Archive for the Patient Category

Progression 3 (P3) (hardest)

This exercise program is not medical advice

Talk to your healthcare team about starting an exercise program before you begin.

This website should not be relied upon or serve as a replacement for medical advice from your healthcare team. Do not disregard or delay or discontinue your ongoing medical treatment because of your use of this website. Your continued treatment by your qualified medical practitioners is important to your health. If you have any concerns, address these with your medical team.

Any medical guidelines or recommendations from your medical practitioner regarding exercise in liver disease supersedes any information on this website. The information on the website is provided on an “as is” basis without any representations or warranties.

Balanced posture using light hand-held weights.

Aerobic

At this level, complete 150 minutes of moderate aerobic activity spread out over the week. For example, walk at a brisk pace or jog continuously for 30 minutes on 5 different days.

The goal is to reach and maintain between 3 to 5 on the Borg Scale – breathing stronger but can carry on a conversation.

Muscle strengthening

Aim to complete 3 to 4 sessions each week.

For each exercise, start with 2 sets of 10 repetitions each. Gradually increase to 3 sets of 15 repetitions.

Once this is achieved, increase the weight or resistance and begin anew with 2 sets of 10 repetitions.

While completing these exercises, aim to reach and maintain between 3 to 5 on the Borg Scale – breathing moderately but can still talk.

At P3, complete all 7 exercises listed. Allow 24 hours between each of these sessions so the muscles can recover. Can alternate between upper and lower exercise sessions if you wish to exercise every day. 

Lateral Arm Raises with hand-held free weights

At P3, the weights should be more than 3 lbs each. Remember to increase the weight slowly to prevent injury.
(upper body)

Bicep Curl – single leg with hand-held free weights

(upper body)

Triceps Dip

Make sure to have someone holding the chair or support. Otherwise use an immovable support like a park bench or car/truck bumper. (upper body)

Leg Extension – with banding

Use a banding with a higher resistance than in P2. (lower body)

Leg Curls – with banding

Use a banding with a higher resistance than in P2. (lower body)

Calf Raises – with banding and single leg

Can use one or two legs . If using two legs, increasing the resistance of the banding. (lower body)

Squats – with hand-held free weights

At P3, the weights should be more than 3 lbs each. (include with either the upper or lower body exercise sessions)

Flexibility

Complete 1 set of 3 repetitions held for 20 to 30 seconds each. Hold the stretch until there is a slight discomfort. Avoid overstretching.

Perform at least two Flexibility sessions each week. These can be part of the cool down after a Muscle Strengthening session, combined with a Balance session, or completed on its own..

Include stretches from Intro (performed while standing) and P2.

Quad Stretch – seated

Balance

Complete 1 set of 10 steps with 3 repetitions at least twice a week. Increase the number of steps as you improve.

Make sure to have access to a wall or railing in case of unsteadiness.

A Balance session can be used as the cool down following a Muscle Strengthening session, can be combined with a Flexibility session, or completed on its own depending upon your schedule.

Heel-to-Toe Walk

Place the heel of one foot in front of the other so that the heal touches the toes. Now, walk in a straight line as far as you can go.

Example of a weekly P3 exercise program

Aerobic: Over 5 different days, complete 30 minutes of aerobic exercise for a weekly total of 150 minutes.

Muscle strengthening: On 3 or 4 days each week, do 2 sets of 10 repetitions of each of the following exercises:

  • Lateral arm raises standing on one leg with hand-held free weights
  • Arm curls with handheld free weights
  • Overhead triceps extensions with hand-held free weights
  • Leg extensions with banding
  • Standing calf raises with banding
  • Hamstring curl with a towel
  • Squat with free weights

Flexibility: On 2 different days, perform all stretches 2-3 times lasting 20-30 seconds on each side.

Balance: On 2 different days, perform 3 repetitions of 10 steps each.

Lateral Arm Raise – single leg with hand-held free weights

Bicep Curl – single leg with hand-held free weights

Triceps Dip

Leg Extensions with banding

Leg Curls with banding

Calf Raises with banding and single leg

Squats with hand-held free weights

References:

The information on this page was adapted (with permission) from the references below, by the Cirrhosis Care Alberta project team (physicians, nurse practitioners, registered nurses, registered dietitians, physiotherapists, pharmacists, and patient advisors).

This information is not intended to replace advice from your healthcare team. They know your medical situation best. Always follow your healthcare team’s advice.

References: 

  1. US Department of Veterans Affairs, Veterans Health Administration 
  2. Canadian Liver Foundation
Last reviewed March 15, 2021

Progression 2 (P2)

This exercise program is not medical advice

Talk to your healthcare team about starting an exercise program before you begin.

This website should not be relied upon or serve as a replacement for medical advice from your healthcare team. Do not disregard or delay or discontinue your ongoing medical treatment because of your use of this website. Your continued treatment by your qualified medical practitioners is important to your health. If you have any concerns, address these with your medical team.

Any medical guidelines or recommendations from your medical practitioner regarding exercise in liver disease supersedes any information on this website. The information on the website is provided on an “as is” basis without any representations or warranties.

Sitting or standing with resistance bands for added muscle strengthening.

Aerobic

Include 6 days of aerobic activity each week, for a total time of 150 minutes per week (e.g., 20-30 minutes each session).

If needed, take short 1 minute rests and work toward continuously exercising for the entire session.

The goal is to reach and maintain between 3 to 5 on the Borg Scale – breathing stronger but can still carry on a conversation.

Muscle strengthening

Aim to complete 3 to 4 sessions each week.

Alternate between the different exercises for the upper and lower body. At P2, include 4 to 5 exercises each session.

For each exercise, start with 2 sets of 10 repetitions each. Gradually increase to 3 sets of 15 repetitions.

While completing these exercises, aim to reach and maintain between 3 to 5 on the Borg Scale – breathing moderately but can still talk.

Lateral Arm Raises with hand-held free weights

To start, use LIGHT weights of 1 lb to 3 lbs each. (upper body)

 

Arm Curls with hand-held free weights

(upper body)

 

Overhead Triceps Extension with hand-held free weights

(upper body)

 

Leg Extensions with banding

This exercise targets the quadricep muscles. (lower body)

Standing Leg Curls with banding

(lower body)

 

Standing Calf Raises with banding

(lower body)

 

Squats with hand-held free weights

To start, use LIGHT weights of 1 lb to 3 lbs each. (middle body or torso)

Flexibility

Complete 1 set of 3 repetitions held for 20 to 30 seconds each. Hold the stretch until there is a slight discomfort. Avoid overstretching.

Perform at least two Flexibility sessions each week. These can be part of the cool down after a Muscle Strengthening session, combined with a Balance session, or completed on its own..

Include stretches from the Intro level but do them while standing.

Stretches for P2 are: quadriceps stretch (video), Hurdler’s, wrist, and calf stretches.

Quadriceps Stretch

Continue with stretches learned in the Introductory and P1 levels.

Balance

Complete 1 set of 3 repetitions of 10 steps at least twice a week. As you improve, increase the number of steps.

If confident of your stability and balance, can try this without holding onto a support. Make sure to have it within easy reach though in case of loss of balance!

A Balance session can be used as the cool down following a Muscle Strengthening session, can be combined with a Flexibility session, or completed on its own depending upon your schedule.

Narrow Walk

Walk in a straight line with a narrow gait (small steps).

Example of a Weekly P2 Exercise Program

Aerobic: Over 6 different days, complete 20-30 minutes of aerobic exercise for a weekly total of 150 minutes.

Muscle strengthening: On 3 or 4 days each week, do 2 sets of 10 repetitions of each of the following exercises:

  • Arm curls with handheld free weights
  • Overhead triceps extensions with hand-held free weights
  • Leg extensions with banding,
  • Standing calf raises with banding,
  • Squat with free weights

Flexibility: On 2 different days, perform all stretches 2-3 times lasting 20-30 seconds on each side.

Balance: On 2 different days, perform 3 repetitions of 10 steps each.

Arm Curls with hand-held free weights

Overhead Triceps Extension with hand-held free weights

Leg Extensions with banding

Standing Calf Raises with banding

Squats with hand-held free weights

References:

The information on this page was developed by the Cirrhosis Care Alberta project team (physicians, nurse practitioners, registered nurses, registered dietitians, physiotherapists, pharmacists, and patient advisors).

This information is not intended to replace advice from your healthcare team. They know your medical situation best. Always follow your healthcare team’s advice.

 

Last reviewed March 15, 2021

Progression 1 (P1)

This exercise program is not medical advice

Talk to your healthcare team about starting an exercise program before you begin.

This website should not be relied upon or serve as a replacement for medical advice from your healthcare team. Do not disregard or delay or discontinue your ongoing medical treatment because of your use of this website. Your continued treatment by your qualified medical practitioners is important to your health. If you have any concerns, address these with your medical team.

Any medical guidelines or recommendations from your medical practitioner regarding exercise in liver disease supersedes any information on this website. The information on the website is provided on an “as is” basis without any representations or warranties.

Can done while seated, good for those who may have balance issues, with or without equipment.

Aerobic

Include 5 days of aerobic activity each week, for a total time of 150 minutes per week.

As in INTRO, take short 1 minute rests as needed and work toward continuously exercising for the entire session.

The goal is to reach and maintain between 3 to 5 on the Borg Scale – breathing stronger but can carry on a conversation.

Muscle strengthening 

Aim to complete 2 to 3 sessions each week.

Alternate between the different exercises for the upper and lower body. At P1, include 4 to 5 exercises each session.

For each exercise, start with 2 sets of 10 repetitions each. Gradually increase to 3 sets of 15 repetitions.

While completing these exercises, aim to reach and maintain between 3 to 5 on the Borg Scale – breathing moderately but can still talk.

Lateral Arm Raises with Banding

(upper body)

Arm Curls with Banding

(upper body)

Over-head Triceps Extension with Banding

(upper body)

Leg Extensions with a Pause

(lower body)

Hamstring Curl with a Towel

Can use a scarf, belt, or a plastic bags knotted together instead of a towel. (lower body)

Standing Calf Raises

(lower body)

Squat (chair assisted)

Stand with your back almost touching a wall. Slowly move down to a squatting position and then return to a standing position. Keep your back straight and head up. This “squat” is similar to the Intro level’s Chair Sit-to-Stand exercise.

Flexibility

Complete 1 set of 3 repetitions held for 20 to 30 seconds each. Hold the stretch until there is a slight discomfort. Avoid overstretching.

Perform at least two Flexibility sessions each week. These can be part of the cool down after a Muscle Strengthening session, combined with a Balance session, or completed on its own..

Include stretches from the Intro level but do these while standing.

Seated Hamstring Stretch

To get a better stretch of the muscles, do this while standing. Use a chair for balance as necessary.

Balance

Complete 1 set of 3 repetitions at least twice a week.

If confident of your stability and balance, can try this without holding onto a support. Make sure to have it within easy reach though in case of loss of balance!

A Balance session can be used as the cool down following a Muscle Strengthening session, can be combined with a Flexibility session, or completed on its own depending upon your schedule.

BALANCE - P1

Single Leg Raises with eyes closed

Make sure to have a chair nearby!

Example of a Weekly P1 Exercise Program

Aerobic: Over 5 different days, complete 150 minutes of aerobic exercise. Remember to take rests as needed!

Muscle strengthening: On 2 or 3 days each week, do 2 sets of 10 repetitions of each of the following exercises:

  • Lateral arm raises with banding
  • Arm curls with banding
  • Leg extension with a pause
  • Hamstring curl with towel
  • Squat

Flexibility: On 2 different days, perform all stretches 2-3 times lasting 20-30 seconds on each side.

Balance: On 2 different days, perform 3 repetitions of 10 steps each.

Lateral Arm Raises with Banding

Arm Curls with Banding

Leg Extensions with a Pause

Hamstring Curl with a Towel

Squat

Move the body the same as this video but do not sit on the chair! Alternatively, can do this with your back near to a wall without a chair.

References:

The information on this page was developed by the Cirrhosis Care Alberta project team (physicians, nurse practitioners, registered nurses, registered dietitians, physiotherapists, pharmacists, and patient advisors).

This information is not intended to replace advice from your healthcare team. They know your medical situation best. Always follow your healthcare team’s advice.

 

Last reviewed March 15, 2021

INTRO (easiest)

This exercise program is not medical advice

Talk to your healthcare team about starting an exercise program before you begin.

This website should not be relied upon or serve as a replacement for medical advice from your healthcare team. Do not disregard or delay or discontinue your ongoing medical treatment because of your use of this website. Your continued treatment by your qualified medical practitioners is important to your health. If you have any concerns, address these with your medical team.

Any medical guidelines or recommendations from your medical practitioner regarding exercise in liver disease supersedes any information on this website. The information on the website is provided on an “as is” basis without any representations or warranties.

No equipment, can be done while lying or reclining in bed or on a couch, suitable for most people with cirrhosis.

Aerobic

Begin by including 5 minutes of aerobic activity on 4 days each week. For example, take a walk down the street or in a local mall. If you need to, take short rests (1 minute) either standing still or sitting down.

The goal is to reach and maintain between 3 to 5 on the Borg Scale – breathing stronger but can still carry on a conversation. If you reach 6 or higher on the Borg Scale, take a rest, then resume the activity.

Once you can complete 5 minutes of continuous aerobic activity, increase the session by 1 to 2 minutes.

Remember to listen to your body and take rests if necessary or decrease the duration.

Other examples of aerobic activity are: swimming, cycling, curling, lawn bowling, dancing, cleaning the garage, mowing the lawn, shoveling snow, and washing the car. Any activity can be “aerobic exercise” providing that the heart rate and breathing are increased.

Muscle strengthening

Resistance exercises improve muscle condition and strength. These exercises target muscle groups in the upper, lower, and middle (torso) of the body.

Each week, do 2 sessions separated by a few days, such as Tuesday & Friday or Thursday & Saturday.

  • Each session should include 3 exercises, with 1 exercise for each body segment: upper, lower, and middle.
  • Select different upper and lower body exercises for each session so that all muscle groups are similarly improved.
  • For each exercise, start with 2 sets of 10 repetitions each. Gradually increase to 3 sets of 15 repetitions.

Once this is achieved, progress to 4 exercises per session.

During this session, aim to reach and maintain levels 3 & 5 on the Borg Scale – breathing moderately but can still talk.

Lateral Arm Raises

(upper body)

Arm Curls

(upper body)

Seated Triceps Extension (without banding)

For Intro level, perform this without using resistance banding. (upper body)

Seated Leg Extensions

(lower body)

Standing Leg Curls

For the Intro level, this can be performed without the resistance banding. (lower body)

Seated Calf Raises

This can be done either seated or lying down. (lower body)

Chair Sit-to-Stand

(middle or torso)

Flexibility

Start with 1 set of 3 repetitions.  Hold each stretch for roughly 20 seconds or until you count to 20..

  • “One Mississippi, two Mississippi, three Mississippi” and so on..

These should be done twice a week. Can be done after the Muscle Strengthening session, on their own, or combined with a Balance session.

Other stretches that can be performed while seated are: lateral side bends, chest reach, and chair-sit and reach.

Shoulder Stretch

For INTRO, perform the stretch while seated.

Triceps Stretch

For the INTRO level, perform the stretch while seated. The triceps are located in the back of the upper arm between the shoulder and elbow.

Seated Hamstring Stretch

The hamstring muscles run along the back of the thigh between the hip and the knee.

Balance

Start with 1 set of 3 repetitions and these should be done twice per week.

This can be done after a Muscle Strengthening session, combined with a Flexibility session, or its own.

Slow and steady is the rule so that multiple muscle groups are involved in controlling fine, well coordinated movements.

Knee to Chin Raises

This can be modified to a sitting position. When seated and the feet flat on the floor, lift one knee up to the chest. Keep the back straight. Repeat with the other leg. Complete for the recommended number of repetitions.

Example of a weekly intro exercise program 

Aerobic: At least 4 times each week, walk continuously for 5-10 minutes. Remember to take a short break if you need to catch your breath!

Muscle strengthening: On 2 different days, do 2 sets of 10 repetitions of each of the following exercises:

  • Arm curls
  • Seated calf raises
  • Chair-sit-to-stands

Flexibility: On 2 different days, perform all stretches 2-3 times lasting 20-30 seconds on each side.

Balance: On 2 different days, perform 3 repetitions of 10 steps each.

Arm curls

Seated Calf Raises

Chair Sit-to-Stands

References:

The information on this page was developed by the Cirrhosis Care Alberta project team (physicians, nurse practitioners, registered nurses, registered dietitians, physiotherapists, pharmacists, and patient advisors).

This information is not intended to replace advice from your healthcare team. They know your medical situation best. Always follow your healthcare team’s advice.

Last reviewed March 15, 2021

Advance Care Planning Documents

Goals of Care Designation (GCD)

To describe the general goal of your care, and the preferred location of that care, your health team uses a Goals of Care Designation. It should reflect the treatments that will be of benefit to you, and your own wishes and values. If you have a personal directive, the goal of your care in that document should be described in a similar way on your GCD form.

The GCD is documented on an Alberta Health Services form by your physician or nurse practitioner. It should be kept along with a copy of your other advance care planning documentation in a plastic Green Sleeve. Keep your Green Sleeve on or near your fridge. Emergency Medical Services will look for it there, when they enter your home. Any time you go to the hospital or to a healthcare appointment, take your Green Sleeve with you.

The terms used on the GCD form can be confusing, because they are written for health professionals. It is however important that you understand what the form means.  There are 3 general approaches to care:

Resuscitative Care (R)

The focus is to lengthen life using any medical or surgical means. This includes, if needed, resuscitation (CPR) to re-start your heart, intubation (a breathing tube that is attached to a machine that breaths for you) and admission to the intensive care unit. People with a chronic illness tend to do worse than people without a chronic illness if they need this level of care. There are many circumstances where it may not be recommended, but this depends on your level of function and how severe your disease is.

Medical Care (M)

Medical tests and treatments are used to cure or control an illness as much as possible. If your heart stops or you needed a machine to keep you breathing, the practitioners would allow you a comfortable death. This is used when resuscitative and life support measures won’t work or when the person chooses not to have these treatments. If resuscitation were not offered, your practitioners would explain this to you. Medical care can be given in many locations, depending on the person’s wishes, values, and how severe the illnes is. Medical care is very aggressive care, and many illnesses such as heart attacks, infections, bleeding, and clots can be well treated within this designation. Complications from cirrhosis such as fluid in the belly (ascites), confusion (encephalopathy), many types of bleeding, and infections can also be treated under this designation.

Comfort Care (C)

The focus of care is to provide comfort to ease a person’s symptoms, without trying to control the underlying illness. Treatments with a main goal of lengthening life are not undertaken. Treatment of conditions that may cause severe symptoms such as infections, mild heart attacks, blood clots, and other, can be considered. These treatments may lengthen life, but the main goal is to provide comfort. There will be a point in everyone’s life, when they no longer want any treatments. Usually when this happens, people are unable to get out of bed, no longer wish to eat, and can tell that their body can no longer tolerate the degree of illness they have. This care can be given in settings such as home, hospital, or hospice, described later in this booklet.

 

Enduring Power of Attorney

This is a legal document that allows you to designate someone to make legal or financial decisions for you. To get more information on Power of Attorney in Alberta, click here.

 

Personal Directive

This document allows you to name a decision maker or agent for your medical treatments in the event you do not have the capacity, or cannot speak for yourself. It can include instructions to be followed such as where you will live or the medical treatment you will receive. Many legal Personal Directives do not say the same thing that the Medical Goals of Care do. To get more information on Personal Directives in Alberta, click here.

 

Wills

This legal document allows you to direct your property after your death. It is usually includes someone named by you to represent and carry out your wishes after your death. To get more information on wills in Alberta, click here.

 

Q&A

How does Cirrhosis affect your response to life sustaining treatments?

Cirrhosis may affect your body’s ability to recover from illness. Many body functions are controlled through the liver. The degree that your liver is affecting the rest of your body, depends on what complications you have experienced. In addition, it depends on how functional you are in your daily life, for example- if you are up and out of the home all day, if you can care for yourself, or if you are in bed most of the time. All of these things are important to think about when deciding about a Goals of Care designation.

Early in cirrhosis care, these won’t seem like important issues. It is however important to know how the health care system operates in Alberta, as it will help you plan for and understand your future health care options. Having a Goals of Care designation is an important part of this.

A Goals of Care designation (stored in a Green Sleeve) can be documented with any of your practitioners. They should understand your values and your support systems, prior to making these decisions. The decisions may also take some time. Many patients wish to take the information home, and discuss it with their family and other people who support them. The Green Sleeve is available to all practitioners, and you can ask to discuss it at any time.

What if you change your mind?

It is important to understand that GOC designations can be changed at any time. People may wish to reconsider their wishes in many situations, but typically we suggest reviewing the designation in these specific circumstances:

  • Any time you need to go to the emergency department or are admitted to the hospital.
  • When you experience a new complication of cirrhosis.
  • If you are noticing your level of function is getting worse.
  • If you experience spiritual, emotional, or social issues that make you reflect on your wishes for your future health.
How do I get a green sleeve or other advance care planning documents?

A Green Sleeve is a plastic pocket that holds your important advance care planning forms.

There are 2 ways to get a Green Sleeve:

  • Ask your healthcare provider (such as your family doctor) for a Green Sleeve.
  • Order a Green Sleeve online. You can have up to 2 Green Sleeves mailed to your home by following these instructions. It can take 5 to 10 business days for your Green Sleeves to arrive. If you need to order extra Green Sleeves (up to a maximum of 2 per household), or if you have questions about your order, email [email protected].

References:

The information on this page was adapted (with permission) from the references below, by the Cirrhosis Care Alberta project team (physicians, nurse practitioners, registered nurses, registered dietitians, physiotherapists, pharmacists, and patient advisors).

This information is not intended to replace advice from your healthcare team. They know your medical situation best. Always follow your healthcare team’s advice.

References: 

  1. US Department of Veterans Affairs, Veterans Health Administration 
  2. Canadian Liver Foundation
  3. My Health Alberta 
Last reviewed March 15, 2021

Advance Care Planning

Cirrhosis is usually considered a chronic disease. This means it is long-lasting and can get worse over time. Each person’s experience with it is different. Some people have no symptoms for a long time. Others have times of feeling unwell that come and go. And for some, cirrhosis can affect their ability to do every day activities.

The chart below shows some examples of how health for different people may progress over time.

Advance care planning is the process of thinking & talking about your wishes, and documenting them. These conversations usually take place over time and can be had with your family, friends and health care team. Documenting your wishes usually includes health, finance and legal planning documents. This is not only recommended for people with chronic conditions, but for everyone.

The best time to make plans for a situation when your health may get worse, is when you are well.

Once decisions regarding your medical wishes have been made, it’s best to focus on keeping as healthy as possible, living life fully and maintaining hope for good days to come.

Palliative Care

Many people think Palliative Care means End of Life Care, and that a person must be close to death to benefit from it. This is not the case. Palliative Care can include End of Life Care, but also focuses on illness at different points in time, even years before we die. Palliative Care can include the following:

  • Tests to better understand and manage symptoms
  • Treatment of pain and other symptoms like nausea
  • Psychological, social and emotional support for you and your loved ones
  • Focus on living as actively as possible

Palliative Care providers are specially trained in chronic disease symptom treatments, as well as the spiritual, social, and emotional aspects of coping with chronic illness. They can also help you understand the illness that you have, and the way that it may progress. Your liver specialist and family physician, may also discuss these issues with you.

Most people and their families need more than just medical advice and treatment explanations while they cope with a chronic disease like cirrhosis. Spiritual, social, and emotional issues play a large role in how satisfied people are with their lives. It’s important to deal with all of these issues, in addition to dealing with your cirrhosis itself.

End of Life Care

Although it can be difficult to think about, most of us will reach a point where we can no longer care for ourselves. You may wonder what options are available for people in this situation. Most communities can offer some degree of following options:

Hospital Care

If you have new symptoms that are not being well managed at home, you may need to go to your local emergency room. The emergency physicians will decide if you need admission to hospital. Sometimes, they can treat the problem and send you back home. In other cases you may need to stay in hospital to manage your symptoms. In general, a hospital is not usually necessary for end of life care, especially if a person has documented their wishes and had advance care planning discussions with their health team and loved ones.

Hospice Care

When a practitioner has estimated that their patient only has 4 or fewer months to live, hospice care can be accessed in Alberta. Hospice care is paid for as part of your Alberta Health benefits. Your practitioners can help you with determining your eligibility, when the time arises. In Edmonton, only Palliative Care specialists at the University of Alberta, Royal Alexandra Hospital, Grey Nuns Hospital, or the Community Palliative Care Team can refer you to be admitted to a local hospice. Typically, people who qualify for hospice are in bed most of the day, and have significant difficulty doing any activities. There are details on all local hospices, listed on www.palliative.org which is the Edmonton Regional Palliative Care Program’s website.

Staying at Home

Many people would like to stay at home until they die. This can be possible in many cases, depending on the supports that a person may have. Some communities have Palliative Home Care, that can support the person in the home with nurses, doctors and other healthcare providers that work together with your family physician in your care. These supports can often allow you to remain in your home, rather than going into a hospital. Many people make the decision that they do not want to go to hospital, when they are close to the end of their lives.

References:

The information on this page was developed by the Cirrhosis Care Alberta project team (physicians, nurse practitioners, registered nurses, registered dietitians, physiotherapists, pharmacists, and patient advisors).

This information is not intended to replace advice from your healthcare team. They know your medical situation best. Always follow your healthcare team’s advice.

Last reviewed March 15, 2021

Liver Cancer (Hepatocellular Carcinoma (HCC))

Liver Cancer or hepatocellular carcinoma, is a type of cancer that starts in the liver. It usually starts out as a small lump, called a tumor, and can grow larger over time. HCC (the short name for hepatocellular carcinoma) doesn’t start all of a sudden. It usually starts slowly in a liver that’s been exposed to risk factors for HCC.

Cirrhosis is, by far, the most important risk factor for HCC. In fact, HCC is rare in people without cirrhosis (except for those who have hepatitis B). It doesn’t matter what caused the cirrhosis—cirrhosis from any cause, is a significant risk factor for HCC.

Symptoms

In the early stage, HCC usually doesn’t cause any symptoms. This means that people can develop HCC and not know it right away. If left untreated, over time people with HCC might experience:

  • Pain is in the right upper abdomen, which can travel to the right shoulder
  • Swelling or fluid build-up in the abdomen
  • Itchy or yellow skin if a tumor blocks the drainage of bile from the liver
  • Nausea, vomiting, or poor appetite
  • Weight changes

Diagnosis

Several tests are used to diagnose HCC. The most important ones are lab tests, physical examination, and imaging tests. In some cases, liver biopsies are also done.

Blood Tests
Your healthcare provider will order lab tests and bloodwork to check how well your liver is functioning. One of your lab tests will be an AFP test. AFP stands for alfa-fetoprotein. A high level of AFP can be a sign of HCC. If you’re considered to be at increased risk of developing HCC, you may get an AFP test along with an ultrasound every 6 months.
Physical Exam

Your doctor might also give you a physical exam. They’ll check your skin for signs of jaundice. They might feel your abdomen for lumps or a change in the size of your liver. They’ll also check for ascites, which is a buildup of fluid in the abdomen (belly).

Scans (Imaging Tests)

Imaging tests are key to diagnosing HCC. HCC can usually be diagnosed solely by imaging tests such as ultrasound, MRI, and CT scan.

Ultrasound

An ultrasound of the abdomen is often the first imaging test that’s ordered. It can identify abnormal masses in the liver such as a tumor. It’s also used to screen for HCC in people who have a higher risk of developing the disease. High-risk patients usually get an ultrasound every 6 months to screen for HCC.

CEUS (Contrast Enhanced Ultrasound)

This is a type of ultrasound that uses microbubble contrast dye to look for tumprs in the liver. There’s no problem doing CEUS with poor renal function. CEUS is only available in a few highly specialized centres.

MRI

An MRI can provide more detail about blood vessels, organs, and lymph nodes. It’s useful for showing subtle differences in cells, and it can make it easier to see the liver and any tumors when there is fat in the liver.

When you get an MRI, you’re injected with a special dye called a contrast. If you have kidney problems or an allergy to iodine, the contrast dye most commonly used for MRIs might be safer for you than the one used for CT scans.

CT Scan

A CT scan combines a series of X-ray views taken from many angles to create a 3D image. It’s associated with a higher exposure to radiation.

CT scan images can provide much more information than plain X-rays. For HCC, a CT scan can show tumors and the blood vessels that the tumors might be growing into or around. A CT scan can also look at surrounding organs and check if the cancer is spreading into lymph nodes and other areas.

When you get a CT scan, you’re injected with a special dye called a contrast. The contrast dye makes the liver more visible.

Biopsy

A liver biopsy removes cells or tissues from your liver so they can be viewed under a microscope for signs of cancer.

A biopsy isn’t usually required to diagnose liver cancer. However, if the tumor doesn’t look like a typical HCC on a CT scan or MRI, a biopsy can be helpful to ensure the diagnosis is accurate prior to treatment.

Treatment

Your scans will be looked at, often by a specialized team that includes your liver specialist and other doctors with experience treating HCC. There are many things this team will consider when deciding which option to recommend for you…. things like:

  • the size, number, and location of tumors
  • your liver function (how well your liver’s working)
  • your age and general health

Depending on your situation, some potential treatment options for HCC are:

Surgery
There are two main types of surgery depending on the stage of the liver cancer:

  • liver resection
  • liver transplant

Liver Resection

If a liver tumor is small and hasn’t spread, your doctor might do surgery to remove the cancerous parts of the liver. This is called a liver resection. This operation is done only if you’re healthy enough for surgery and if all of the tumor can be removed while leaving enough healthy liver behind.

Cancerous parts of the liver that may be removed include:

  • a small portion of tissue
  • an entire lobe or even more

Before surgery, you’ll have imaging tests such as an MRI or CT scan to see if the cancer can be removed. Even with these kinds of tests, your doctor might discover during surgery that the cancer is too large or widespread to be removed. In this case, the partial resection is cancelled.

After surgery, risk of bleeding is a concern. Damage to the liver before and during the surgery can add to the potential bleeding problem. Other possible side effects include complications from anesthesia, blood clots, infections, and wound complications including hernias.

Also, the remaining liver still has the disease that led to the cancer (for example, cirrhosis). So there’s a chance that a new HCC can develop elsewhere in the liver after a partial resection.

Most liver resections are performed using an open technique, but some may be performed using a laparoscopic approach. The recovery time for surgeries varies from person to person. In general, these are the ranges:

Edit
Type of Partial Resection How Long in Hospital Total Recovery Time
Open liver resection:
performed through a fairly large incision
5 to 10 days 6 to 8 weeks
Laparoscopic liver resection: performed using a special scope, through 3 or 4 very short incisions 3 to 5 days 3 to 6 weeks

Liver Transplant

In a liver transplant, the entire liver is removed and replaced with a healthy donated liver. A liver transplant will be considered when the cancer:

  • is only in the liver
  • can’t be treated as well by other standard treatment options

Usually only people with liver cancers up to a maximum size are candidates for a liver transplant. The precise size varies a bit from centre to centre. Your doctor will discuss transplant with you if it’s an option in your case.

With a transplant, the risk of a new HCC in the liver is reduced because all of the old liver is removed. There could, however, be a recurrence of the original cancer.

There are many things that will need to be consider aside from your HCC if you are being evaluated for liver transplant.

More information on Liver Transplant can be found here.

Watch a video on Ablation

 

Watch a video on Embolization

 

Watch a video on Radiation Therapy

 

Chemotherapy Medications

Targeted chemotherapy medications works differently from other chemotherapy because they attack a specific target—like cancer-related proteins—rather than attacking all body tissue. They often have different and less severe side effects.

Sorafenib

One example of a targeted chemotherapy medication for liver cancer is sorafenib. This medication is available as a pill. Sorafenib has been shown to stop the growth of cancer cells. It won’t cure liver cancer, but it can increase the lifespan of people who have this disease, typically for about 3 or 4 months.

Researchers are also studying the use of sorafenib in the early stages of liver cancer, often in combination with other kinds of treatment. They haven’t studied it much in people who have poor liver function, so it’s not known if it’s safe for these people.

Like other anticancer drugs, sorafenib has side effects including:

  • diarrhea
  • dry mouth
  • dry or peeling skin
  • itchiness
  • rash, sometimes with blistering of hands and feet
  • acne
  • fatigue
  • hair loss
  • loss of appetite
  • nausea and vomiting
  • weight loss
Symptom Management

Symptom management, is always part of treatment, but can be the main focus if other treatment options are not available

References:

The information on this page was adapted (with permission) from the references below, by the Cirrhosis Care Alberta project team (physicians, nurse practitioners, registered nurses, registered dietitians, physiotherapists, pharmacists, and patient advisors).

This information is not intended to replace advice from your healthcare team. They know your medical situation best. Always follow your healthcare team’s advice.

References: 

  1. US Department of Veterans Affairs, Veterans Health Administration 
Last reviewed March 15, 2021

Anxiety

Anxiety is a feeling many people get at times in their life. It can be more common in people with chronic health conditions, like cirrhosis. Anxiety can cause physical symptoms like a fast heart rate or feeling tired. If can also affect your mood, causing symptoms like feeling nervous, panic, and having trouble sleeping. If feelings of anxiety are not going away or interfere with your daily life, it may be more serious.

For more information, check out the videos below from My Health Alberta, or visit their website topic by clicking here: Anxiety

Anxiety: What Is It?

Anxiety: How to Change Anxious Thoughts

Anxiety: Is Treatment Right for You?

Anxiety: Treatment Options

Anxiety: Paying Attention to How You are Doing

References:

The information on this page was adapted (with permission) from the references below, by the Cirrhosis Care Alberta project team (physicians, nurse practitioners, registered nurses, registered dietitians, physiotherapists, pharmacists, and patient advisors).

This information is not intended to replace advice from your healthcare team. They know your medical situation best. Always follow your healthcare team’s advice.

References: 

  1. US Department of Veterans Affairs, Veterans Health Administration 
  2. Canadian Liver Foundation
Last reviewed March 15, 2021

Core Patient Education

Below are important steps for patients and their families to take prior to going home from hospital.

Step 1- review a printed version of the handout

Step 2- watch the 2 discharge videos

Step 3- watch the applicable complication videos

Step 1- Patient Care Handout

Cirrhosis basics (for use in Alberta)

Click the image below to open/print.

 

Step 1- Patient Care Handout

Cirrhosis basics (for use outside of Alberta)

Click the image below to open/print.

Step 1- Patient Care Handout

Eating Well with Cirrhosis

Click the image below to open/print.

Step 2- Discharge Videos

These 2 videos are important for anyone who has (or wants to learn about) cirrhosis. They cover the basics of common complications, self-management and what to watch for.

What is cirrhosis

Living with cirrhosis

 

Step 3- Complication Videos

These 3 videos include more information about common cirrhosis complications.

Ascites and Pleural effusion

Hepatic encephalopathy

Varices

Exercise_Select Your Program_Intro

Jump to:

For those living with cirrhosis, please review the medical disclaimer presented on the “Exercise in Cirrhosis” webpage.

This exercise program is intended to be completed with the knowledge and clearance of your physician to ensure that it is appropriate, modified as necessary, and safe.

For individuals with other chronic diseases, please consult your physician in advance of engaging in this exercise program.

AEROBIC

Begin by including 5 minutes of aerobic activity on 4 days each week. For example, take a walk down the street or in a local mall. If you need to, take short rests (1 minute) either standing still or sitting down.

The goal is to reach and maintain between 3 to 5 on the Borg Scale – breathing stronger but can still carry on a conversation. If you reach 6 or higher on the Borg Scale, take a rest, then resume the activity.

Once you can complete 5 minutes of continuous aerobic activity, increase the session by 1 to 2 minutes.

Remember to listen to your body and take rests if necessary or decrease the duration.

Other examples of aerobic activity are: swimming, cycling, curling, lawn bowling, dancing, cleaning the garage, mowing the lawn, shoveling snow, and washing the car. Any activity can be “aerobic exercise” providing that the heart rate and breathing are increased.

MUSCLE STRENGTHENING

Resistance exercises improve muscle condition and strength. These exercises target muscle groups in the upper, lower, and middle (torso) of the body.

Each week, do 2 sessions separated by a few days, such as Tuesday & Friday or Thursday & Saturday.

  • Each session should include 3 exercises, with 1 exercise for each body segment: upper, lower, and middle.
  • Select different upper and lower body exercises for each session so that all muscle groups are similarly improved.
  • For each exercise, start with 2 sets of 10 repetitions each. Gradually increase to 3 sets of 15 repetitions.

Once this is achieved, progress to 4 exercises per session.

During this session, aim to reach and maintain levels 3 & 5 on the Borg Scale – breathing moderately but can still talk.

Lateral Arm Raises

(upper body)

 

Arm Curls

(upper body)

 

Seated Triceps Extension (without banding)

For Intro level, perform this without using resistance banding. (upper body)

 

Seated Leg Extensions

(lower body)

 

Standing Leg Curls

For the Intro level, this can be performed without the resistance banding. (lower body)

 

Seated Calf Raises

This can be done either seated or lying down. (lower body)

 

Chair Sit-to-Stand

(middle or torso)

 

FLEXIBILITY

Start with 1 set of 3 repetitions.  Hold each stretch for roughly 20 seconds or until you count to 20..

  • “One Mississippi, two Mississippi, three Mississippi” and so on..

These should be done twice a week. Can be done after the Muscle Strengthening session, on their own, or combined with a Balance session.

Other stretches that can be performed while seated are: lateral side bends, chest reach, and chair-sit and reach.

Shoulder Stretch

For INTRO, perform the stretch while seated.

 

Triceps Stretch

For the INTRO level, perform the stretch while seated. The triceps are located in the back of the upper arm between the shoulder and elbow.

 

Seated Hamstring Stretch

The hamstring muscles run along the the back of the thigh between the hip and the knee.

 

BALANCE

Start with 1 set of 3 repetitions and these should be done twice per week.

This can be done after a Muscle Strengthening session, combined with a Flexibility session, or its own.

Slow and steady is the rule so that multiple muscle groups are involved in controlling fine, well coordinated movements.

Knee to Chin Raises

This can be modified to a sitting position. When seated and the feet flat on the floor, lift one knee up to the chest. Keep the back straight. Repeat with the other leg. Complete for the recommended number of repetitions.

 

EXAMPLE of a Weekly INTRO Exercise Program

 

Aerobic: At least 4 times each week, walk continuously for 5-10 minutes. Remember to take a short break if you need to catch your breath!

Muscle strengthening: On 2 different days, do 2 sets of 10 repetitions of each of the following exercises:

  • Arm curls
  • Seated calf raises
  • Chair-sit-to-stands

Flexibility: On 2 different days, perform all stretches 2-3 times lasting 20-30 seconds on each side.

Balance: On 2 different days, perform 3 repetitions of 10 steps each.

Arm curls

Seated calf raises

Chair Sit-to-Stands