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    What causes cirrhosis of liver along with fatigue?

Posted on Fri, 11 Aug 2017 in Digestion and Bowels
Question: My husband has been a heavy drinker for about 3 years. Recently, he visited the doctor and she did some testing thinking that he had cirrhosis or liver cancer. As it turns out, his liver was inflamed with no sign of either cirrhosis or cancer, thankfully. He continued to drink for the next week. This past Thursday, I took him to the ER because he was very weak. They rehydrated him and gave him Ativan because he was willing at that point to detox and get some help. Even though his bilirubin was 18 and to me he looked ill, they sent him home and said he could detox at home and that he really didn't meet admission requirements for detoxing in the hospital. He was doing fairly well at home with the Ativan but was occasionally getting confused and he didn't drink very many fluids because he was very drowsy from the Ativan. The next day he was very confused and profusely sweating and weak so I called an ambulance and in the ER they said they were admitting him because his bilirubin was now at 24 and his lactic acid (which they apparently didn't check the day before) was 15. They said he was very ill but didn't put him in the ICU. They gave him a lot of fluids and said would just treat the detox with Ativan. Friday he mostly slept the rest of the day and wasn't really aware of anything happening. They had to give him only 1 dose of Ativan. Saturday morning he was very groggy and they told me that his labs looked slightly better but they were concerned with some electrolytes. Saturday afternoon he finally became more alert and was able to express the desire to be up, although he was too weak to walk. He was having fairly lucid conversations, just some confusion about a few things. I left him to come home and they had to give him 5 doses of Ativan through the night. He was very groggy again this morning. They said his bilirubin was down to 19 the day before but was now up to 20, either his AST or ALT had been 650 the day before and was now down to around 420 and then the other had been 210 but was now down to 160. Because of his bilirubin level they apparently weren't able to determine his ammonia level, and his lactic acid was down to 4.4 or so. I'm sorry for being so long winded in my explanation, but I am wondering about a couple of things and no one has been able to give a very good answer. One question I have is if his other liver enzymes are going down, shouldn't his bilirubin also be going down instead of going down and then increasing slightly? Also, is it normal for him to be so "snowed"? I know Ativan can cause extreme drowsiness but one nurse says at day 3 of detox being tired out and very sleepy is normal and the other one says he should be more awake but possibly his drowsiness is from his high bilirubin levels and of course, he could have high ammonia levels that they are unable to determine. Tonight, he was slightly confused, but talkative and was even able to eat a few bites of a regular diet. I am wondering how long he will be so out of it during the day (he seems to perk up in the evening so I am wondering if his days and nights are mixed up.) Should this tiredness be getting better the less Ativan he needs and also as his liver function improves?
Answered by Dr. Ramesh Kumar 1 hour later
Brief Answer:
Change your doctor and get him admitted under a gastroenterologist asap .

Detailed Answer:
Thanks for posting query.
Before giving answers to your question let me first give you a briefing about what clicked in my mind after going through your detailed narration.This may help you understand things better.
"Even though his bilirubin was 18"
"his bilirubin was now at 24"-24 bilirubin is a very high value its almost 8 times elevated then normal clinically significant levels.elevation of SGOT and SGPT more then 3 times the upper normal value is clinically significant.His lft is almost 10 times the normal.
"They gave him a l............. just some confusion about a few things."- Hepatic encephalopathy (HE) is the occurrence of confusion, altered level of consciousness, and coma as a result of liver problem. In the advanced stages it is called hepatic coma or coma hepaticum. It may even be fatal if not treated properly.Cirrhosis often has no signs or symptoms until liver damage is extensive. Please specify the tests done by your gastro to see if there is some liver problem or not-"she did some testing thinking that he had cirrhosis or liver cancer"
Please specify the test done.
My suggestion-
Firstly get him admitted under a gastroenterologist.
Go for these lab tests

Kidney function. Your blood is checked for creatinine as kidney function may decline in decompensated liver
Tests for hepatitis B and C. Your blood is checked for the hepatitis viruses.
Clotting. Your international normalized ratio (INR) is checked for your blood's ability to clot.

Non invasive test like
Magnetic resonance elastography should be done . These noninvasive imaging tests detect hardening or stiffening of the liver and may eliminate the need for a liver biopsy.
If requirwed-
Biopsy. A tissue sample (biopsy) is not necessarily needed to diagnose cirrhosis. However, your doctor may use it to identify the severity, extent and cause of liver damage.

Apart from ativan he should be given lactulose. In liver disease lactulose works by reducing the absorption of ammonia from the gut. The liver normally breaks down ammonia, but in liver disease such as cirrhosis the blood may bypass the liver, allowing this poisonous substance to pass to the brain.

Now lets come to your questions dear attendant-

1)Liver function tests consists of liver enzymes and bilirubin
While other liver enzymes like sgot and sgpt are produced exclusively in liver their levels depends on liver condition.For eg if liver is inflammed its membrane would become more permeable hence level of these enzymes increases.As the inflammation settles down the permeability decreases and enzyme level decreases.
Bilirubin is not produced by liver.Bilirubin is a yellow compound that occurs in the normal catabolic pathway that breaks down heme.Heme is a part of hemoglobin.Bilirubin is formed by the breakdown of red blood cells in the body. The liver helps to excrete it. The levels of bilirubin in the blood can indicate the health of the liver.So metabolism of bilirubin is totally different from other liver tests. So its not necessary that if liver enzymes are decreasing bilirubin would also decrease.

For snowing i had given you all details of possibile hepatic encephalopathy(possibly his ammonia levels are quiet high causing drowsiness).

Take home message-
Change doctor
Get him admitted under a Gastroenterologist. He needs proper investigation and treatment.
I don't think giving ativan in high doses is a good idea.
Even ativan is hepatotoxic.

Hope i answered your query well.
Feel free to follow up.
Above answer was peer-reviewed by : Dr. Kampana
Follow up: Dr. Ramesh Kumar 6 hours later
They have done CT scan and ultrasound which showed liver inflammation and nothing else. His labs relating to his kidneys were slightly off but improving. As far as the lactulose, even not knowing his ammonia level can they give that to him? What if it's not high? They have told me ativan can affect the liver but said that's what they use for alcohol detox symptoms in patients in withdrawals with liver issues because there really isn't anything better. Also I believe they are or have tested for hepatitis a,b,c. As I know it was mentioned at one point.
Answered by Dr. Ramesh Kumar 14 hours later
Brief Answer:
Follow up.

Detailed Answer:
Hello dear,
If CT scan and ultrasound are normal then it can't be liver problem.I don't think there is any role of lactulose in treatment.
What i feel is that all issues like drowsiness letharge etc are due to high doses of ativan.
Lactulose is a very safe drug(laxative).So it's often used in patients with constipation safely without any problem.

As scans are normal i don't think that you need to worry right now.
Wait and watch should be the best policy as of now.

Above answer was peer-reviewed by : Dr. Remy Koshy
Follow up: Dr. Ramesh Kumar 1 hour later
They have diagnosed him with alcoholic hepatitis as the liver is inflamed. They started him on lactulose and rifaximin and there has been a slight improvement already in alertness level. He is also on meropenem because lactic acid increased a little and they think he has an infection. Repeat ultrasound and cat scan show inflammation and gallbladder looked OK.
Answered by Dr. Ramesh Kumar 12 hours later
Brief Answer:
follow up.

Detailed Answer:
This is a perfect approach to treat alcoholic liver disease.
To keep him away from alcohol is necessary at any cost.
Except that everything else is ok.
Above answer was peer-reviewed by : Dr. Prasad
Follow up: Dr. Ramesh Kumar 3 hours later
How long does it reasonably take for the encephalopathy to clear up using those drugs? They say he's at least grade 2and possibly 3.
Answered by Dr. Ramesh Kumar 6 hours later
Brief Answer:
follow up.

Detailed Answer:
Hi again,
Initially treatment should be given for 21 days and levels of enzymes should be re evaluated after that.
It may take almost 3 months for enzymes to return to normal.

Above answer was peer-reviewed by : Dr. Remy Koshy
Answered by
Dr. Ramesh Kumar


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