. All patients with cirrhosis should avoid alcohol. Most patients with
alcohol induced cirrhosis experience an improvement in liver function with
abstinence from alcohol. Even
patients with chronic hepatitis B and C can substantially reduce liver damage
and slow the progression towards cirrhosis with abstinence from alcohol.
Eradicate hepatitis B and hepatitis C virus by using anti-viral medications.
Not all patients with cirrhosis due to chronic viral hepatitis are candidates
for drug treatment. Some patients may experience serious deterioration in liver
function and/or intolerable side effects during treatment. Thus, decisions to
treat viral hepatitis have to be individualized, after consulting with doctors
experienced in treating liver diseases (hepatologists).
Remove blood from patients with hemochromatosis to reduce the levels of iron
and prevent further damage to the liver. In Wilson's disease, medications can be
used to increase the excretion of copper in the urine to reduce the levels of
copper in the body and prevent further damage to the liver.
Suppress the immune system with drugs such as prednisone and azathioprine
(Imuran) to decrease inflammation of the liver in autoimmune hepatitis.
Treat patients with PBC with a bile acid preparation,
ursodeoxycholic acid (UDCA), also called ursodiol (Actigall). Results of an
analysis that combined the results from several clinical trials showed that
UDCA increased survival among PBC patients during 4 years of therapy. The
development of portal hypertension also was reduced by the UDCA. It is
important to note that despite producing clear benefits, UDCA treatment
primarily retards progression and does not cure PBC. Other medications such as
colchicine and methotrexate also may
have benefit in subsets of patients with PBC.
Immunize patients with cirrhosis against infection
with hepatitis A and B to prevent a serious deterioration in liver function.
There are currently no vaccines available for immunizing against hepatitis C.
Treating the complications of cirrhosis
Edema and ascites. Retention
of salt and water can lead to swelling of the ankles and legs (edema) or abdomen
(ascites) in patients with cirrhosis. Doctors often advise patients with
cirrhosis to restrict dietary salt (sodium) and fluid
to decrease edema and ascites. The amount of salt in the diet usually is
restricted to 2 grams per day and fluid to 1.2 liters per day. In most patients
with cirrhosis, however, salt and fluid restriction is not enough, and diuretics
have to be added.
Diuretics are medications that work in the kidneys to promote the elimination of
salt and water into the urine. A combination of the diuretics spironolactone
(Aldactone) and furosemide can reduce or eliminate the edema and ascites in most
patients. During treatment with diuretics, it is important to monitor the
function of the kidneys by measuring blood levels of blood urea nitrogen
(BUN)
and creatinine to determine if too much diuretic is being used. Too much
diuretic can lead to kidney dysfunction that is reflected in elevations of the
BUN and creatinine levels in the blood.
Sometimes, when the diuretics do not work (in which case
the ascites is said to be refractory), a long needle or catheter is used to draw
out the ascitic fluid directly from the abdomen, a procedure called abdominal
paracentesis. It is
common to withdraw large amounts (liters) of fluid from the abdomen when the
ascites is causing painful abdominal distension and/or difficulty breathing
because it limits the movements of the diaphragms.
Another treatment for refractory ascites is a procedure called transjugular
intravenous portosystemic shunting (TIPS, see below).
Bleeding from varices. If
large varices develop in the esophagus or upper stomach, patients with cirrhosis
are at risk for serious bleeding due to rupture
of these varices. Once varices have bled, they tend to rebleed and the
probability that a patient will die from each bleeding episode is high
(30%-35%). Therefore, treatment is necessary to prevent the first (initial)
bleeding episode as well as rebleeding. Treatments include medications and
procedures to decrease the pressure in the portal vein and procedures to destroy
the varices.
Propranolol (Inderal), a
beta blocker, is effective in lowering pressure in
the portal vein and is used to prevent initial bleeding and rebleeding from
varices in patients with cirrhosis. Another class of oral medications that
lowers portal pressure is the nitrates, for example, isosorbide dinitrate (
Isordil). Nitrates often are added to propranolol if propranolol alone does not
adequately lower portal pressure or prevent bleeding.
Octreotide (Sandostatin) also decreases portal vein pressure and has been used
to treat variceal bleeding.
During upper endoscopy (EGD), either sclerotherapy or
band ligation can be performed to obliterate varices and stop active bleeding
and prevent rebleeding. Sclerotherapy involves infusing small doses of
sclerosing solutions into the varices. The sclerosing solutions cause
inflammation and then scarring of the varices, obliterating them in the
process. Band ligation involves applying rubber bands around the varices to
obliterate them. (Band ligation of the varices is analogous to rubber banding
of hemorrhoids.) Complications of sclerotherapy include esophageal ulcers,
bleeding from the esophageal ulcers, esophageal perforation, esophageal
stricture (narrowing due to scarring that can cause dysphagia), mediastinitis
(inflammation in the chest that can cause chest pain), pericarditis
(inflammation around the heart that can cause chest pain),
and peritonitis (infection in the abdominal cavity). Studies have shown that
band ligation may be slightly more effective with fewer complications than
sclerotherapy.
Transjugular intrahepatic
portosystemic shunt (TIPS) is a non-surgical
procedure to decrease the pressure in the portal vein. TIPS is performed by a
radiologist who
inserts a stent (tube) through a neck vein, down the inferior vena cava and
into the hepatic vein within the liver. The stent then is placed so that one
end is in the high pressure portal vein and the other end is in the low
pressure hepatic vein. This tube shunts blood around the liver and by so doing
lowers the pressure in the portal vein and varices and prevents bleeding from
the varices. TIPS is particularly useful in patients who fail to respond to
beta blockers, variceal sclerotherapy, or banding. (TIPS also is useful in
treating patients with ascites that do not respond to salt and fluid
restriction and diuretics.) TIPS can be used in patients with cirrhosis to
prevent variceal bleeding while the patients are waiting for liver
transplantation. The most common side effect of TIPS is hepatic
encephalopathy. Another major problem with TIPS is the development of
narrowing and occlusion of the stent, causing recurrence of portal
hypertension and variceal bleeding and ascites. The estimated frequency of
stent occlusion ranges from 30%-50% in 12 months. Fortunately, there are
methods to open occluded stents. Other complications of TIPS include bleeding
due to inadvertent puncture of the liver capsule or a bile
duct, infection, heart failure, and liver failure.
A surgical operation to
create a shunt (passage) from the high-pressure portal vein to veins with
lower pressure can lower blood flow and pressure in the portal vein and
prevent varices from bleeding. One such surgical procedure is called distal
splenorenal shunt (DSRS). It is appropriate to consider such a surgical shunt
for patients with portal hypertension who have early cirrhosis. (The risks of
major shunt surgery in these patients is less than in patients with advanced
cirrhosis.) During DSRS, the surgeon detaches the splenic vein from the
portal vein, and attaches it to the renal vein. Blood then is shunted
from the spleen around the liver, lowering the pressure in the portal vein and
varices and preventing bleeding from the varices.
Hepatic encephalopathy.
Patients with an abnormal sleep cycle, impaired thinking, odd behavior, or other
signs of hepatic encephalopathy usually should be treated with a low protein
diet and oral lactulose. Dietary protein is restricted because it is a source of
the toxic compounds that cause hepatic encephalopathy. Lactulose, which is a
liquid, traps the toxic compounds in the colon. Consequently, they cannot be
absorbed into the blood stream and cause encephalopathy. To be sure that
adequate lactulose is present in the colon at all times, the patient should
adjust the dose to produce 2-3 semiformed bowel
movements a day. (Lactulose is a laxative, and the
adequacy of treatment can be judged by loosening or increasing frequency of
stools.) If symptoms of encephalopathy persist, oral antibiotics such as
neomycin or metronidazole (Flagyl), can be added to the treatment regimen. Antibiotics work by blocking
the production of the toxic compounds by the bacteria in the colon.
Hypersplenism. The filtration of blood by an enlarged spleen usually results in
only mild reductions of red blood cells (anemia), white blood cells (leukopenia)
and platelets (thrombocytopenia) that do not require treatment. Severe anemia,
however, may require blood transfusions or treatment with erythropoietin or
epoetin alfa (Epogen, Procrit), hormones that stimulate the production of red
blood cells. If the numbers of white blood cells are severely reduced, another
hormone called granulocyte-colony stimulating factor is available to increase
the numbers of white blood cells. An example of one such factor is filgrastim
(Neupogen).
No approved medication is available yet to increase the
number of platelets. As a necessary precaution, patients with low platelets
should not use aspirin or
other nonsteroidal antiinflammatory drugs (NSAIDS) since these drugs can
hinder the function of platelets. If a low number of platelets is associated
with significant bleeding, transfusions of platelets usually should be given.
Surgical removal of the spleen (called splenectomy) should be avoided, if
possible, because of the risk of excessive bleeding during the operation and the
risk of anesthesia in advanced liver disease.
Spontaneous bacterial peritonitis (SBP). Patients suspected of having
spontaneous bacterial peritonitis
usually will undergo paracentesis. Fluid that is removed is examined for white
blood cells and cultured for bacteria. Culturing involves inoculating a sample
of the ascites into a bottle of nutrient-rich fluid that encourages the growth
of bacteria, thus facilitating the identification of even small numbers of
bacteria. Blood and urine samples often are obtained as well for culturing
because many patients with spontaneous bacterial peritonitis also will have infection in their blood and
urine. In fact, many doctors believe that infection may have begun in the blood
and the urine and spread to the ascitic fluid to cause spontaneous bacterial
peritonitis. Most patients with
spontaneous bacterial peritonitis are hospitalized and treated with intravenous antibiotics such as
ampicillin, gentamycin, and one of the newer generation cephalosporin. Patients
usually treated with antibiotics include:
Patients with blood, urine, and/or ascites fluid
cultures that contain bacteria.
Patients without bacteria in their blood, urine, and ascitic
fluid but who have elevated numbers of white blood cells (neutrophils) in
the asciticfluid(>250 neutrophils/cc). Elevated neutrophil numbers in ascitic fluid often means
that there is bacterial infection. Doctors believe that the lack of bacteria
with culturing in some patients with increased neutrophils is due either to a
very small number of bacteria or ineffective culturing techniques.
Spontaneous bacterial peritonitis is a serious infection. It often occurs in patients
with advanced cirrhosis whose immune systems are weak, but with modern
antibiotics and early detection and treatment, the prognosis of recovering from an episode of
spontaneous bacterial peritonitis is good.
In some patients oral antibiotics (such as
Cipro or
Septra) can be prescribed to
prevent spontaneous bacterial peritonitis. Not all patients with cirrhosis and ascites should be treated with
antibiotics to prevent spontaneous bacterial peritonitis, but some patients are at high risk for developing
spontaneous bacterial peritonitis and warrant preventive treatment:
Patients with cirrhosis who are hospitalized for
bleeding varices have a high risk of developing
spontaneous bacterial peritonitis and should be started on antibiotics early
during the hospitalization to prevent spontaneous bacterial peritonitis
Patients with recurring episodes of spontaneous bacterial peritonitis
Patients with low protein levels in the ascitic fluid (Ascitic fluid with low
levels of protein is more likely to become infected.)
Prevention and early detection of liver cancer
Several types of liver disease that cause cirrhosis are
associated with a particularly high incidence of liver cancer, for example,
hepatitis B and C, and it would be useful to screen for liver cancer since early
surgical treatment or transplantation of the liver can cure the patient of
cancer. The difficulty is that the methods available for screening are only
partially effective, identifying at best only 50% of patients at a curable stage
of their cancer.
Despite the partial effectiveness of screening, most patients with cirrhosis,
particularly hepatitis B and C, are screened yearly or every six months with
ultrasound examination of the liver and measurements of cancer-produced proteins
in the blood, e.g. alpha fetoprotein.
Liver transplantation
Cirrhosis is irreversible. Many patients' liver function
will gradually worsen despite treatment and complications of cirrhosis will
increase and become difficult to treat. Therefore, when cirrhosis is far
advanced, liver transplantation often is the only option for treatment. Recent
advances in surgical transplantation and medications to prevent infection and
rejection of the transplanted liver have greatly improved survival after
transplantation. On average, more than 80% of patients who receive transplants
are alive after five years. Not everyone with cirrhosis is a candidate for
transplantation. Furthermore, there is a shortage of livers to transplant, and there usually is a
long (months to years) wait before a liver for transplanting becomes available.
Therefore, measures to retard the progression of liver disease and treat and
prevent complications of cirrhosis are vitally important.
Cirrhosis of The Liver - Symptoms at Onset of DiseaseQuestion: The symptoms of cirrhosis of the liver can vary greatly from patient to patient. What were your symptoms at the onset of your disease?
Gallstones are stones that form when substances in the bile harden. Gallstones (formed in the gallbladder) can be as small as a grain of sand or as large as a golf ball. There can be just one large stone, hundreds of tiny stones, or any combination. The majority of gallstones do not cause symptoms.
Liver cancer is the fifth most common cancer in the world and the majority of patients with liver cancer will die within one year as a result. Patients with associated cirrhosis caused by chronic hepatitis B or C infections, alcohol, and hemochromatosis are at the greatest risk of developing liver cancer. Many patients with liver cancer do not develop symptoms until the advanced stages of the tumor which usually makes prognosis poor. The combination of an imaging study (ultrasound, CT, or MRI scans) and an elevated blood level of alpha-fetoprotein will most effectively diagnose liver cancer, while a liver biopsy can make a definitive diagnosis. Medical treatments, including chemotherapy, chemoembolization, ablation, and proton beam therapy, are not very effective. Surgical removal of the tumor or a liver transplant may be most effective in certain cases.
Liver disease can be cause by a variety of things including infection (hepatitis), diseases such as gallstones, high cholesterol or triglycerides, blood flow obstruction to the liver, and toxins (medications and chemicals). Symptoms of liver disease depends upon the cause; however, common symptoms may include nausea, vomiting, upper right abdominal pain, and jaundice. Treatment depends upon the cause of the liver disease.
Hepatitis C is an inflammation of the liver due to the hepatitis C virus (HCV), which is usually spread by
blood transfusion, hemodialysis, and needle sticks, especially with intravenous
drug abuse. Chronic hepatitis C may be treated with interferon, usually in combination with anti-virals.
Jaundice is a yellowish staining of the skin and whites of the eyes (sclerae) with bilirubin, the pigment found in bile. Jaundice can be an indicator of liver or gallbladder disease, or it may result from the rupture of red blood cells (hemolysis).
Alcoholism is a disease that includes alcohol craving and continued drinking despite repeated alcohol-related problems, such as losing a job or getting into trouble with the law.
Internal bleeding occurs when an artery or vein is damaged and blood to escapes the circulatory system and collects inside the body. Internal bleeding can be caused by a variety of situations such as blunt trauma, deceleration trauma, medications, fractures, and spontaneous bleeding. Treatment of internal bleeding depends on the cause of the bleeding.
The hepatitis B virus is a unique, coated DNA virus belonging to the Hepadnaviridae family of viruses. The course of the virus is determined primarily by the age at which the infection is acquired and the interaction between the virus and the body's immune system. Successful treatment is associated with a reduction in liver injury and fibrosis (scarring), a decreased likelihood of developing cirrhosis and its complications, including liver cancer, and a prolonged survival.
Ascites, the accumulation of fluid in the abdominal cavity is most commonly caused by cirrhosis of the liver. Some of the other causes of ascites include portal hypertension, congestive heart failure, blood clots, and pancreatitis. The most common symptoms include increased abdominal girth and size, abdominal bloating, and abdominal pain. Treatment depends on the cause of ascites.
The spleen enlarges if it is asked to do excessive work in filtering or manufacturing blood cells, if there is abnormal blood flow to it, or if it is invaded with abnormal cells or deposits. Symptoms of an enlarged spleen may include weakness and fatigue, easy bleeding, and poor white blood cell function. Treatment of an enlarged spleen is focused toward the cause of the splenomegaly. Surgery may be required to remove the spleen.
Hyponatremia is a condition where the level of sodium in the blood is low. Causes of hyponatremia can occur from excess fluid in the body, or a loss of sodium in body fluid. Some of the symptoms of hyponatremia include headache, muscle cramps or spasm, seizures, weakness and confusion. Treatment of hyponatremia depends on the cause.
Pleurisy, an inflammation of the lining around the lungs, is associated with sharp chest pain upon breathing in. Cough, chest tenderness, and shortness of breath are other symptoms associated with pleurisy. Pleurisy pain can be managed with pain medication and by external splinting of the chest wall.
Nonalcoholic fatty liver disease (NAFLD) refers to a wide spectrum of liver disease ranging from simple fatty liver (steatosis), to nonalcoholic steatohepatitis (NASH), to cirrhosis (irreversible, advanced scarring of the liver). All of the stages of NAFLD have in common the accumulation of fat (fatty infiltration) in the liver cells (hepatocytes).
Insulin resistance is the diminished ability of cells to respond to the action of insulin in transporting glucose (sugar) from the bloodstream into muscle and other tissues. Causes of insulin can include conditions such as stress, obesity, metabolic syndrome, and steroid use. Some of the risk factors for insulin resistance include fatty liver, heart disease, strokes, peripheral vascular disease, high cholesterol, and smoking. Treatment for insulin resistance are lifestyle changes and if necessary, medication.
Thrombocytopenia refers to a decreased number of platelets in the blood. There are many causes of thrombocytopenia such as decreased platelet production (viral infections for example rubella, mumps, chickenpox, hepatitis C, and HIV); increased platelet destruction or consumption (for example sulfonamide antibiotics, heparin, blood transfusions, and lupus); or increased splenic sequestration (enlarged spleen due to conditions for example liver disease, blood cancers, and more). Treatment of thrombocytopenia depends on the cause.
Cystic fibrosis is a disease of the mucus and sweat glands. Cystic fibrosis is an inherited disease. The outcome of the disease leaves the body malnourished, bulky and fouls smelling stools, vitamin insufficiency, gas, painful or swollen abdomen, infertility, susceptible to heat emergencies, and respiratory failure. There is no cure for cystic fibrosis, treatment of symptoms is used to manage the disease.
Hepatitis is most often viral, due to infection with one of the hepatitis viruses (A, B, C, D, E, F (not confirmed), and G) or another virus (such as those that cause infectious mononucleosis, cytomegalovirus disease). The main nonviral causes of hepatitis are alcohol and drugs. Many patients infected with hepatitis A, B, and C have few or no symptoms of illness. For those who do develop symptoms of viral hepatitis, the most common are flu- like symptoms including: loss of appetite, nausea, vomiting, fever, weakness, tiredness, and aching in the abdomen. Treatment of viral hepatitis is dependant on the type of hepatitis.
Hereditary hemochromatosis (iron overload) is an inherited disorder in which there is excessive accumulation of iron in the body. Individuals may have no symptoms or signs, or they can have severe symptoms and signs of iron overload. The most effective treatment for hemochromatosis is therapeutic phlebotomy.
Encephalopathy means brain disease, damage, or malfunction. Causes of encephalopathy are varied and numerous. The main symptom of encephalopathy is an altered mental state. Other symptoms include lethargy, dementia, seizures, tremors, and coma. Treatment of encephalopathy depends on the type of encephalopathy (anoxia, diabetic, Hashimoto's, hepatic, hyper - hypotensive, infectious, metabolic, infections, uremic, or Wernicke's) are examples of types of encephalopathy.
Pleural effusion is an excess fluid between the two membranes that envelop the lungs. There are two classifications of causes of pleural effusion; transudate and exudate. The treatment of pleural effusion depends on the cause.
The main features of metabolic syndrome include insulin resistance, hypertension (high blood pressure), cholesterol abnormalities, and an increased risk for clotting. Patients are most often overweight or obese. Lifestyle modification such as the Mediterranean diet, exercise, and quitting smoking are the preferred treatment of metabolic syndrome.
Primary Biliary Cirrhosis is a chronic disease characterized by progressive inflammation and destruction of small bile ducts within the liver. The bile ducts transport bile from the liver to the intestine for the absorption of fat and elimination of waste products. The causes of Primary Biliary Cirrhosis may involve autoimmunity, infection, or genetic predisposition, acting alone or in combination. There are many medications and treatment options available for those with this and other associated diseases of Primary Biliary Cirrhosis.
The liver is the largest solid organ in the body, and is actually an gland. The liver has a wide variety of critical functions such as manufacturing proteins and metabolizing fats and carbohydrates. The liver also eliminates harmful biochemical waste products from the body (alcohol, drugs, toxins). The liver secretes bile that aids in digestion. Examples of diseases of the liver include cirrhosis, hepatitis, cancer, and fatty liver. Symptoms of liver disease include bleeding, easy bruising, edema, fatigue, and jaundice.
Coma is the inability to waken or react to the surrounding environment. The Glasgow Coma Scale is frequently used to measure the depth of coma. Causes of coma include trauma, bleeding, edema, lack of oxygen, poisoning, or hypoglycemia. Prognosis for a patient in a coma depends on the cause of the coma.
Male breast cancer accounts for 1% of all breast cancers, and most cases are found in men between the ages of 60 and 70. A man's risk of developing breast cancer is one in 1,000. Signs and symptoms include a firm mass located below the nipple and skin changes around the nipple, including puckering, redness or scaling, retraction and ulceration of the nipple. Treatment depends upon staging and the health of the patient.
Gynecomastia, an enlargement of the gland tissue in the male breast is the caused by an imbalance of hormones. Certain medical conditions may also lead to gynecomastia such as cirrhosis, malnutrition, disorders of the male sex organs, kidney failure, thyroid disorders, and medications. Gynecomastia is generally treated with medication, and if necessary surgery.
Portal hypertension is most commonly caused by cirrhosis, a disease in which results from scarring of a liver injury. Other causes of portal hypertension include blood clots in the portal vein, blockages of the veins that carry the blood from teh liver to the heart, and a parasitic infection called schistosomiasis.
Primary sclerosing cholangitis (PSC) is a chronic, progressive disease of the bile ducts that channel bile from the liver into the intestines. There is an association between primary sclerosing cholangitis and ulcerative colitis and Crohn's disease. Symptoms of primary sclerosing cholangitis include abnormal liver blood tests, itching, fatigue, and jaundice. Primary sclerosing cholangitis is treated with medications and in some cases, liver transplant.
Digestion is the complex process of turning food you eat into the energy you need to survive. The digestive process also involves creating waste to be eliminated, and is made of a series of muscles that coordinate the movement of food.
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