LIVER CIRRHOSIS

PATIENT INFORMATION
BOOKLET
(BRING THIS BOOK TO EVERY APPOINTMENT)

DEPARTMENT OF GASTROENTEROLOGY & HEPATOLOGY

TEL: (02) 9463 2450 FAX: (02) 9463 2041
ANZ/XIF5/0515/0067
 DEPARTMENT OF GASTROENTEROLOGY & HEPATOLOGY

TABLE OF CONTENTS
Welcome Page 3

What is liver cirrhosis? Page 4

Why is cirrhosis a problem? Page 5

What are the symptoms of cirrhosis? Page 6

Some signs and symptoms of decompensation Page 7

Managing your cirrhosis Page 10

Nutrition and liver cirrhosis Page 12

Resource list Page 14

Examples of high protein and high energy foods Page 15

Nutritional supplements Page 15

Meet the team Page 16

Appointment diary Page 16

Clinical progress table Page 18

Liver cancer (HCC) screening Page 19

Gastroscopy bookings Page 21

Vaccinations Page 22

Bone density (DEXA) scans Page 22

Medications Page 23

Page 1
 WELCOME!
Welcome to the Royal North Shore Hospital Liver Clinic

We are an experienced and trusted multidisciplinary team dedicated to managing patients

with Liver Cirrhosis and Advanced Liver Disease.

However, you as the patient can help US to help YOU. You can make a huge difference
to your health by attending your appointments and scans, maintaining a healthy weight,
eating right and taking all of your prescribed medications.

If you have any questions, please feel free to contact us on 9463 2450

Page 3
WHAT IS LIVER CIRRHOSIS?
Liver cirrhosis simply means scarring of the liver. Scarring of the liver is a concern as it
causes healthy liver cells to die and be replaced by stiff scar tissue. This process happens
slowly and is often irreversible and may lead to the whole liver hardening and becoming
scarred and shrunken.

There are many causes of liver cirrhosis. The most common causes are chronic hepatitis B
and C infections as well as long term heavy alcohol consumption. It may also be caused by
fat build-up in the liver. This is seen in people who are overweight or who have diabetes.

There are other less common causes of cirrhosis such as autoimmune hepatitis (where the
body’s immune system attacks the liver) as well as certain medications and environmental
chemicals.

Page 4
WHY IS CIRRHOSIS A PROBLEM?
A liver with cirrhosis becomes very
hardened and lumpy with scar tissue.
This makes it very hard for blood to flow
through the liver. This causes a build-up or
pressure on one side of the liver causing
the pressure to increase inside the veins
that are attached to the liver.

Imagine a hose full of water that has been

kinked at one end. This causes the water
to build up and flow back toward the tap.

One of the veins affected is called the

portal vein, which is responsible for bringing blood to the liver. When the pressure in this
vein is increased it is called portal hypertension.

This then causes a backflow of blood (like the kinked up hose) up into the spleen. The
size of the spleen then increases causing it to destroy platelets (a type of blood cell)
which affect how well your blood clots.

Besides causing problems with blood flow, the scar tissue also limits how well the liver
can do its job.

The liver’s main role is to filter and remove toxins, produce bile to break down nutrients,
control blood clotting and produce important proteins.

When the liver cannot carry out these vital roles it causes many of the toxins to escape
into the body causing confusion and trouble concentrating.

Page 5
WHAT ARE THE SYMPTOMS OF CIRRHOSIS?
There are two different stages of cirrhosis – compensated and decompensated.

Compensated cirrhosis often has little or no symptoms. This is because there are still
enough healthy cells in the liver to do its job. At this point the liver can ‘compensate’ or
make up for the previous damage.

However, if the liver continues to be damaged (from untreated hepatitis, poor diet or
alcohol use) the healthy liver cells will become stressed and no longer function well.

Symptoms you may feel include;

* Fatigue * Poor Appetite * Weight loss

When the healthy liver cells become too overwhelmed you may progress from
compensated to decompensated cirrhosis.

Decompensated cirrhosis is very serious. People with decompensated cirrhosis notice a

rapid decline in their health and will experience signs and symptoms of liver failure.

Page 6
 SOME SIGNS AND SYMPTOMS OF DECOMPENSATION
1. Variceal Bleeding

Because of increased pressure in the veins, some of the larger blood vessels in your
oesophagus (swallowing tube) become swollen and enlarged.

This can put you at risk of the vessels bursting open – these are called bleeding varices.

WHEN THIS HAPPENS IT IS AN EMERGENCY. IF YOU VOMIT BLOOD OR NOTICE

YOUR STOOLS BECOMING BLACK AND TARRY YOU MUST GO TO YOUR NEAREST
EMERGENCY ROOM IMMEDIATELY.

Liver with
Oesophagus cirrhosis

Oesophageal varices

Portal vein

Stomach

Oesophageal varices Bleeding varices

Page 7
2. Encephalopathy ( Mental Confusion )

When you have cirrhosis your liver is unable to filter toxins out of your body. When
this happens toxins such as ammonia can enter the brain and cause confusion. This
is called encephalopathy (en-cef-a-lop-a-thy).

Early stages of encephalopathy affect your sleep patterns. You may notice that you
have trouble sleeping at night and feel very sleepy during the day.

You or your loved ones may also notice changes to your mood and concentration. All
of these symptoms may be early stages of encephalopathy and need to be mentioned
at your next appointment.

You may be prescribed medications to prevent encephalopathy occurring.

It is important that if prescribed you take this medication regularly in order to prevent
you getting encephalopathy.

ENCEPHALOPATHY CAN BE VERY SERIOUS.

IF YOU OR YOUR LOVED ONES NOTICE THAT YOU ARE CONFUSED OR VERY SLEEPY
YOU SHOULD GO IMMEDIATELY TO THE HOSPITAL EMERGENCY ROOM.

Page 8
3. Ascites

High pressure in the veins that is caused by cirrhosis

can also cause a build-up of fluid in the stomach.
This is called ascites (uh-sigh-teez ).

The belly becomes very large and you will notice a

sudden increase in weight.

You will probably feel quite uncomfortable and

eating will become difficult as you will always feel
full.

You may also find that breathing becomes difficult,

especially when you lie down.

ASCITES CAN BE LIFE-THREATENING IF YOU GET AN INFECTION IN THE FLUID.

IF YOU SUDDENLY EXPERIENCE STOMACH PAINS OR GET A FEVER YOU NEED TO
GO TO THE HOSPITAL EMERGENCY ROOM IMMEDIATELY.

4. Jaundice

Jaundice is yellowing of the skin and whites of the eyes that is caused by a build-up
of bilirubin. Bilirubin is a substance that is normally filtered by the healthy liver.

If you notice jaundice for the first time, it could be a sign that your liver may be
getting worse or a sign of an infection. See your doctor immediately if this happens.

Page 9
MANAGING YOUR CIRRHOSIS
Although there is no cure for cirrhosis, there are many things we do to monitor how well
your liver is coping with having cirrhosis.

Liver Cancer Screening

When you have cirrhosis you are at a higher risk of having liver cancer. Liver cancer is
very serious and for this reason we will send you for an ultrasound of your liver and a
blood test every 6 months to monitor this.

It is very important that you have the tests and attend these appointments so we can
detect liver cancer as early as possible (when they are still small) as treating liver cancer
when it is found early can increase the chance of cure and survival.

Ascitic Fluid Drainage

If your ascites becomes too uncomfortable or large you may need to have the fluid
drained. This is called a paracentesis or ascitic tap. Your doctor or nurse will explain the
procedure further if it is required.

Blood Tests

Before your appointments in the clinic

you will need to have blood tests done
so that we can monitor how well your
liver is working. It is important that
you have these blood tests done as
close to your appointment as possible.

Page 10
Get Vaccinated (Immunised)

People with cirrhosis are more prone to getting infections like the flu and pneumonia.
We recommend you have regular vaccinations to reduce the chance of you getting these
infections.

The flu-vax is performed annually and the pneumovax is performed every 5 years by
your GP.

We also advise people with cirrhosis to have the hepatitis A and hepatitis B
immunisations to protect the liver from developing these diseases, as getting these
infections may put further strain on the liver (liver failure).

Maintain Healthy Bones

People with liver cirrhosis have a tendency to having thinning of the bones (osteopenia
or osteoporosis). If bone thinning develops, you may have a higher chance of having
fractures (broken bones). A healthy diet (with calcium containing foods) and vitamin
supplements may be recommended to prevent this happening.

It is important for you to have a scan of your bones (DEXA scan) every 2 years so we can
monitor for thinning of the bones.

Surgery

CAUTION IF YOU EVER NEED ANY KIND OF SURGERY.

YOU SHOULD LET YOUR SURGEON KNOW THAT YOU HAVE LIVER CIRRHOSIS AND
LET YOUR LIVER DOCTOR KNOW IF YOU ARE PLANNED FOR ANY SURGERY. THIS
IS BECAUSE SOME KINDS OF SURGERY CAN PUT A STRAIN ON YOUR LIVER AND
PUT YOU INTO LIVER FAILURE.

WE WILL NEED TO PLAN ANY SURGERY WITH YOU AND YOUR SURGEON TO
MAKE SURE ANY SURGERY PERFORMED IS DONE AS SAFELY AS POSSIBLE.

Page 11
NUTRITION AND LIVER CIRRHOSIS
As part of your regular clinic visits to manage your cirrhosis, your doctor or nurse may
suggest that you make an appointment to see the clinic dietitian.

When you have cirrhosis, the liver may have a reduced ability to store glycogen (the
stored version of glucose) which provides the body with energy. This causes the body to
use your fat and muscle stores for energy instead.

This leads to unhealthy weight loss and muscle wasting which can be very serious for
your health.

To prevent this, the dietitian will thoroughly assess your dietary requirements and help
you to formulate an eating plan that focuses on a high energy, high protein diet to
maintain muscle and to keep the body working normally.

Why is nutrition important in liver cirrhosis?

Good nutrition is very important to
support your liver’s function when
you have liver cirrhosis. Nutritional
deficiencies, weight loss and muscle
wasting are common in liver cirrhosis,
and can be managed with the right diet.
Not everyone with liver cirrhosis will
need to follow the same diet, therefore
it is important to see a dietitian at your
liver clinic who can provide dietary
information specific to your condition.

Do I need to follow a special diet?

In the early stages of liver cirrhosis, there is often no need for a specialised diet. Good
nutrition can support your liver function and overall health. You should follow a healthy
and well balanced diet and maintain a healthy weight. Your diet should contain lots of
variety from all food groups including breads and cereals, fruits and vegetables, lean
meats (and alternatives like lentils and legumes), and dairy (and alternatives like soy).
Each food group provides your body with essential nutrients so it is important that you do
not remove any of these food groups from your diet. All meals & snacks should contain a
lean source of protein. It is recommended to have a snack just before bed.
Page 12
Advanced Liver Disease
If your liver cirrhosis is more advanced your dietitian will recommend a more specialised
diet. It is common to experience symptoms such as a poor appetite, nausea, reduced
energy levels or fluid retention in the legs (oedema) or abdomen (ascites). These
symptoms often make it difficult to eat as much food (particularly protein) as your body
needs. A poor diet, as well as poor liver function, can cause malnutrition and muscle
wasting (particularly in your arms and around your shoulders, chest and back). If you have
advanced liver disease it is very important that you speak to your doctor and dietitian
about your diet. They may recommend a high protein, low salt (sodium) diet.
High Protein Diet
• 
If you have been advised to follow a high protein diet, foods that you should eat
more of include: meat, poultry, seafood, eggs, milk, yoghurt, cheese, nuts, seeds,
lentils, legumes and soy products. Your doctor or dietitian may also recommend
special protein supplement drinks.
Low Salt Diet
• 
If you have been advised to follow a low salt (low sodium) diet you should not add
salt to foods in cooking or at the table, and you should avoid high salt processed
foods, takeaway foods and condiments.
Fluid Restriction
• 
You may be asked to restrict your daily fluid intake. Your doctor will advise you if this
is needed and how much fluid to take each day.
Most people with advanced liver disease find that eating several small meals a day helps,
especially if your appetite is poor. It is recommended that you eat six to eight small
meals per day, and have a snack containing protein and carbohydrate before you go to
bed. It is important not to go longer than 7-8 hours without eating.

Page 13
How can I see a dietitian?

Your doctor or liver nurse can refer you to see a dietitian. In your first appointment with a
dietitian, they will conduct a nutritional assessment which involves:

• Taking measurements of your weight, height, body mass index (BMI). They may
sometimes measure your hand grip strength and the size of your muscles in your
upper arms.

• Asking about your clinical symptoms which may

be impacting on how much you can eat and drink.

• Assessing the foods and drinks you are having,

specific to the needs of your liver and any other
medical conditions that you have.

The dietitian will then provide you with practical

recommendations about your diet and nutrition to
help support your liver function and overall health.
Your dietary needs may change over time, so your dietitian will follow up with you to
make sure you are always eating the best diet for your liver.

RESOURCE LIST
Patient information sheets are available for free download at the website of
Gastreonterological Society of Australia:

http://www.gesa.org.au/resources/patient-information/

High protein, high energy diet:

http://membes.gesa.org.au/membes/files/Consumer%20Information/High%20Protein%20
High%20Energy.pdf

No added salt diet:

http://membes.gesa.org.au/membes/files/Consumer%20Information/No%20Added%20
Salt.pdf

Dietitian Name:

Phone:

Page 14
EXAMPLES OF HIGH PROTEIN AND
HIGH ENERGY FOODS
HIGH PROTEIN HIGH ENERGY
Meat Potato and sweet potato
Chicken Bread and bread products
Fish Cakes
Cheese Biscuits
Eggs Corn
Legumes like lentils, baked beans and Pasta, rice and noodles
chickpeas
Nuts and seeds Butter, margarine and oil
Tofu Cream
Yoghurt, milk and soymilk Mayonnaise
Milk powder, custard Breakfast cereals
Spreads like honey, jam, golden syrup
*If you have been advised to take a low salt diet, please consult your dietician as some of these foods may be high in salt.

NUTRITIONAL SUPPLEMENTS
Supplement Frequency Script Date

Page 15
MEET THE TEAM
Dr Brett Jones, Hepatologist Dr Venessa Pattullo, Hepatologist

Dr Paul O’Farrell, Gastroenterologist Dr Neomal Sandanayake, Gastroenterologist

Dr Gordon Park, Gastroenterologist Dr Philip Chang, Hepatologist

Jocelyn Schramko, Clinical Nurse Consultant

Ms Elsa Chu, Clinical Nurse Specialist
9463 2455

APPOINTMENT DIARY
Date Time Appointment type Location Referral
needed
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Page 16
APPOINTMENT DIARY (CONTINUED)
Date Time Appointment type Location Referral
needed
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Page 17
CLINICAL PROGRESS TABLE
Date Weight MELD CPC

Page 18
LIVER CANCER (HCC) SCREENING (6 monthly ultrasound and AFP)
Date Next Due

AFP

Ultrasound

AFP

Ultrasound

AFP

Ultrasound

AFP

Ultrasound

AFP

Ultrasound

AFP

Ultrasound

AFP

Ultrasound

AFP

Ultrasound

Page 19
LIVER CANCER (HCC) SCREENING (6 monthly ultrasound and AFP)
Date Next Due

AFP

Ultrasound

AFP

Ultrasound

AFP

Ultrasound

AFP

Ultrasound

AFP

Ultrasound

AFP

Ultrasound

AFP

Ultrasound

AFP

Ultrasound

Page 20
GASTROSCOPY BOOKINGS
Date Result

Page 21
VACCINATIONS: Influenza (yearly); Pneumococcal (5 yearly)
Vaccination Date Vaccination Date
Hepatitis A Hepatitis A
Hepatitis B Hepatitis B
Influenza Influenza
Pneumococcal Pneumococcal
Influenza Influenza
Influenza Influenza
Influenza Influenza
Influenza Influenza
Influenza Influenza
Pneumococcal Pneumococcal
Influenza Influenza
Influenza Influenza
Influenza Influenza
Influenza Influenza

BONE DENSITY (DEXA) SCANS: (every 2 years)

DEXA Scan Date Result Next Due Date

Page 22
MEDICATIONS
There are many different medications that
you may be prescribed by the doctors at the
liver clinic. It is very important that they are
taken exactly as prescribed. Some of the
common medications that you may need
are listed below.

Medications to prevent encephalopathy

(confusion)

• Lactulose: lactulose is a liquid laxative medication. It works by absorbing the toxins

in your body and passes them out with a bowel motion. It can increase the amount of
times you open your bowels each day and in general we would aim for you to have
2-3 soft bowel motions per day. Although this may be inconvenient it is extremely
important that you continue with this medication. Please feel free to speak to the
clinic nurses if you are having problems with taking lactulose (eg too many bowel
motions, diarrhoea) as your dose may need to be adjusted.

• Rifaximin: rifaximin is a type of antibiotic that can reduce the amount of chemicals in
the bowel and bloodstream that contribute to encephalopathy.

Medications to reduce fluid accumulation (ascites and/or ankle swelling)

• Diuretics: spironolactone (Aldactone) and frusemide (Lasix) are two medications that
can help to get off some excess fluid which is passed out in the urine. Your doctor will
need to monitor your kidney function (by blood tests) if you take these medications and
adjust the dose of the medications if they are putting too much strain on your kidneys.

Medications to prevent variceal bleeding

• Propranolol (Inderal): propranolol is a blood pressure lowering medication which can
reduce the chance of having varices bleeding. If you start this medication, your blood
pressure and heart rate will be monitored. If you feel light headed when starting this
medication, let your doctor know as your dose may need to be adjusted.

Supplements
• Vitamin D and calcium: your doctor may prescribe these if you are low in vitamin D.
These supplements, in addition to eating a healthy diet, will help strengthen your
bones and reduce your chance of having broken bones (fractures).

Page 23
 LIVER CIRRHOSIS MAY AFFECT HOW YOUR BODY HANDLES OTHER
MEDICATIONS. IF YOU ARE PRESCRIBED NEW MEDICATIONS BY
YOUR GP OR OTHER DOCTORS, IT IS IMPORTANT FOR YOU TO LET
YOUR OTHER DOCTORS KNOW THAT YOU HAVE LIVER CIRRHOSIS.
SOME MEDICATIONS MAY NOT BE SUITABLE FOR YOU, OR MAY NEED TO HAVE A
LOWER DOSE BECAUSE OF YOUR LIVER CIRRHOSIS.

ALSO LET YOUR LIVER DOCTOR KNOW IF OTHER DOCTORS HAVE PRESCRIBED
NEW MEDICATIONS. YOU SHOULD BRING THE NEW MEDICATIONS ALONG TO YOUR
LIVER SPECIALIST APPOINTMENT AND UPDATE THE MEDICATION LIST IN THIS
BOOKLET.

MANY COMPLEMENTARY AND HERBAL TREATMENTS CAN CAUSE LIVER DAMAGE

AND MAY NEED TO BE STOPPED. YOUR DOCTOR WILL ADVISE YOU.

MEDICATION LIST
MEDICATION Dose (mg) Frequency

Page 24
MEDICATION Dose (mg) Frequency

Page 25
 MEDICATION Dose (mg) Frequency

PLEASE NOTE:
1. Some medications are affected by liver cirrhosis. Please consult your doctor
before starting any new medications.
2. Avoid any complementary or herbal medications.
3. Report any drug side effects as soon as possible.

Page 26
NOTES

Page 27
NOTES

Page 28
NOTES
RNSH Outpatient Liver Clinic

Gastro / Liver Department

Ph: (02) 9463 2450
Fax: (02) 9463 2041
Email: [email protected]

Ambulatory Care Centre

Level 3 Acute Services Building, RNSH
St Leonards NSW 2065
Ph: 02 9463 1400
To make an appointment fax or email.
Fax 02 9463 1065
Email: [email protected]

FOR URGENT REFERRALS OR ADVICE, CONTACT CNC Jocelyn Schramko (Mon‐Fri)

Phone: 94632455
Email: [email protected]
Original booklet development: Carlie Stephens CNC Hepatology - Liver Clinic, St George Hospital, UNSW