End-Stage Liver Disease and Palliative Care

End-Stage Liver Disease (ESLD)

• ESLD is a term used to describe advanced liver disease, liver failure, and decompensated cirrhosis.
• ESLD develops after an inflammation of the liver, leading to fibrosis (scarring) and loss of regular liver function.
• The only cure for ESLD is liver transplantation, but many patients may not receive a transplant due to wait times or other health issues.

Symptoms of ESLD

• Common physical symptoms include:
  • Abdominal pain
  • Fatigue
  • Confusion
  • Pruritis (itchiness)
  • Jaundice – a yellowing of the skin and eyes due to the buildup of bile
  • Muscle cramps
  • Edema (swelling) in the legs
  • Dyspnea - shortness of breath
  • Nausea and vomiting
  • Constipation
  • Diarrhea
  • Malnutrition

Complications of ESLD

• Complications of ESLD are related to portal hypertension or increased difficulty of blood flow through the liver.
• Specific complications include:
  • Ascites - swelling of the abdomen due to fluid buildup
  • Spontaneous bacterial peritonitis - infection of the fluid from ascites
  • Esophageal and gastric varices - blood flow through the liver is impaired, resulting in blood flow being rerouted around the liver into small veins in the passageway between the throat, stomach, and abdomen.
  • Hepatic encephalopathy (HE) - deterioration of brain function, which can cause:
    • Trouble sleeping at night
    • Difficulty thinking clearly
    • Disorientation
    • Poor concentration or shortened attention span
    • Mild to severe confusion
    • Forgetfulness
    • Shortened attention span
    • Poor judgement
    • Personality or mood changes
    • Slow reaction time
    • Anxiety
    • Depression
    • Worsening of handwriting or fine motor movements
    • Unusual movements (shaking of hands or arms)
    • Slurred speech
    • Slowed movement
    • Decreased alertness and responsiveness
  • Hepatorenal syndrome (HRS) - impaired kidney function
  • Coagulopathy – prolonged bleeding
  • Spontaneous bruising
  • Bleeding inside the stomach or intestine
  • Bloating

Managing Symptoms of ESLD

• Pain management:
  • Medications may be used
  • Alternative methods include acupuncture and mindfulness
• Ascites management:
  • Low-salt diet and oral diuretics (medication to help remove fluids from the body)
  • More invasive options may be considered if treatments begin to lose effect
• Hepatic encephalopathy management:
  • Laxatives and antibiotics are used to help preserve brain function
• Itchiness management:
  • Medication called cholestyramine is used to help with itchiness
• Malnutrition management:
  • Ensuring sufficient calorie intake, especially protein, and vitamin replacement is recommended

Life Expectancy with ESLD

• Life expectancy is hard to predict due to many factors, including the degree of liver disease or complications and the presence of other diseases.
• Certain symptoms are associated with worsening disease and shorter life expectancy, such as:
  • Ascites that does not respond to treatment
  • Kidney failure
  • Bleeding from the gastrointestinal tract
• The Model for End-Stage Liver Disease (MELD) score is used to predict long-term outcomes for ESLD and prioritize patients waiting for a liver transplant.

Advance Care Planning (ACP)

• ACP is a process of thinking about and sharing wishes for future health and personal care.
• It can help prepare everyone when a person becomes ill and unable to communicate.
• Palliative care programs are available to support individuals with ESLD.

Definition and Stages

• End-stage liver disease (ESLD) is a condition where the liver can no longer perform its essential functions, leading to multi-organ failure.
• ESLD is the final stage of liver disease, often resulting from chronic liver damage or cirrhosis.
• The stages of liver disease progression are: inflammation and fibrosis, cirrhosis, decompensated cirrhosis, and end-stage liver disease (ESLD).

Pathophysiological Changes

• Hepatocellular dysfunction reduces liver cell mass and function, impairing detoxification, protein synthesis, and metabolism.
• Portal hypertension increases blood pressure in the portal vein, causing splenomegaly, esophageal varices, and ascites.
• Splanchnic vasodilation decreases vascular resistance in the splanchnic circulation, leading to increased blood flow and portal hypertension.
• Systemic vasoconstriction increases vascular resistance in the systemic circulation, leading to decreased cardiac output and peripheral hypoperfusion.

Complications

• Ascites involves the accumulation of fluid in the peritoneal cavity, leading to abdominal distension and discomfort.
• Spontaneous bacterial peritonitis (SBP) is an infection of ascitic fluid, leading to sepsis and mortality.
• Hepatorenal syndrome (HRS) is a functional renal failure due to splanchnic vasodilation and decreased cardiac output.
• Hepatic encephalopathy (HE) is a neurological dysfunction due to impaired ammonia detoxification and increased inflammation.

Gut-Liver Axis

• Dysbiosis alters the gut microbiome, leading to increased toxins and inflammation.
• Increased intestinal permeability leads to leakage of toxins and bacteria from the gut into the bloodstream, exacerbating liver damage.
• Cytokine imbalance increases pro-inflammatory cytokines and decreases anti-inflammatory cytokines, leading to further liver damage.

Consequences

• Mortality rates increase with ESLD disease progression.
• ESLD significantly impairs quality of life, with symptoms including fatigue, jaundice, and abdominal pain.
• Liver transplantation is the only curative treatment option for ESLD, but is limited by organ availability and surgical risks.

Learn about End-Stage Liver Disease (ESLD), its causes, symptoms, and treatment options, including liver transplantation and palliative care.