Vaccines and protecting yourself from infection
People with liver disease are more vulnerable to infections, and if they do get an illness, are more likely to become severely ill. As a result, it is really important to keep up-to-date with vaccinations. As with medications, it is important to make the doctor or nurse aware of your liver condition and tell them if there have been any changes in your condition, before having treatment.
- Flu: visit your GP for a flu jab every autumn.
- Pneumococcal infection: get a jab to protect against this major cause of chest infection, when you are diagnosed with liver disease and then every 10 years.
- Hepatitis A and B: these infections are much more serious in people who already have another liver disease, so visit your GP for the full course and the booster when due.
- If you are travelling abroad it is important to make sure your vaccinations are up-to-date. If you are immunosuppressed, for example due to taking steroids for autoimmune hepatitis or following a liver transplant, you should avoid ‘live’ vaccines such as MMR, TB, yellow fever and oral typhoid vaccine. In these circumstances it is important that family members do not receive live vaccines either. Your doctor can advise on how best to protect yourself.
There are also a number of fairly simple precautions you can take to avoid infection.
- Avoid close contact with adults and children carrying infections – from the common cold to chicken pox.
- Avoid inhaling dust particles or smoke.
- Keep good standards of hygiene – for example, washing your hands after going to the toilet or changing a baby’s nappy.
- Brush your teeth after every meal and floss daily.
- Visit the dentist every 6 months.
- Keep toenails and fingernails clean and trimmed.
- Thoroughly clean all cuts and grazes before applying a clean, dry dressing or plaster, and keep an eye on them to make sure they are healing.
- Do not clean out the cat litter or bird cages, or go near animal excrement, without gloves.
- For women, use only small tampons, change frequently and do not use overnight.
Managing fatigue and sleepiness
Many people with advanced liver disease feel very tired and have low energy levels. This can be due to your medical condition, external stresses or a combination of the two. Fatigue affects people differently and can come and go. One day you may feel able to live normally and the next you may have difficulty getting the energy and strength to do even the smallest tasks.
Planning your day and the week ahead is very important if you experience fatigue.
- Plan in time to rest during the day.
- Think about which things are the highest priorities for you and your family, and make sure these get done first.
- Be realistic about what you can do and don’t try to do too much.
- Ask for help, not just from your family, but think about which tasks a friend or neighbour might be able to do for you.
- Explain to people that you need to be flexible, so that you can leave early from a party or social engagement.
Some people also experience sleepiness, and can even fall asleep when talking. This can be due to fatigue, but it can also be a symptom of hepatic encephalopathy, which can be more serious. If you experience this sleepiness, talk to your doctor about it. They may prescribe medication such as lactulose, and you may be able to adjust the dose yourself until you get the best effects. You may also need to be admitted to hospital.
Some people experience sleep problems. This can mean that you need to sleep during the day, or perhaps that you have difficulty sleeping through the night. Plan your day to suit your body’s needs, taking naps during the day if you need to.
There are many sources of help if you are suffering from fatigue or sleepiness. There may be a hospital social worker who can direct you on to help or you can contact your local authority’s social services department. They can organise things like meals on wheels, home help, childcare or transport. You may have to pay for some of these services.
Is it ok to drive?
If you experience sleepiness, confusion or severe fatigue, it is important to think about whether some activities put yourself or others at risk. For example, it may not be safe to drive, operate machinery or do other things where you are exerting yourself or carrying responsibility for others.
Eating a good, balanced diet is one of the most important things you can do to keep yourself well. Regular meals containing protein (such as meat, fish or beans), starch (such as bread, potatoes or rice) and vitamins (in fruit and vegetables) are the best approach. It is particularly important to make sure you are getting enough protein in several meals throughout the day.
Many people with advanced liver disease find that they have a small appetite or cannot manage normal sized meals. This can be a problem if you are unable to take in all the nutrients your body needs.
- Try smaller, more frequent meals and snacks.
- Include protein in these, such as a boiled egg, cheese or beans on toast, or fish fingers.
- You may also benefit from being prescribed a supplement or a special food drink.
- Talk to your medical team and ask to be referred to a dietician.
Some people with advanced liver disease are advised to follow a low-salt diet. This can be very important in managing the impact of liver failure and preventing serious complications.
- Some salty foods have to be avoided altogether, such as crisps, cured meat (like bacon and ham) and cheese.
- Many foods contain ‘hidden’ salt, such as bread, biscuits, sauces and cereals. Check the labels of any bought food so you can see how much salt, often called sodium, they contain.
- Avoid using salt in cooking – microwave or steam vegetables to retain flavour.
- It is also helpful to get the advice of a dietician who can offer tips and meal plans tailored around your food preferences.
Alcohol and smoking
Alcohol is processed by your liver, and as a result, it can be dangerous for anyone with liver problems. Check with your doctor whether it is safe for you to drink any alcohol, and if so, how much.
It is important to be honest with your doctor about how much alcohol you drink. This will help them give you the right advice and care for your liver problem.
If you are, or have ever been, alcohol dependent or an alcoholic, discuss this with your doctor. In these circumstances it is important to get medical help to give up drinking, as stopping suddenly can, in some cases, lead to severe withdrawal symptoms, including hallucinations and seizures. There are many sources of support and help they can give you or direct you to.
Smoking is dangerous to everyone’s health. People with liver disease are more vulnerable to infection and to poor health overall, so smoking or exposure to passive smoking is not advisable. There is good evidence that it has a particularly damaging effect on people with hepatitis C, speeding up liver damage. If you smoke, speak to your doctor about what help is available with cutting down and giving up.
Illegal drugs such as cannabis, ecstasy and cocaine are all broken down by the liver. These can be particularly dangerous in people with liver disease and should be avoided completely. As with alcohol, if you have become dependent on a drug it is important to discuss this with your doctor and get medical help with withdrawal.
Having liver disease is not just a physical problem. It can place a huge burden on your body and mind.
- The physical tiredness and sleep problems that go with many liver diseases make it even harder to cope with the emotional burden.
- Many people with advanced liver disease find themselves feeling more emotional than normal.
- Fatigue can make people seem impatient and demanding.
- It can also make people withdraw from socialising and relationships, as they can be too much effort.
- Liver disease often fluctuates, meaning that one day you could feel well and the next be severely ill or too tired or sleepy to do anything. This makes it hard to predict and plan your life.
- Uncertainty is a big feature of liver disease. Waiting for a liver transplant is a particular strain, as people are left worrying and anxious on the transplant list. People on treatment for hepatitis C are not given certainty about whether the treatment will clear the virus.
All of this can leave patients and their families frustrated and anxious and place additional emotional strain on life. Try to explain to those close to you how you feel so they can help you plan your day and your week, and be sympathetic if plans need to change. Talking about your worries and how you feel can not only make them seem less, but allows your family to feel involved and can help to relieve their own anxieties.
"The people close to you are affected by your illness too. They can become sidelined if you leave them out of your day to day worries and concerns.” Phil, Hants.
Side effects of treatment
Some medications, particularly those for treatment of hepatitis C, can have side effects which affect people emotionally. Some people experience headaches, fatigue, depression, anxiety, sleep disturbance and poor concentration. There is some comfort in knowing that these side-effects are not unusual and it is ‘not just me’. It is also important to remember that treatment is for a limited time and many symptoms subside after the first month or so.
However, for some people, these side-effects are too severe or too dangerous to put up with. It is important to talk to your doctor about side-effects and how they are affecting you. Don’t just stop taking the medicines. It may be that the doctor can give you another medicine or prescribe something to help with the side-effects such as anti-depressants.
You may find it helpful to use a journal to record how you are feeling each day. This can act as a reminder of things to discuss with your doctor and can also show patterns in symptoms which it may be possible to address.
Advanced liver disease can also reduce your sex drive (as can some of the medications used to treat it) and make it difficult to have sex. This is a sensitive area but one you and your partner should not be afraid to discuss with your doctor. Counselling, for you and your partner on the impact of liver disease on your relationship, may be helpful.
Serious illness can bring people closer and hugging or cuddling can be very comforting, especially if you don’t feel up to talking.
Hepatic Encephalopathy (HE)
Many people with advanced liver disease have some degree of Hepatic Encephalopathy. This may be so subtle that only someone close to you can tell that it is affecting you. It can affect you in a huge range of ways.
Mild symptoms can include:
- being slightly sleepy
- disturbed sleep patterns – sleepy during the day but awake at night
- having difficulty concentrating or remembering things
- seeming a bit less ‘with it’ and alert
- slightly lower performance in word games or calculations
- less clear or shaky writing
- perhaps a bit teary or more emotional than usual.
More advanced symptoms can include:
- a tremor that prevents you holding a drink without spilling it
- personality changes
- staggering or falling.
For example you may find yourself getting very irritable or even unkind with your close family. It is important for you and them to recognise that this is a symptom of encephalopathy, rather than a real change in the affection between you.
“The thing that upset me most was when my partner developed encephalopathy and I didn’t realise. If I had known about encephalopathy and its effect on personality I could have coped far better.” Lynda, Surrey.
Problems such as HE can be a sign of worsening liver function so it is important to discuss this with your doctor as soon as possible.
It is important to get both medical help and other sources of help for these symptoms and emotional issues. This can include help from mental health professionals, counsellors, social workers and social care staff which your medical team or GP practice will be able to direct you to, as well as from friends, family and organisations listed in the ‘Who else can help?’ section.
Sharing your concerns
Attitudes to liver disease can make people even with only mild, or no symptoms, withdraw from friends and family, and make it hard to talk about how it affects you. This is one reason that support groups for people affected by liver disease can be a great comfort; you can meet and discuss how you feel with people going through the same experience. Support groups provide an opportunity to share tips and thoughts with sympathetic people in a safe environment. The Trust can provide information on support groups in your area.
It is also worthwhile thinking of other sources of support, including those in your local community. Some people find great comfort from the hospital chaplaincy service or from other types of religion.