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HCV Advocate Newsletter

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October 2009 HCV Advocate

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In This Issue:

Unlocking Interferon
Alan Franciscus, Editor-in-Chief

Top 10 Post Counseling Messages
Alan Franciscus, Editor-in-Chief
Heather Lusk, Hepatitis C Coordinator
Hawai`i Department of Health

HealthWise: Swine Flu
Lucinda Porter, RN

Treating Hepatitis C in Prison
Liz Highleyman

Symptoms and Complications of Cirrhosis
Alan Franciscus, Editor-in-Chief




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Unlocking Interferon
—Alan Franciscus, Editor-in-Chief

Two separate news stories released in September are shedding some light on a little known single nucleotide polymorphism (SNP) that is believed to affect both patients who naturally clear HCV as well as those who will not respond to pegylated interferon plus ribavirin therapy.  

In the first news report from Johns Hopkins Medicine, researchers analyzed DNA at the IL28B gene of 1008 patients—388 patients who were able to naturally clear HCV after an acute infection and 620 patients who were not able to naturally clear the virus.  Of the 388 patients who were able to naturally resolve HCV infection, 264 patients carried a C/C variation near the IL28B gene.  When the researchers looked at the gene variation by race the results were very interesting: In Asians, 738 out of 824 samples carried the variation; in Europeans 520 out of 761 carried the variation and in Africans only 148 out of 428 carried the variation.  Although the news report didn’t reference the implications of the gene and HCV treatment response rates, it is interesting that, when you look at current treatment response rates by race, the variation somewhat mirrors the general response rates by race. 

In another news story, Nature Genetics on-line reported on two studies that looked at the effect of IL28B on predicting treatment response with pegylated interferon alpha-a plus ribavirin.  The first study, the Australian genome-wide association study (GWAS), evaluated blood samples from 293 genotype 1 HCV patients—131 who responded to pegylated interferon plus ribavirin treatment  and 162 who did not.  The authors found that a single nucleotide polymorphism (SNP) on chromosome 19 between IL28A and IL28B was the only SNP that was significantly associated with treatment non-response at the genome-wide level.

A separate study by the Japanese genome-wide association identified the same SNP among 154 HCV genotype 1 Japanese patients—72 responders, 82 non-responders.  To replicate the results they conducted another study of 174 Japanese genotype 1 patients—122 responders and 52 non-responders and confirmed the earlier results.   The authors noted that in 85% of patients who did not respond to treatment, an SNP at IL28B was detected.  

The author speculated that a combination of different types of interferons such as alpha and lambda may be more effective in treating hepatitis C than using just a single type of interferon. 


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Top 10 Post Counseling Messages
—Alan Franciscus, Editor-in-Chief
Heather Lusk, Hepatitis C Coordinator

Hawai`i Department of Health

When someone is diagnosed with hepatitis C there are many messages we can give to advise the newly diagnosed person during this difficult period.  The person can be counseled about HCV transmission and prevention, but the key is to talk with the person and offer messages that alleviate some of the fear and offer hope.   Our list for the top ten post counseling messages include (not in any particular order): 

  • HCV Antibody Positive:  If only an HCV antibody test was performed remind the person that they will need to have an HCV RNA viral load performed to find out whether the HCV infection is resolved or if they are currently infected with HCV.
     
  • Don’t panic:  For the vast majority of people diagnosed with HCV, liver disease progression is slow and if there is serious disease progression it usually takes many years. 
         
  • Liver Monitoring:  See a medical provider on a regular basis for health monitoring.
         
  • Vaccinate against HAV & HBV:  If people have never been infected with or vaccinated against hepatitis A or hepatitis B they should begin the vaccination series as soon as they can to prevent getting another hepatitis virus on top of an already compromised liver. 
         
  • Lifestyle Changes:  There are many things that people can do to help them stay healthy, such as eating a healthy and nutritious diet, avoiding or cutting back on alcohol, cigarette smoking or any substances that could potentially harm the liver.  Don’t forget to drink plenty of water. 
         
  • Debunk Myths:  There are many myths about hepatitis C.  One common myth is that hepatitis C is a death sentence, and we know that for most people this is not the case. 
         
  • Avoid Mega Doses of Vitamins:  Mega doses of vitamins especially Vitamin A and D should be avoided because they can damage the liver. Tell your doctor about any herbs or vitamins you are taking.
         
  • Avoid Raw/Undercooked Shellfish:  People with any liver disease should avoid raw or undercooked shellfish because of the potential of severe HAV and Vibrio vulnificus infections.
         
  • HCV Transmission/Prevention:  Talk about the ways that HCV is transmitted and how to prevent transmission, such as not sharing razors or anything that may have blood on it.  Also bring in messages about how HCV is not transmitted.
         
  • Join a Support Group:  One of the best ways to find out about hepatitis C and get much needed support is to join an HCV support group in person or online.  Support group members have been in the same “place” and can help other members deal with the many aspects of being newly diagnosed.  

We would like to learn from our audience about what they were told or what they tell others that helped after a diagnosis of hepatitis C.  Please email your comments to alanfranciscus@hcvadvocate.org

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Healthwise: Swine Flu
Lucinda K. Porter, RN

Take the flu seriously.  In 1918-19, over 50 million people died worldwide from Spanish flu.  This exceeded the number of deaths during the 14th century’s bubonic plague.  According to the Centers for Disease Control and Prevention (CDC), 5-20% of the U.S. population gets the flu.  Annually, more than 200,000 people are hospitalized from flu complications and roughly 36,000 people die from flu-related causes.

Earlier this year, a new strain made the headlines. H1N1, or swine flu.  Most cases of flu occur in the winter.  H1N1 virus is unusual because it appeared in April of this year and it is going strong.  It is estimated that 90,000 people in the U.S. will die from H1N1.  That is 8 times more than those who will succumb to hepatitis C-related deaths.

What is the flu and, specifically, what is swine flu? Let’s start with what is not the flu—the common cold.  Although also caused by viruses, cold symptoms are less intense than flu symptoms.   People with colds are likely to have a runny or stuffy nose and rarely have serious complications.

Influenza is caused by various viruses, most commonly influenza virus A and influenza virus B.  Symptoms include fever, chills, body aches, sore throat, extreme fatigue, headache, perhaps a cough and respiratory symptoms.  Unlike the common cold, the flu may turn into severe problems such as pneumonia, bacterial infections, or hospitalization.

Those at high risk for major flu complications are older adults, young children, and people with certain health conditions.  Is hepatitis C considered a high risk condition for flu-related complications? Probably.  Liver disorders are included on the CDC’s list of certain health conditions that may mean higher risk for flu-related complications.  Your medical provider will advise you of your risk.  If you are undergoing treatment for hepatitis C, theoretically your immune system is increased by interferon.  However, your medical provider may advise H1N1 immunization. 

Unfortunately, flu shots are not 100% guaranteed, particularly for those 65 and over.  The aging immune system is not as strong and simply may not make enough antibodies to resist illness.  However, two things are certain:

  • Flu shots really help. 
  • It is a myth that the vaccine causes the flu. 

You cannot get H1N1 from eating pork.  H1N1 is spread person-to-person and is highly contagious.  This is usually via coughing or sneezing, but it can be spread by direct contact with the virus residing on surfaces or people.  Those with H1N1 are most infectious a day before they have symptoms until about 5 to 7 days after.  The general rule is if you do get the flu, stay home for at least 24 hours after your fever has passed without fever-reducing medications.  However, if you are coughing or sneezing, you may still be contagious, so take care to avoid spreading germs.

The H1N1 vaccine is based on the same basic formula that has been used in vaccines for many years, so it isn’t really new.  A myth that is circulating is that the swine flu vaccine causes a paralyzing condition known as Guillain-Barré Syndrome.  This myth is based on the 1976 swine flu vaccine that contained squalene.  The Guillain-Barré risk was 1 in 100,000.  To date, none of the H1N1 formulations contain squalene.  Those with egg allergies should talk to their medical provider about alternatives, such as FluMist or antivirals. 

The regular flu vaccine offers no protection against H1N1 and vice versa.  The H1N1 vaccine is slated to be available mid-October.  Due to delays and shortages, the CDC recommends vaccination for high risk individuals first.  These are:

  • Pregnant women
  • Household contacts and caregivers for children younger than 6 months
  • Healthcare and emergency medical services personnel
  • All people from 6 months through 24 years of age
  • Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza, particularly liver, kidney, blood, respiratory, heart disorders, diabetes, or cancer.  Those with neurological or neuromuscular disorders are at risk.  Anyone with a weakened immune system is especially at risk.  

An interesting feature about H1N1 is that only about 1% of those infected are over the age of 55.  One theory is that some older adults may be immune because of previous exposure to a similar strain in 1957.   However, if they do contract it, older adults are at risk for complications.  At least 45 people over age 65 have died from H1N1. 

In addition to vaccination, prevention is key.  If you don’t get H1N1, you can’t spread it.  If you do get it, you must take care to contain it.  Here are the CDC’s prevention suggestions:

  • Cover your nose and mouth with a tissue when you cough or sneeze.  Throw the tissue in the trash after you use it.  If you don’t have tissue, cough into your elbow. 
  • Wash your hands often with soap and water, especially after you cough or sneeze.  Alcohol-based hand cleaners are also effective.  
  • Avoid touching your eyes, nose or mouth.  Germs spread this way.  
  • Try to avoid close contact with sick people. 
  • Follow public health advice regarding school closures, avoiding crowds and other social distancing measures.

The symptoms of H1N1 flu are about like any other flu—fever of 100 degrees F or higher, cough, sore throat, runny or stuffy nose, body aches, lack of energy, poor appetite, headache, chills and fatigue.  Diarrhea and vomiting have been reported.  Serious complications may occur with H1N1, including death.  Seek emergency care if you or someone you care for has the following warning signs:

In children:

  • Fast breathing or trouble breathing
  • Bluish or gray skin color
  • Not drinking enough fluids
  • Severe or persistent vomiting
  • Not waking up or not interacting
  • Being so irritable that the child does not want to be held
  • Flu-like symptoms improve but then return with fever and worse cough

In adults:

  • Difficulty breathing or shortness of breath
  • Pain or pressure in the chest or abdomen
  • Sudden dizziness
  • Confusion
  • Severe or persistent vomiting
  • Flu-like symptoms improve but then return with fever and worse cough

If you do get the flu, stay home for at least 24 hours after your fever has passed without fever-reducing medications.  Stay away from others as much as possible except if you need medical care.  If you think you have any type of influenza, call your medical provider and see if they want to see you or advise you over the phone.  If your medical provider wants to see you, the office will likely provide a face mask. 

Treatment for H1N1 includes taking care of the symptoms.   Use acetaminophen (Tylenol®) as directed for fever, headache and body aches.  Drink plenty of liquids and get lots of rest. 

Prescription antiviral medications may reduce the intensity of H1N1.  Oseltamivir (trade name Tamiflu) and zanamivir (Relenza) are most effective if taken within 2 days of getting the flu.  However, unless you are in a high-risk group, your medical provider might not prescribe these medications. 

Information about H1N1 is updated daily.  To stay current, check out the resources provided at the end of this article.  Be sure your immunizations are up to date, including a regular flu shot.  Stay healthy by exercising, eating right and getting sufficient sleep.  The more you do for yourself today; the better off you will be tomorrow.

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Treating Hepatitis C in Prison
Liz Highleyman

Hepatitis C is much more common among people in jails and prisons compared to the population as a whole, and it is estimated that about one-third of people with HCV in the U.S.  – approximately 1.5 million – pass through the correctional system each year.

In recent years an increase in the number of prisoners with advanced HCV-related liver disease and growing public health awareness about the need for treatment has collided with ever-rising healthcare costs and, now, a stubborn recession eating away at correctional system budgets.

How Common Is It?
The high prevalence of hepatitis C in prisons is largely attributable to the fact that sharing drug use equipment is an efficient means of transmission, and a substantial proportion of prisoners are incarcerated for drug-related offenses. 

Epidemiological studies have observed prison HCV infection rates in various areas the U.S.  ranging from about 10% to more than 50% (averaging around 30%-40%), compared with approximately 2% for the general population.  A recent California study found about half of women and 40% of men entering state prisons had hepatitis C, while a survey of shorter-term jail inmates in Chicago, Detroit, and San Francisco found an infection rate of 13%.

Many individuals enter prison already HCV-infected, but a significant number acquire the virus behind bars.  In addition to injection drug use – which occurs despite strict rules and the challenges of obtaining drugs and needles – inmates may contract HCV through non-sterile tattooing or exposure to blood during fights.

Furthermore, increasing evidence indicates that sexual transmission of HCV is more common than previously believed, especially when it involves “rough sex,” exposure to blood, or concurrent infection of HIV or other sexually transmitted diseases.  Coerced unprotected anal sex would presumably be particularly risky.

Advocates and public health experts have urged prisons to adopt harm reduction strategies such as condoms, clean needles, and methadone maintenance.  The World Health Organization recommends that prisoners should have access to condoms and bleach for cleaning injection equipment, and several countries and some U.S.  states have implemented various harm reduction measures.  But officials in most jurisdictions oppose this approach, arguing that it condones prohibited behavior. 

Whom to Treat, and When?
The Centers for Disease Control and Prevention (CDC) recommends that all incoming inmates should be screened for HCV, and those who test positive should be evaluated for treatment.  But these guidelines are not mandatory, and states have widely varying polices.  Some jurisdictions do not offer routine antibody screening, fearing that testing would obligate them to provide treatment. 

Incarcerated people may not receive appropriate hepatitis C treatment for a variety of reasons, potentially turning a limited term of incarceration into a death sentence.  Cost is the most commonly cited factor.  A year of treatment with pegylated interferon plus ribavirin costs around $25,000.  Jails holding short-term inmates have an incentive to withhold treatment so the expense becomes someone else’s problem.  Longer-term institutions may delay therapy so long that prisoners are eventually released or become too sick to benefit. 

Many clinicians have traditionally been unwilling to offer hepatitis C treatment to people with conditions assumed to predict poor adherence or response, including ongoing drug use.  Some feel similarly about giving interferon to people with pre-existing depression or other psychiatric conditions. 

While incarceration often leads to “enforced abstinence,” and most prisons offer 12-step programs, many inmates manage to continue using drugs behind bars.  Older guidelines recommended that patients should be abstinent from drugs or alcohol for at least six months before starting hepatitis C treatment.  According to current National Institutes of Health and AASLD guidelines, however, active drug users and those receiving maintenance therapy such as methadone should not automatically be denied treatment. 

Treatment for chronic hepatitis C is indicated when people begin to experience liver disease progression.  But a majority of people with chronic hepatitis C never go on to develop advanced disease, and therefore may not need therapy.  The challenge is determining in advance who falls within which group in a prison setting.

Many prisoners who were infected with HCV years or decades ago are now reaching the later stages of disease, with rising rates of advanced fibrosis, cirrhosis, hepatocellular carcinoma (HCC), and end-stage liver failure.  Recent analyses of inmates of the Texas Department of Criminal Justice, for example, found that 54 people per 100,000 had HCC and 131 per 100,000 had end-stage liver disease. 

In a presentation to the NCCHC (National Commission on Correctional Health Care), hepatologist Bennet Cecil estimated that about 20% of prisoners with hepatitis C have advanced liver disease, so about 6% of all prisoners – 20% of the one-third believed to be HCV-infected – are potentially eligible for treatment.

Liver disease progression is best determined by liver biopsy; a significant proportion of patients experience disease progression despite persistently normal liver enzyme (ALT and AST) levels.  As with HCV antibody screening, prison jurisdictions vary in their policies regarding biopsies – which are themselves expensive – and treatment.  Liver transplantation is even more restricted due to its extremely high cost, the shortage of donor livers, and the associated political controversy.

The Federal Bureau of Prisons recommends treatment according to AASLD criteria, but states set their own policies.  Some offer treatment as seldom as they can get away with, leading to several legal challenges based on the premise that withholding standard-of-care therapy violates the Eighth  Amendment prohibition against cruel and unusual punishment.

Treatment Effectiveness
A growing body of evidence shows that people in correctional settings and former inmates can be successfully treated for hepatitis C, though sustained response rates tend to be lower than those observed in clinical trials.

In the October 1, 2008 issue of Clinical Infectious Diseases, D.  Maru and colleagues reported findings from a study of inmates at Connecticut Department of Correction facilities treated with pegylated interferon plus ribavirin during 2000-2006.  Sustained virological response (SVR) rates were 43% for patients with HCV genotype 1 and 59% for those with genotypes 2 or 3.  This compares with overall average response rates of about 50% for genotype 1 and 70%-80% for genotypes 2 or 3 for the hepatitis C population as a whole.

More recently, K. Chew and colleagues reported in the August 2009 Journal of Clinical Gastroenterology that inmates at Rhode Island Department of Corrections facilities treated with the same regimen had somewhat lower SVR rates, 18% for genotype 1 and 50%-60% for genotypes 2 and 3. 

Hepatitis C treatment in correctional settings presents numerous challenges.  A disproportionate number of prisoners are black, and a large body of research shows that people of African descent respond less well to interferon-based therapy.  But surprisingly, the Connecticut and Rhode Island studies did not see differences in sustained response rates between black and white patients.

Many prison inmates with hepatitis C are coinfected with HIV, which both accelerates liver disease progression and impairs response to treatment.  Side effects of interferon-based therapy can be difficult under the best of circumstances, but dealing with depression, fatigue, and malaise can be even harder given the hardships of life on the inside.  Furthermore, frequent transfers between facilities and release before treatment is completed can lead to interruption of therapy and treatment failure.

On the other hand, incarceration also offers some unique opportunities.  As noted, an estimated one-third of people with hepatitis C pass through correctional facilities annually, many of whom belong to underserved populations and might not otherwise have access to HCV screening and treatment. 

Treatment in prison allows for directly observed therapy, frequent monitoring of early response and drug tolerance, and counseling and support around adherence and side effects management.  It is critical, however, to provide pre-release planning to ensure continuation of care in the community.

Both treated inmates and those who do not need treatment can receive education about how to prevent HCV transmission (including using condoms and not sharing needles) and encouraging liver-healthy habits such as limiting alcohol consumption and maintaining a healthy weight.  In addition, those who are not already immune should be offered hepatitis A and B vaccination.

It should also be emphasized that successful treatment does not protect against future infection, and there is no vaccine for hepatitis C.  A study reported at the Interscience Conference on Antimicrobial Agents and Chemotherapy in September found that 22% of current or former prisoners in Vancouver who achieved sustained response to interferon-based therapy became re-infected with HCV.  Re-infection was mostly attributable to injection drug use (76%), though 15% had other known risk factors including tattooing, piercing, sexual activity, or direct contact with blood during a fight.

Changing Policies
While there is ample research indicating that many inmates need hepatitis C treatment and interferon-based therapy can be successful in prison settings, evidence is not always enough to encourage greater access to appropriate care. 

Many states are unwilling to shoulder the cost of treatment, and some that once provided relatively good care have scaled back in the wake of the ongoing budget crisis.  In California, in fact, the budget deficit is so severe that the state is releasing prisoners early.

But deferring treatment can be “penny wise and pound foolish.” Treatment at earlier disease stages can prevent more serious consequences requiring much more expensive management later on. 

As reported in the November 2008 issue of Hepatology, a mathematical modeling study by J.  Tan and colleagues showed that without using biopsies to determine disease stage, treating all HCV-infected inmates with pegylated interferon plus ribavirin would be cost-saving for all ages and genotypes.  This strategy, however, would expose many people who do not need therapy to unnecessary side effects.  If pretreatment biopsies were performed, treatment was still cost-saving for prisoners of all ages and genotypes found to have advanced fibrosis or cirrhosis.

Some studies suggest that interferon-based therapy may help slow liver disease progression even if it does not produce a sustained virological response.  Furthermore, inmates who are treated and cured will not go on to transmit HCV to others, either in prison or in the community after release.  Given these benefits – and the humanitarian imperative to provide good care for people in government custody – advocates and legislators are working to expand access to hepatitis C education and treatment.

In the future, new treatment options may help turn the tide.  Directly-targeted oral agents may be better tolerated, produce higher response rates, and be effective with a shorter course of therapy, tipping the balance toward prompt, presumptive treatment.

Selected References:
Chew, K. et al.  Treatment Outcomes with Pegylated Interferon and Ribavirin for Male Prisoners With Chronic Hepatitis C.  Journal of Clinical Gastroenterology 43(7): 686-691.  August 2009.

Farley, J. et al.  Treatment of HCV infection in intravenous drug users in inmates of correctional institutions, Canada: four year follow up − significant likelihood of reinfection.  49th Interscience Conference on Antimicrobial Agents and Chemotherapy.  San Francisco.  September 12-15, 2009.  Abstract H-219.

Hennessey, K. et al.  Prevalence of infection with hepatitis B and C viruses and co-infection with HIV in three jails: a case for viral hepatitis prevention in jails in the United States.  Journal of Urban Health 86(1): 93-105.  January 2009.

Maru, D. et al.  Clinical outcomes of hepatitis C treatment in a prison setting: feasibility and effectiveness for challenging treatment populations.  Clinical Infectious Diseases 47(7): 952-961.  October 1, 2008.

Tan, J. et al.  Treating hepatitis C in the prison population is cost-saving.  Hepatology 48(5): 1387-1395.  November 2008.


 

 








 

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Symptoms and Complications of Cirrhosis
—Alan Franciscus, Editor-in-Chief

After many years of infection with hepatitis C the liver can become severely scarred.  The process starts with inflammation which can lead to light scarring—fibrosis.  Over time (usually many years) the liver can become extensively scarred—this is called cirrhosis.  Cirrhosis is classified into two types—compensated and decompensated. 

Compensated cirrhosis is defined as a liver that is heavily scarred but can still perform most of the  important chemical functions that keep the body running smoothly.  In fact, people may not even know that the liver is damaged because many people will have only a few or non-specific symptoms.  For this reason, it is important for everyone with hepatitis C to be monitored on a regular basis.  The need for constant monitoring is even more important once someone develops cirrhosis since HCV disease progression and complications of cirrhosis speed up or accelerate.   

Many people mistakenly believe that once someone develops cirrhosis it is an automatic death sentence.  This is not necessarily the case.  People with compensated cirrhosis can live for a long time, and it is the ideal time to make healthy lifestyle changes and seek treatment with HCV medications that will hopefully stop, slow down or even reverse some of the damage that hepatitis C has caused.    

Decompensated cirrhosis means that the liver is severely scarred and damaged.  At this stage HCV treatment is not usually recommended because treatment with interferon can quicken or accelerate the disease progression process—sometimes very quickly.   Having said this, people with decompensated cirrhosis are the most in need of immediate HCV medical treatment.   Treatment with HCV medications in people with decompensated cirrhosis is most successful when it is conducted in a liver transplant center where patients can be regularly monitored to watch out for and prevent accelerated HCV disease progression.   Although the studies have only included a small number of patients, several have yielded surprisingly successful outcomes.

The symptoms of decompensated cirrhosis can be serious and have life-threatening consequences, but many of them can be successfully managed.  The most common conditions and symptoms include (in alphabetical order):

Ascites & Edema
A complication of portal hypertension is the accumulation of fluid in the abdominal cavity, called ascites.  Albumin is the substance that is made by the liver and helps to maintain blood volume.  The formation of ascites is a two-pronged breakdown—first, the liver does not produce enough albumin; second, blood is not able to pass through the liver because of the scarring and the body tries to compensate by equalizing the pressure by reducing the volume of blood.  During this process plasma leaks out of vessel walls into the abdominal cavity.  Another complication is when there is excess fluid in tissue – called edema.  This usually affects the lower extremities. 

Ascites is treated by reducing the amount of sodium (salt) in the body through diet and medications called diuretics (spironolactone and fursemide).  If sodium reduction and the use of diuretics doesn’t work, a large-volume paracentesis (LVP) is performed that removes the fluid from the abdominal cavity through a catheter inserted into the abdominal cavity.  At the same time albumin is given intravenously to help normalize blood volume and to help stop the ‘leakage’ of fluid into the abdominal cavity.  In addition, a procedure called TIPS (see bleeding Varices)  is used to increase the flow of blood through the liver which will help to maintain normal blood volume. 

Bleeding Varices
Another complication of portal hypertension is that the blood that normally flows through the liver is forced into smaller veins (especially those veins in the esophagus and stomach).  The veins will become stretched and, due to the increased pressure produced by portal hypertension, these veins can rupture causing hemorrhage.  Since the liver is not producing enough proteins to help blood clot, people can have massive bleeding episodes. 

Treatment of bleeding varices consists of using beta-blockers (propranolol or nadolol), esophageal variceal band ligation (banding the veins that will or have ruptured) along with various medications that will prevent infection and decrease the blood flow in the portal vein.  A combination approach of using band ligation and beta-blockers has been shown to work better than using just one type of treatment.  Another procedure used – transjugular intrahepatic portosystemic shunts or TIPS – are placed between the portal vein and the hepatic vein in the liver to increase the flow of blood through the liver to reduce the degree of complications caused by portal hypertension. 

Bruising and Bleeding
The liver manufactures proteins that help blood to clot.  When the production of these proteins is reduced or stopped easy bruising and bleeding can occur.  One example would be frequent nose bleeds.  There are currently no medications approved to help produce the proteins that help the blood to clot, but there are some drugs in the pipeline that look promising. 

Gynecomastia
Another possible complication of liver disease is enlarged breasts in men, also called gynecomastia.  In addition to liver disease causing gynecomastia certain medications, alcohol, street drugs, other health conditions, malnutrition and certain herbal products can also cause it.  It occurs in people with cirrhosis because the liver is unable to effectively regulate testosterone (male hormone) and estrogen (female hormone).   A common misconception is that only males produce testosterone and females produce estrogen, but both males and females produce both hormones.  The job of the liver is to regulate the hormones based on a person’s gender.  Gynecomastia is  sometimes confused with fatty breast tissue (false gynecomastia), but is not the same condition.  The symptoms of gynecomastia include swollen or enlarged breast tissue and tenderness.   Men may also lose chest hair and testicles may shrink. 

Hepatic Encephalopathy
One of the most important functions of the liver is to filter out or remove toxins such as ammonia.  If the liver is badly damaged these toxins accumulate in the blood stream and travel to the brain, which can lead to encephalopathy.  The symptoms of encephalopathy include changes in sleep patterns (reversal of sleep cycle—insomnia at night and daytime sleepiness), difficulty concentrating and loss of memory.  A person may become confused and disorientated.   Severe symptoms include changes in personality, coma, swelling of the brain and possibly death.  

Treatment of encephalopathy consists of the use of disaccharides such as lactulose, and antibiotics such as neomycin and rifaximin to flush out the ammonia from the body.  Rifaximin recently entered into phase III studies for the treatment of hepatic encephalopathy.  In people with minimal hepatic encephalopathy yogurt that contains live bacteria has also been found to help. 

Infections
When cirrhosis develops the liver’s ability to produce immune factors is impaired.  At this point a person should be monitored very carefully, and medications should be used to help prevent common infections from getting severe. 

Itching (Pruritis)
When the skin itches it is called pruritus.  It can be caused by many factors including medications, allergies, dry skin, etc.  Excessive itching in someone with decompensated cirrhosis may indicate that bile excretion from the liver is blocked and that bile salts are being deposited in the skin.

Jaundice
In the late stages of decompensated cirrhosis the liver is unable to process the by-product of old red blood cells, called bilirubin.  Instead of the bilirubin being excreted into the bile and eliminated from the body via feces, it will accumulate in the blood.  The symptoms of jaundice include yellowing of the skin, whites of the eyes and bodily fluids. 

Kidneys
When the liver is damaged it can also affect other organs like the kidneys.  The term used for this is hepatorenal syndrome or HRS.  HRS is a life-threatening condition caused when a failing liver affects the flow of blood into the kidneys.  Treatment of HRS is usually a combination of intravenous albumin (stabilizes blood volume) and drugs to stabilize pressure within arteries and veins. 

Liver cancer
Liver cancer, or hepatocellular carcinoma, can develop in someone with severe fibrosis or cirrhosis.    Treatment of liver cancer can involve chemotherapy, resection (to remove the tumor) and, if the cancer hasn’t spread beyond the liver, liver transplant.

Menstrual Irregularities
Women may experience changes in their menstrual cycles because the liver isn’t able to regulate the balance between testosterone and estrogen hormones. 

Nail changes
The appearance of nails (finger, toe) may change—the nails may be more curved and the appearance may be more white than pink.

Portal hypertension
Portal hypertension occurs when the liver is so scarred and damaged that blood which normally flows into and out of the liver is restricted.  The blood is blocked from entering the liver and it can back up causing a form of high blood pressure in one of the main veins of the liver called the portal vein.   Portal hypertension can lead a variety of complications many of which are listed in this article.

Please see bleeding varices for a description of the various treatment approaches that also pertain to the treatment of portal hypertension.

Spider angioma (Nevi )
Spider nevi are commonly found on the face, neck, upper trunk and arms.  The majority of cases are seen in people with liver disease, but they can also occur in women who are taking hormones.   In people with liver disease, spider nevi are caused by the inability of the liver to process or detoxify estrogen, which leads to high levels of estrogen in the blood.  Spider nevi appear as a red dot with veins radiating from the central spot (like a spider). 

Sepsis
Sepsis refers to a bacterial infection in the blood or body tissues that can be caused by the inability of the liver to fight off a severe bacterial infection.  Severe sepsis is life-threatening. 

Malnutrition
When nutrient rich blood from the intestines is blocked from entering the liver malnutrition can occur.  Symptoms of malnutrition include fatigue, dizziness, weight loss and impaired immune response.  Treatment of malnutrition typically involves the replacement of the missing nutrients and treatment of the symptoms as required. 

Signs and Warnings of Decompensated Cirrhosis
If you have loved ones or clients that have some of these symptoms they should seek medical care as soon as possible.

  • Jaundice—yellowing of the skins and white of the eyes
  • Easy bruising or excessive bleeding episodes (especially frequent nose bleeds)
  • Ascites – you can actually hear the ascetic fluid if a person moves from side to side.  Legs and feet will also be swollen from edema
  • Mental problems—inability to concentrate, loss of intelligence, sleepiness, changes in behavior, violent episodes
  • Flapping—when hands are bent at the wrist, the hands will flap
  • Severe itching (pruritis)
  • Severe weight loss



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