I wanted to mention the standard treatment to prevent variceal bleeding.
All quotes are from the AASLD Practice Guideline for for managing Varices.
'Prevention and Management of Gastroesophageal Varices and Variceal Hemorrhage in Cirrhosis'
8. In patients with medium/large varices that have not bled but have a high risk of hemorrhage (Child B/C or variceal red wale markings on endoscopy),
nonselective -blockers (propranolol or nadolol) or EVL may be recommended for the prevention of ﬁrst variceal hemorrhage (Class I, Level A).
9. In patients with medium/large varices that have not bled and are not at the highest risk of hemorrhage (Child A patients and no red signs), nonselective -blockers (propranolol, nadolol) are preferred and EVL (banding) should be considered in patients with contraindications or intolerance or non-compliance to -blockers (Class I, Level A).
10. If a patient is placed on a nonselective -blocker, it should be adjusted to the maximal tolerated dose; follow-up surveillance EGD is unnecessary. If a patient is treated with EVL, it should be repeated every 1-2 weeks until obliteration with the ﬁrst surveillance EGD performed 1-3 months after
obliteration and then every 6-12 months to check for variceal recurrence (Class I, Level C).
11. Nitrates (either alone or in combination with -blockers), shunt therapy, or sclerotherapy should not be used in the primary prophylaxis of variceal
hemorrhage (Class III, Level A).
What this is saying is that all patients with varices should be taking a beta-blocker to prevent the first bleed. It reduces the portal hypertension that we with scared livers have. Why is this important and basic treatment for all cirrhotics? Because once we bleed the chances of future bleeds goes way up. All pretransplant patients that I know use them. I have been taking Nadolol for 3-4 years now and have no bleeds. It is the only proven way to prevent bleeds other than banding which is the next thing to be done before bleeding. Bleeding from varices is a potentially life-threatening complication of cirrhosis. You can actually lose most of the body's blood during a bleed.
'Patients who survive an episode of acute variceal hemorrhage have a very high risk of rebleeding and death. The median rebleeding rate in untreated individuals is around 60% within 1-2 years of the index hemorrhage, with a
mortality of 33%.'
'Nonselective -blockers have no role in the prevention of the development of esophagogastric varices but are the gold standard in the prevention of ﬁrst variceal hemorrhage in patients with medium/large varices. Endoscopic variceal ligation (banding) has been established as an alternative to nonselective -blockers for the prevention of initial variceal hemorrhage.'
I am glad you are in Memphis where you will be able to see a hepatologist.
Methodist is where Steve Jobs had his liver transplant.
Maybe you can get a referral from your current doctor to have the transplant center do an evaluation so you know what options are available to you.
Methodist University Hospital Transplant Institute
1265 Union Ave.
Memphis, TN 38104
Transplant Outpatient Clinic
A good candidate for a transplant is determined by a full medical evaluation and input from several medical professionals. The transplant team performs this evaluation in the Pre-Clinic. This team is composed of the transplant surgeon, hepatologist/nephrologist, pre-coordinator nurse, financial case manager, and social worker.
The evaluation process begins with a referral from a potential candidate's primary care physician. The candidate then answers a variety of health and lifestyle questions. This information helps the transplant team decide the eligibility of the transplant candidate.
During an initial visit, a transplant candidate will meet with a financial coordinator and a social worker and receive detailed information about the transplant process. For those who are identified as potential candidates, a complete medical evaluation is performed. The medical evaluation is a series of tests dependent upon the specifics of each case. The surgeon reviews the results of this medical examination to further determine eligibility. If the evaluation indicates the candidate is appropriate for transplantation, staff members work with the patient to finalize financial arrangements.
The candidate will receive written confirmation and be listed with the United Network for Organ Sharing (UNOS), a non-profit scientific and educational organization that administers the only national patient waiting list. Once listed with UNOS, patient evaluations must be performed at regular intervals to determine continual eligibility for transplantation. Should an organ become available, it is offered to a patient on the list based on a defined set of criteria established by UNOS.
Local Support Group
Get the support you need with Living Kindly, monthly support group sponsored by Methodist Healthcare. The group is open to caregivers, family members, transplant candidates, donors and those who have had a transplant. You will have access to knowledgeable speakers discussing a variety of subjects, such as medication side effects, living donation, financial concerns, blood donation and maintaining a healthy lifestyle.
Methodist University Hospital Transplant Institute staff is on hand at each meeting to offer support, share their knowledge and answer any questions you might have. More importantly, other transplant donors and recipients are available to share their transplant experiences or provide mutual peer support to you and your family.
Not a joiner? That's okay. You are welcome to attend and listen. Living Kindly is designed to give donors and recipients access to as much information as possible to assist with their transplantation journey.
The group currently meets the second Thursday of each month in Stratton Auditorium, which is located at Methodist University Hospital (1265 Union Avenue). The class starts at 3:30 p.m., with a medication education session beginning at 3 p.m.
Food and beverages are served and parking is free.
I would highly recommend you meet others who are waiting for transplants. It is a good way to learn a lot and you will see that many others are going through what you are going through.
I know you're right about your splenomegaly being responsible for your low platelet count.
I had a liver transplant but the spleen does not return to it's normal size post transplant, so my platelets tend to run on the low side too.
The problem with having very low platelets, in the 20s, is that if you were in an accident you could bleed to death internally. My hepatologist said the problem is not about simply having a cut.
Those of us doing hep C treatment often have low platelets. Unfortunately I know of no way to raise platelet count.
Since it can take the liver quite some time to repair itself from cirrhosis, I'm guessing that as your liver heals, your platelet count will improve.
Somewhat off topic: Do you know how damaged your liver became prior to stopping your drinking ? Did you have a biopsy ? If so when and what were the results ?
Splenomegaly is a common complication of cirrhosis.
Many cirrhotics have platelet counts in the 60,000s.Including myself for at least 2-3 years.
It is not something to worry about. And it doesn't need to be treated. You have plenty of platelets to properly clot your blood. The biggest issue with low platelet counts is that hepatitis C treatment that includes interferon reduces platelet counts even more and may reduce the platelet count to dangerously low levels below 20,000 in cirrhotics.
Platelet transfusions and Promacta (which is currently seeking FDA approval for use during hep C treatment) can raise platelets on a temporary basis and can help hepatitis C patients get through treatment if they have responded to treatment and clear the virus.
Why platelet counts become low in cirrhotics:
Blood flows from the spleen...through the portal vein...then through the liver.
Scar tissue in the liver (cirrhosis) can interfere with that blood flow, causing pressure to build up in the portal vein (portal hypertension), and the spleen to enlarge (splenomegaly).
As the spleen enlarges, it traps platelets. (The amount of platelets in the bloodstream is reduced because the spleen is busy trapping them).
So usually---people with cirrhosis end up having a problem with portal hypertension and an enlarged spleen, and a reduced platelet count in the bloodstream.
As time goes by, the liver may try to repair itself by growing new cells. If there is a lot of scar tissue already present--- the new cells grow between scar tissue (and result in abnormal nodules). The nodules and scar tissue further interfere with blood flow through the liver. So over time people with advanced cirrhosis can end up having a problem with more and more abnormal nodules and scar tissue forming...which interferes even more with blood flow through the liver.....which makes the spleen continue to enlarge....and the platelet count continue to drop.
Thank you very much for your responses! Also welcome to MedHelp's cirrhosis of the liver community!
In the beginning my MELD was calculated to be around 15. Today I am at 9 :) Never biopsied/CT Scan was performed for diagnosis March 2010. I have avoided folic acid although recommended by my doctor to increase cell reproduction. I found early on that this could cause more problems than good under my circumstances such as cancer. I am screened every 6 months.
I have always used vitamin C with rosehips to strengthen the walls of my blood vessels (grade 3 varices) and assist with my platelet count. I am very fortunate to never have needed banding.
I recently was reading that antioxidants can play a key role in helping a low platelet count. Red foods are key. Tomatoes, plums, watermelons, cherries and berries are loaded with vitamins and minerals and have strong anti-oxidant properties which helps to stop platelets from being destroyed.
Avoid all refined and processed foods – sugar, saturated fats, and aerated drinks. Include fresh and organic foods. This will help in stimulating the body’s internal mechanism and increase platelet count.
Am I on the right track here?
Gee, I dunno, but I never had any problem with varicies and I never took vitamin C;
Can't say if it was because of my diet or just luck of the draw.
Of course eating a healthy diet, staying away from processed foods, is always best.
I read beets and artichokes are liver healthy foods. Although I never liked beets I learned to eat them by making them with grated fresh ginger and olive oil.
It makes sense that to help a scarred liver, to avoid processed food and eat as organically as possible.
A doctor told me egg whites and tofu were good for albumin levels.
What I do know is if the cirrhosis is decompensated you should avoid salt and red meat.
Since you have cirrhosis, you should be under the care of a hepatologist at a transplant center. All changes in diet, drugs, vitamins, supplements should be cleared by your hepatologist first as many are toxic to the liver when a person has cirrhosis.
Taking vitamin C can increase iron levels.
Iron and Vitamin C
'Some people with hepatitis C, particularly those with cirrhosis, have above-average levels of iron in their body. Too much iron can damage organs. If these people take multivitamin/mineral pills, they should take the ones without iron. These pills usually are marketed as formulas for men or adults over 50. These people also should avoid taking large doses of vitamin C because vitamin C helps the body absorb iron. You do not want to take iron supplements if you have hepatitis C, unless you are specifically told to take iron by your provider.'
No diet has been shown to increase platelet counts or slow the progress of liver disease.
Platelets are produced in the bone marrow. They normally only live for just 5 to 9 days. So even if your bone marrow produced more platelets they would still be trapped in the larger spleen and destroyed anyway.
As I said previously, platelet counts are not a major issue for people with cirrhosis. If a person's cirrhosis is caused by a factor they can control then they should stop the thing that is injuring the liver. For example alcohol, toxic drug use, hepatitis B & C.
What is important for patients with cirrhosis it to not expose the liver to any toxins or other substances that can injure the liver and cause the liver disease to progress more rapidly.
A CT scan is not diagnostic of the stage of liver disease. A biopsy is the gold standard for diagnosing the grade of inflammation and the stage of fibrosis in the US. Liver biopsies are important for many reasons, such
as accurate diagnosis or ruling out any coexisting liver disease, staging
and grading the severity of liver disease, treatment decisions, patient and
provider reassurance, and as a benchmark for gauging future disease
The METAVIR system was developed by French researchers to score the severity of liver fibrosis associated with HCV
Stage 0 (F0) is indicative of no scar tissue.
Stage 1 (F1) describes mild fibrosis around the portal tracts.
Stage 2 (F2) indicates that the scar tissue is beginning to branch out from the portal tracts, forming a few septa.
Stage 3 (F3) indicates that the branches have extended to the point where the portal tracts begin to bridge, often known as bridging fibrosis, and numerous septa are observed.
Stage 4 (F4) describes the expansion of scar tissue to form thick bands in the liver, also characterized as cirrhosis.
I would suggest you talk to your hepatologist and have them explain want can be done to assess the degree of your liver disease and minimize your future liver damage.
Good luck to you!