Education: Stages of Liver Disease

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1Shelly1
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Date Joined Oct 2007
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   Posted 3/16/2008 10:51 AM (GMT -7)   

Hi Everyone:

Many of you are aware of the different stages that determine how advanced the diagnosis of liver disease is determined. On the other hand many do not. I thought that it may be helpful to post them so we can all see what the criteria is and what the symptoms are for the different stages. The following list may seem a bit ambiguous but to date it is what Dr’s are using. It is called the West Haven Classification System.

 

Stages of Liver Disease:

Stage 0: Minimal encephalopathy. The changes are almost undetectable because the changes are minimal. Some minor changes in mood and concentration. The marker is the inability to maintain concentration.

Stage 1: Sleep disturbances (often sleeping during the day and awake at night, hypersomnia, or insomnia), mood swings including depression, irritability, and sometimes euphoria. Increased talkativeness, poor concentration, poor attention span, restlessness, and often some tremors in the hands.  Mild confusion is noticeable. They have minute changes is concentration, memory, and coordination.  The patient isn’t able to do some basic arithmetic like adding and subtracting numbers or drawing figures like stars or circles. Possible Asterixis (arm flapping when arms are extended).

Stage 2: Some noted arm flapping (asterixis) when the arms are extended, changes in reflexes (usually slower), difficulty with articulating words, and uncoordinated muscle movement. Lethargy or apathy, slurred speech, noticeable difficulty performing mental tasks, inappropriate behavior, drowsiness, noted personality changes, disorientation especially regarding time, possible sweet odor to their breath called “Fetor Hepaticus”, and a decrease in body temperature may be present along with rapid breathing “hyperventilation”.

Stage 3: Aggressive behavior, talks in monotonous tones, an increase in reflexes, decreased level of consciousness, sleeps a lot but can be aroused when you wake them,  increased confusion and disorientation, at times incomprehensible speech (muttering nonsense) occasionally they will have fits of rage, amnesia, and can not perform mental tasks. Probable “Fetor Hepaticus”. Decreased body temperature is often noted. They sleep most of the time.

Stage 4: Coma

 

I hope this helps you all to at least have some idea at how the Dr’s determine how severe the liver disease is. This does not address lab values. It is solely based on behavior both physically and mentally.

Shelly

 


1Shelly1
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   Posted 3/16/2008 1:49 PM (GMT -7)   

dansbrother, we are all guilty of wanting them to remain on this earth so you are not alone in that. We are at some level happy that they are no longer suffering and are finally escaping the ravages of the illness yet we don't want to let them go. I think the biggest sacrifice I made when my mother was passing was to tell het it was OK to let go. I can rest in the fact that she is at peace now. This helps me not to dwell on the past and her suffering. Life is for the living and I know that she would want me to and the rest of the family to do just that....Live.

 Shelly


exhaused
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Date Joined Nov 2007
Total Posts : 445
   Posted 3/16/2008 9:03 PM (GMT -7)   

Shelly  Re-the stages of Liver Disease-Do all of these symptoms apply if they are taking medication.  Or does it matter.  Jerry has had all of those symptoms at one time or another.  But they seem to get better at time then come back.  He is just now starting to get sleepy  a lot.  I thought that was due to dehydration.  I looked in to his eyes tonight and they have this strange look to them.  Its like they have no life!  I'm not sure how to explain it.  For the first time the lactalose doen't seem to be working as well.  He gets a dose every hour until he has a BM.  Normally it gets things going but the last few days it will get things going then stop again.  Could it have something to do with dehydration?  I think I'm just grasping!!  I want him to go to the hospital so they cana make him feel better so he can come home and I can have him a little longer.  Selfish I know I'm just not ready to give up.  Not tonight that is!!!  Tomorrow morning we go for blood then to counseling then home to wait.  I will keep you posted.  Thank you so much for giving up your time to help us all. 

JoAnn


1Shelly1
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   Posted 3/16/2008 9:32 PM (GMT -7)   
JoAnn, hi sweetie. I know that you are facing some tough times ahead but you know that none of us can tell when something will occur. You also know that my motto is "Never Give Up". As far as the symptoms in staging goes it is a diagnostic tool only. It gives the medical professionals a guideline to evaluate the progression and severity of the disease process. AS his caregiver you know him better than anyone. That said let your judgements be based on what you see and hear from him. You have to monitor the changes and report them when necessary. As for the look in his eyes I can only tell you that I have seen it before in my patients and I also saw it in my mothers eyes. I knew instinctively that in her case it was near the end. Please keep in mind that I am not suggesting that is the case with your beloved-simply that it was true in my moms case. I called it "dead eyes". Gruesome to some people but for me it was a fact that I had to face what was to come. Like Jerry the lactulose virtually quit working on her. We considered putting her on antibiotics but we had to rationalize and come to terms that in her case it would just occur again. Is any other behavior patterns different? Does he have the sweet breath? Have you had an open discussion with him about what he wants? I know how difficult this is to even think about let alone actually do but in all fairness to him it should be done while he can still nswer questions coherently. If he is dehydrated (that happens alot) it could certainly make matters worse. I hope he sees the Dr for a re-evaluation soon. Keep me posted and GOD Bless. We are all here for you.
Shelly

hep93
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Date Joined Jul 2005
Total Posts : 12014
   Posted 3/17/2008 8:52 PM (GMT -7)   

JoAnn, I am so sorry for what both you and Jerry are going through.  Please let us know the outcome of the labs, etc.!  I remember an orthopedic P.A. encouraging me to get hep C treatment over 5 yrs. ago (prior to the liver cancer diagnosis), saying that dying of liver failure is "not a pretty sight."  Now I understand what she meant.

It's odd, but I don't remember seeing ammonia in any of my lab work.  Do they only test for levels of ammonia if there are symptoms of confusion, etc.?

I do have my nights and days mixed up...hard to get to sleep before 3 AM.  Still tired all the time, though not as bad as prior to the liver cancer being eradicated.  I also have the "dropsies."  Some days it is really bad.  My short-term memory has gotten much worse in the past few years.  It's hard to know what can be attributed to liver disease and what may just be natural aging (I'll be 65 next week!)

Hugs,

Connie


1Shelly1
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   Posted 3/17/2008 9:18 PM (GMT -7)   

Connie-65 is still a puppy for heavens sake! VIEW IMAGE I have to admit that with all the information overload these days I'm surprised any of us can even function sometimes.

 Shelly


exhaused
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Date Joined Nov 2007
Total Posts : 445
   Posted 3/17/2008 9:58 PM (GMT -7)   

Hi Connie.  Its funny you should mention about ammonia levels.  Jerry's liver Dr. at Vandy was telling us liver Dr. never check ammsonia.  They just go by the way the patient acts.  The gastro Dr. here do it a lot.  But I have learned to watch for it.  You can smell it when its bad.  Jerry has only have a few episodes when he actually gets goofy!  One of those he wore my bathrobe to the hospital.  I can laugh at it now but at the time I was new to ammonia problems and it really scared me.  Jerry is doing pretty good this evening.  We had blood work today then went to our counseling session.  I'm the one that is unloading to the counselor.  Jerry just sits there.  High ammonia and all.  The counselor doesn't really think Jerry needs him any longer but we are just trying to keep Vandy happy.  Besides I'm getting a lot from the counseling.  It gives me a chance to unload.  Its almost midnight here and I need to get to bed.  I'm feeling a little better today maybe because I got some good sleep this weekend.  We did not get Jerry's blood results today yet.  He has started vomiting some each day.  That is not going to help his dehydration.  He can hardly stay awake now.  I try and get him to walk some every day his muscles are just wasting away.  Its so hard to look at him.  He's like a walking skeleton.  Even though he is still eating several small meals a day.  I will let you all know as soon as I know what the next step is.  Thank you so much for taking the time to care in the mist of all your problems.  Makes me feel bad for even complaining

 

JoAnn


exhaused
Regular Member


Date Joined Nov 2007
Total Posts : 445
   Posted 3/17/2008 10:03 PM (GMT -7)   

Shelly  We don't have the results of the blood work yet.  Jerry is doing pretty good tonight.  Yes, he does have all his affairs in order but I just can not discuss anything with him.  I can't even make myself bring it up.  I'm just not ready to do that yet.  I just keep hoping he will get on the list and get a new liver.  We just have to keep praying.  I promised the counselor today I would do something for myself every week.  Now I just have to figure out what to do!! Tomorrow is another day!!!

 

JoAnn

 

 


1Shelly1
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Date Joined Oct 2007
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   Posted 3/17/2008 10:32 PM (GMT -7)   

JoAnn. I understand truly I do. You have to do what's right for you. I am hopeful that Jerry gets a new liver soon too. I get so frustrated with the whole process as it seems like they dangle a carrot and you just have to hope you can run fast enough to get it. Maybe it's just me and my unwillingness to accept defeat. Did you ever find out about the appetite stimulant? I can tell you it really helped my mom as far as her eating went. After 2 months of barely eating 500-600 calaries a day she zoomed up to about 1300-1500 a day. It was  GOD send for her and us. As for doing something for yourself I whole heartedly agree. You are probably worn to a frazzle. Do you have a day spa near you? Maybe a little pampering is in order. It would certainly give you some much needed R&R. You wouldn't have to an all day thing if you don't want to but you could do 3-4 hours maybe. A nice soothing massage/rub down, a facial and maybe getting your nails and hair done. It sounds really good to me as I'm writing this. Makes me want to sign up right now, ha ha.

 Hugs, Shelly


hep93
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Date Joined Jul 2005
Total Posts : 12014
   Posted 3/18/2008 12:35 AM (GMT -7)   
"Thank you so much for taking the time to care in the mist of all your problems. Makes me feel bad for even complaining."

JoAnn, complain all you want and don't feel bad about doing it! My problems are minor blips compared to yours! If the counseling helps you, continue on as long as they will let you.'

My major pampering thing that makes me feel wonderful is a spa pedicure. I also get a manicure at the same time, but the pedicure is heavenly...warm, vibrating footbath, vibrating reclining chair, foot massage, etc., and they even use warm stones...not to mention the toenail clipping, cuticle cleanup, callous scrubbing, etc. Since I can't really reach my toes (due to artificial hips, it's a no-no), it's really a necessity for me. Right now I'm trying to hold off until the first week in April, just because I can't really afford it this month. I'll probably cave sooner, though, since my feet have been bothering me a lot lately.

Hugs,
Connie

lavendar
Regular Member


Date Joined Nov 2007
Total Posts : 426
   Posted 3/19/2008 3:07 AM (GMT -7)   
1Shelly1 Good morning Here I am another puppy not able to sleep at 2:50 am. I can still balance my check book, have rarely had the body odor, only had a mild like coma I sort of lost 3 or 4 days woke up in hospital. Thats when the whole ball started rolling down hill. As far as the stages you mentioned. I have had them all , I think they are getting worse because my husband seems to be getting a bit annoyed with some of the things I say and do. Especially the talking. But who am I to talk to if not him . No one wants to hear the sad story every three minutes because you forget you've already told it. My short term memmory is totaly messed up especially when my ammonia levels go up. I just don't understand it I eat basically vegetarian meals only have cheese and eggs on occation. My source of protein is Soy milk and soy products. Well my ammonia leveles had gone down slowly in the past year , three months ago they were less than 14 last week they were over 100 .
What I am curious about are the physical stages of the disease. I have minor swelling of the ankles. But I'd like to know when in the stages of 1-4 is that physical problem or is there any order to it. Not that I want any more. The mental part is bad enough. Any response from anyone would be appreciated. june.

1Shelly1
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Date Joined Oct 2007
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   Posted 3/20/2008 8:19 PM (GMT -7)   
June17, I am sure you are feeling a bit out of sorts right now. I think that most people are aware that they have short term memory problems and even know when they are slightly confused. The whole thing is a big vicious circle isn't it? To answer the question if I understood you correctly the symptoms are progressive in nature so it stands to reason that you have had most if not all of them if you have end stage liver disease. With medication some of the symptoms can be controlled but the disease continues to worsen in most cases. The stages have both physical and mental symptoms which progress into the next stage from 1-4. If you are asking me if the symptoms have be in the order they are listed
(for example: Stage 1: Sleep disturbances (often sleeping during the day and awake at night, hypersomnia, or insomnia), mood swings including depression, irritability, and sometimes euphoria. Increased talkativeness, poor concentration, poor attention span, restlessness, and often some tremors in the hands. Mild confusion is noticeable. They have minute changes is concentration, memory, and coordination. The patient isn’t able to do some basic arithmetic like adding and subtracting numbers or drawing figures like stars or circles. Possible Asterixis (arm flapping when arms are extended)
Sleep disturbances followed by mood swings followed by irritability etc., then the answer is no. In this and all the stages the symptoms occur at various times throughout that stage. Once the symptoms increase and become more profound then that puts them into the next stage.
If this doesn't answer your uestion just let me know and I will try again OK?
 Shelly
 
 When you fall - I'll get you up and help you walk,when you can't walk I'll carry you, and when I can no longer carry you I'll stay by your side.


exhaused
Regular Member


Date Joined Nov 2007
Total Posts : 445
   Posted 3/20/2008 9:52 PM (GMT -7)   

June  I have noticed with Jerry that all the symptoms are getting worse.  The flapping and sleepy are much worse the and lactalose isn't working as well and even when it does he still is shaking and sleepy which is high amonia.  They have now put him on an antibiotic.  AFter two days I am seening a big change.  I kept telling the Dr.'s here that when ever he was on an antibiotic (twice this last winter for sinus infection and every time he is hospitalised) he just snaps out of his feeling rotten and gets so tuned up.  He starts eating alot more etc.  I hope this helps.  Hang in there.

JoAnn

 

Rainbeau where are you?????  I hope you are OK


lavendar
Regular Member


Date Joined Nov 2007
Total Posts : 426
   Posted 3/21/2008 12:48 AM (GMT -7)   
I believe I understood your answer. What I was trying to ask was about stomach acites, varcies, pain etc. I am on lactulose for the ammonia since that is my major issue (encepalopathy) which I am well aware of when it's going on. My six month check up showed improved lab results and a MELD score that is still holding at 9. My biggest problem is lack of sleep. I am really tired but cannot sleep. The team dr. told me it was o.k. to take benadryl 50-100 mg. I have never taken that much before. So I stuck to 25mg. last night and had a terrible night . It was not a restfull sleep. I had the strangest dreams. I have suffered from panic attacks and was on meds for that on occation and at times took it to help me fall asleep. The team psychi. told me to stop taking them because they were addictive. So now what is supposed to happen? On like the past , ending up in emergency room? Being told I'm not dying of a heart attack only having an anxiety attack (then giving me the same meds I had before). Oh well. Thanks to all. june

1Shelly1
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Date Joined Oct 2007
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   Posted 3/21/2008 8:02 PM (GMT -7)   
June, I can tell you that if you were on xanax for anxiety attacks it is extremely addictive. I also suffered from anxiety attacks and went to ER several times because I thought I was having a heart attack. They are so horrible aren't they? I started doing some old fashioned things to get some control over them. When I felt one coming on I immediately put ICE WATER all over my face and neck, I open the freezer door and actually stick my head in, I rub ice up and down my wrists and neck, and I do the pursed lip breathing. (Deep breath in thru the nose and blow it out slowly from your mouth). After awhile I was able to gain some control but I still had tachycardia (rapid heart rate). They did an echocardiagram and found that I had a mitral valve prolapse. The Dr told me it was benign but that the anxiety attacks were probably related. They put me on a medication called Atenalol .25mg a day. After about 2 weeks on the medicine I stopped having the attacks.
Now for your not sleeping-that's a whole new ball game. I worked midnights for a long time and I took 25mg of benadryl for a few weeks to help me sleep. I think I would have gone into coma with 100 mg but I am very drug sensitive.I had a problem with it because I started having nightmares. I stopped the Benadryl. I am not sure if you can take Melatonin or not you would have to ask your DR. Do you have any idea why you can't sleep? Such as anxiety or fear of falling asleep? I ask that because I know that with cardiac patients they suffer from acute insomnia. It is very common with patients that fear that they will die in their sleep so they simply don't sleep except cat naps. Fear can do us so much damage it's amazing.
 Shelly
 
 When you fall - I'll get you up and help you walk,when you can't walk I'll carry you, and when I can no longer carry you I'll stay by your side.


lavendar
Regular Member


Date Joined Nov 2007
Total Posts : 426
   Posted 3/22/2008 3:31 AM (GMT -7)   
Shelly I'll try to remember my last post. I lost it somehow. Thanks for your info. I'm really not sure I want to try benadryl again numerous dreams is bad enough I don't need nighmares added to that. I have tried meletonin in the past . It didn't work at the time maybe I'll try it again. The medication my Dr. gave me is on the same catigory as the last one so I probably wont be able to take it either. I think you are right . There seems to be a part of my brain (that still works ha ha) where I am afraid of going to sleep. The word I hear in everything medical from ( A-Z arthritis -zanax ) is could result in COMA . It's probably in part to that movie COMA (of course who would want my deteriorated body HA!!! HA!!) I've been close to the light to many times. First when I had hepititis A as a child, then phemonia hospitalized for months. Then when my son was born , he was breach and my heart stopped for a while , three weeks later had to have gallbladder removed along with appendix which were at the point of rupture. (this was done before laproscopy.) Since then I have been on who knows how many meds. for hypertention now on 40mg.benazapril and 200mg. atenolol a day. When I went for the endoscopy they had asked me not to take the atenolol fpr three days prior because it would interfere with the anesthetic by then my heart started to act up so I had to reschedule till after the echocardiogram. That was yet another close call . Cardiologyst told me my heart skips because one of my valvue does not close properly (probably the same thing you have) and the atenolol sort of desensitized me to that feeling (in other words it there all the time but I only feel it once in a while. When stressed out which these day is every day. Thanks to all who responded It helps to know some one is listening to me ramble on.

Thanks Joann and Connie, I don't always respond but I'm still here listening (o.k. reading. Please excuse my fractured sense of humor It just sort of comes out sometimes. june

1Shelly1
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Date Joined Oct 2007
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   Posted 3/23/2008 3:33 PM (GMT -7)   
Hi June, it sounds like you may have a Mitral Valve Prolapse with Regurg. That means that the valve is malfunctioning and some of the blood that passes thru the chamber goes back up into the chamber because the valve doesn't shut tight. Simplistic explanation I know but I think you get the picture. I worry what is happening to you as a result of not sleeping. There has to be an alternative to medication. Your fear of dying in your sleep is a common problem with some people. The rational part of us knows that when your time is up it won't matter if you are sleeping or awake. The irrational part of us says if I don't sleep then I won't die. It is really difficult for some people to keep the rational part of our brain dominate isn't it? Well, at least know that your fears are common among ill patients. On the other hand you are going to have to fight the irrational fear and get some needed sleep. Our bodies heal best during sleep-did you know that? That's why when we are sick with colds or the flu or whatever we are so tired. Our bodies are screaming at us "Let me sleep will ya?" When you stay awake when you need the sleep you are actually making things worse. You are utilizing energy that the body needs to recover. We need to put our heads together and find a healthy solution.

 Shelly
 
 When you fall - I'll get you up and help you walk,when you can't walk - I'll carry you, and when I can no longer carry you - I'll stay by your side for there is always hope. 


lavendar
Regular Member


Date Joined Nov 2007
Total Posts : 426
   Posted 3/24/2008 1:05 AM (GMT -7)   
Thanks Shelly I know your right. Hope I can get a little bit of rest now because I have an appointment with the podiotrist at 10:00a.m.. ZZZZZZZZZZZ Night june

Mischa
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Date Joined Mar 2008
Total Posts : 47
   Posted 4/4/2008 9:09 AM (GMT -7)   
Just wondering, Does the disease progress in this order or is it possible to have symptoms from different stages that surface and then disappear? The reason I ask, I have seen the asterixis, and various other symptoms of stage 2 as well as many symptoms of stage 3. When he was really bad before he was diagnosed he did slip into a 3 day coma at home which would indicate stage 4. Now, with the medications he stays pretty much bouncing between the symptoms of stages 1, 2 and 3, depends on the day. Is this usual?? I had thought some of the symptoms might be from ammonias getting to high but he drinks a good bit of lactulose lately to help reduce this.
He has had a fairly good last few days, No ascites in the lung this week for the first time in almost 2 months!!! they did draw 3 liters from his stomach but that is much better than what they were getting :)
Therese

1Shelly1
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   Posted 4/4/2008 10:05 AM (GMT -7)   
Therese, that is a good question to ask. It is only a Dr that can assess what stage your husband is in. The stages that are listed in this forum are the guidelines that the Dr uses. But.........the reality is that your husband could be in stage 3 but is at some level controlled at this time. The symptoms you described are literally a combination of stages but he may still be listed as stage 3. Does that make sense to you?

 Shelly
 

“Life is not the way it's supposed to be. It's the way it is. The way you cope with it is what makes the difference."

 


Mischa
Regular Member


Date Joined Mar 2008
Total Posts : 47
   Posted 4/4/2008 7:14 PM (GMT -7)   
thanks shelly, yes it does make sense. The local dr stage he was end stage, level 3 but we go to St Lukes Hosp next week for the testing toget on the transplant list so hopefully we will get a MELD score and get him on the llist

exhaused
Regular Member


Date Joined Nov 2007
Total Posts : 445
   Posted 4/4/2008 10:33 PM (GMT -7)   
Therese My thoughts are with you. We have just gone through all the stuff you are getting ready to go through. The testing was not bad at all. Its the waiting that messed with my mind. Now that my husband is on the list I really seem to be able to relax more. You are almost there. It took us 3 months just to get an appointment. It all seemed like it just moved so slow. I think where ever you are going seems to be moving faster. That is so good. Hang in there and just remember you can do it!

JoAnnhttp://www.healingwell.com/community/emoticons/cool.gif cool :-) http://www.healingwell.com/community/emoticons/smile.gif

sistah
New Member


Date Joined Apr 2008
Total Posts : 1
   Posted 4/12/2008 10:48 PM (GMT -7)   
Hi I am new to this forum my brother was diagnosed with sarcoidosis about five years ago that disease causes excess scar tissue to build in your major organs they put him on steroids at first to try and treat the scar tissue in his lungs. On March 11 the doctors informed him that the disease had taken over his liver and there was nothing else they could do. His is now on an at home Hospice program due to the liver failure he has alot of swelling in his legs and lower abdomen. He has in the past 4 days become very disoriented and sleeping alot. I was wondering if anyone out there had any helpful information for us my brother is only 35 years old and he is the only brother I have.

cablecargal
New Member


Date Joined Apr 2008
Total Posts : 7
   Posted 5/3/2008 7:27 PM (GMT -7)   
Hello everyone and thanks,
I know there is no definitive answer, but when does the end come normally? Every person is different, but if I've been diagnosed with cirrhosis in Oct. 2006 and have never had a drink again. If I do blood tests and CAT scans every three months, and he says they're staying the same, and they saw "something" in the liver but they don't think it's cancer, do they tell you if they think you're close? I am scared b/c I had bouts of confusion that were "Senior Moments," I presumed.
I got a call out of the blue saying I was approved for disability for three months starting last week. If I do that, don't I have to pay my own medical? Then, in CA, we only have 12 weeks' safety from being fired which sounds to me like I take three months off of work, (first since I was 7), and have no money? I don't have an advocate to ask; no family or friends. I'm only 41.
Thanks everyone and I feel for you Sistah and you're in my prayers.

JohnCT
Regular Member


Date Joined Mar 2008
Total Posts : 202
   Posted 5/3/2008 11:02 PM (GMT -7)   
Hi Christina,
Please slow down so that you can make a plan for your financial survival. From what you've posted, I think it's way too early to be thinking about "the end". While cirrhosis and liver tumors are a part of liver disease, neither are necessarily 'final indicators'.
I am no expert but have been diagnosed with liver disease of one sort or another for as long as you have been alive. My point is that I have had plenty of time to consider the diseases and additionally was blessed having one of the nation's top liver researchers as a neighbor for 4 years.
Many of us have had cirrhosis for many years and my understanding is that it is simply a symptom, a deadening and hardening of the liver, causing reduced liver function. So the degree of cirrhosis is key to how it will affect you.
The tumor(s) are another scaled factor. I was told that if a tumor is not cancerous, monitoring its growth is critical and if it is aggressive or there are too many, it becomes serious and additional points are added to your MELD score, which determines placement on the liver transplant list.
So as an amateur, I suggest that you make a list of questions for your doctor so that you fully understand where the disease stands. If you don't have financial resources, I suggest that you immediately contact a free advocate organization. I don't know who that might be but others on the forum can probably guide you. Based on my experience, I suggest that you not quit working until you absoluty must so that you put some savings away and sign up for any assistance that qualify for, Medicare, Social Security, etc.
I'm sorry that you need to deal with this disease -- it's not easy and society often is not helpful.
I hope that we get to spend a lot of years posting about our situations. Stay positive and plan well ahead so you'll be ready to deal with survival.
Sorry to offer so much unsolicited advice but I know how many people think that life is over and are delivered. I trust that you'll be one of those people.
Be well, John (if you have a chance, do the Sam Spade walking tour. it's too cool)
PS - If you can do MRI's instead of CT Scans, you will do a lot to head off other problems. It appears that CT Scans expose you to outrageous levels of radiation while MRI's are magnetic. J
I have to get up the creek! Now where's that paddle?
Mind-fogged again.

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