Question: 66yoF with end stage cirrhosis. Has hx of esophageal varices with banding from 12/2010--no further varices and EGD in July, 2016 showed original varices scarred over and no new varices. Pt. contracted Hep C in 1970's and has gone through anti-viral tx 3 yrs ago with success--still no detectable virus. Pt. has portal hypertension on Propranolol, she takes Coumadin for SMV thrombosis, takes Lexapro, Prilosec BID, Lasix and Spironolactone for edema both lower extremities--pitting edema most of the time. Pt. dx with pleural effusion, HE on Xifaxan BID and she takes Ultram PRN pain--stated to her husband several weeks ago that she was taking too many pain pills. Last lab work showed a MELD of 16 but that is with her taking Coumadin. Her hepatologist calculated MELD without the INR and came up with a score of 11. Bilirubin--3.2, Alb-3.1, Hgb--10.2; Hct--32.7, Plt-42,000, Serum Protein-5.6. Pt has clubbing, palmar erythema, muscle wasting, appears malnourished and sleeps 16-18 hrs daily. She has said for months that she is getting better and will live to be "an old lady". She saw her hepatologist last week and he told her she was NOT going to get better and that she should not drive but it hasn't stopped her. Pt moves extremely slowly and the husband stated she has aged markedly in the last six months. Pt has cholecystectomy in 9/2014 and almost bled out on the table. The surgeon at the time told the husband the cirrhosis was "really bad." The hepatologist told her last week she would probably not be a transplant candidate due to her bleeding problems from last surgery so her hopes for a transplant have pretty much been crushed.
Pt has been on Levaquin 3 times since January for UTI and in July also dx with URI and was told to increase Levaquin dosage. A few days later she was treated for the flu. 3 weeks ago pt. got very worried in the night when she had a large amount of blood in the urine and later that morning told her husband she also had a "slight" nosebleed. She told her husband she thought it was the Coumadin so she was going to stop it for a couple of days.
In Feb and March of this the pt had significant problems with her finances and her husband had to pay some of her expenses because she ran out of money. I told him he may need to take over her finances because it was due to the HE but he is unwilling to do so.
With this information can you give me an idea of life expectancy for this patient? She was told last week that she does not have ascites but I know she does have pleural effusion. Any information would be greatly appreciated. Family members are at a loss with what is to come in the future. Pt is scheduled for MRI to be done in October--U/S done in April did not pick up lesion that was seen on MRI in January. Husband seems to think the Dr. is thinking she may have liver cancer and, if so, I know that will change all predictions for her future. The husband is very tired and I don't know how much more of this he can handle so anything you can give is appreciated. Thank you in advance.

Thank you so much for your response. Any information is appreciated.

I didn't give you possibly pertinent information with my earlier question so I don't know whether this information will influence your response. With her last labs, the K+ level was at 2.8 and she was told by her Dr. to take one daily. That's the way the medicine is prescribed but she was taking it when she felt she needed it. Also, last week she woke her husband up in the middle of the night and asked him to get her a glass of orange juice with sugar in it. When she normally has a blood sugar drop, she is able to get up and get a snack that she needs. But, this time she was so unsteady that she had to have her husband get it for her. I realize she could have more metabolic abnormalities and any of them could cause her some major issues. This patient is a cardiovascular RN so she tends to treat her symptoms as they appear. She has not been hospitalized since her cholecystectomy in 2014--prior to that she had a cat bite and was in the hospital for a couple of weeks with sepsis. She went home with the vacuum on her leg for several weeks.

I understand this patient is extremely sick and is in liver failure. For the family's sake, I've tried to prepare them as much as I can. The patient refuses to acknowledge that she has a terminal illness. I visited them 3 weeks ago and was told by her that she was stable and doing well with her illness. I'm trying to get information for the family so they are not "blind-sided" when something drastic happens to her. Thank you in advance for you time and response.

The husband is in the process of collecting her most current lab results and I will attempt to get them to you--thanks for your response.

This patient admitted to her husband 2 nights ago that she is "afraid to die". She knows she is terminal but is afraid to die. Due to her behavior lately, the husband stated that he is "waiting for her next crash" and expects it to happen soon.

Thank you so much for your responses. I will get labs for you as soon as he gets them to me.

I'm hoping to get lab results from the husband tomorrow.

More info--the patient told the husband last night she was almost ready to go to the hospital because she felt so bad--lots of dizziness and nausea. She did tell her husband that her bowels are brown so she knows she's NOT bleeding. I told him her stools should be light colored with liver failure. I realize she can have normal looking stools. She has been in bed mostly the last 2 days--got up early this AM to get some juice but said she was feeling a little better than yesterday.

Patient has diagnosis of hepatic encephalopathy on Xifaxan 550mg, BID. She was off of it for 3 days in April and had significant issues and had to get back on it. The fact that she must take the meds daily tells me she has an overt encephalopathy--either recurrent or persistent.

Her husband has finally gotten me latest labs but verbally so I can't download them to you. Some of these values have improved slightly since April. This was NOT a fasting test.

K+--3.2; Glucose--76; BUN--16; Crea--.79; Bili--3.2; Alb--2.9; Serum Protein--6.2; Plt--45,000; Hgb--11.2; Hct--35.1; WBC--3.4; RBC--3.98. Her platelet count in April was 39,000. Also noted in April spleen was enlarged at 16.7cm. And on April U/S was noted that the pancreas is atrophied. A focal liver lesion from January, 2016 MRI was not noted on April U/S but husband says he thinks the hepatologist thinks she may have liver cancer. A follow-up MRI is to be done in October.

If you need any further lab results, let me know. I'm hoping this gives you enough information to be able to come to a conclusion.


Should have added above--the dx of Hepatic encephalopathy was given probably 2-3 yrs. ago. The patient told me in January of this year that she had been on Lactulose for a period of time and did not like the side effects so she was placed on the Xifaxan. She has been on it since getting off of the Lactulose. I know the HE is causing her problems--I noticed when I was there 3 wks. ago that she could not stay on topic in a discussion. She prides herself on being "on top of things" but I think she's slowly losing the ability to mentally keep up. She is aware enough to know she's "afraid to die" and she is able to take care of her finances for now. During Feb. and March of this year, she was having a struggle making her finances work and was having to have her husband pay some of her expenses. She seems to have straightened that matter out for now.

I realize a lot of her symptoms could be from low blood sugar OR from the HE. The husband has mentioned the last couple of days that he seems to think a major "crash" is getting ready to happen with her but he can't give me any specifics. He says she has just not been acting properly and he expects just about anything to happen at any time.

Thank you again for any response you can give. Hopefully, the current lab values will help. Her MELD was 16 but that is an inflated value since she takes Coumadin for SMV thrombosis. The thrombosis has recanalized.