Protein, Ammonia, Cirrhosis, and Hepatic Encephalopathy: What I Learned

My last post, “Hepatic Encephalopathy: On Knowing I Didn’t Know What I Knew I Know,” ended with me trying to cope with an episode of confusion, temporary loss of lifelong memories and inability to form new ones a week following the installation of a Transjugular Intrahepatic Portosystemic Shunt (TIPS) to deal with the portal hypertension resulting from cirrhosis, a consequence of Primary Biliary Cirrhosis (or Cholangitis) (Regular readers will be used to the growing “This is the house that Jack built” nature of my introductory sentences.).

I believe I have regained all I had lost of my memory. The treatment was (and continues to be as a preventive) an extreme laxative called Lactulose that “works by drawing ammonia from the blood into the colon where it is removed from the body.” It is a sickeningly sweet liquid that makes my intestines feel as if they’ve been invaded by frolicsome ferrets, but this transient discomfort is trivial compared to the frightful alternative of hepatic encephalopathy.

After the TIPS was installed, I was told to avoid fried food and red meat and I complied (by the way, pork is not “the other white meat” when it comes to ammonia: it is a red meat). However, because of the events of the two weeks preceding my encephalopathy (days at the nursing home, my mother’s death, 300 mile each way trip to UAB, two endoscopies with conscious sedation, general anesthesia with the TIPS, etc.) I had become very irregular, backed up as it were.  I was not getting food processed and through my digestive system efficiently, and certainly not quickly (now the Lactulose helps with that).

My understanding of why I should avoid red meat and eat small amounts of protein over the course of the day rather than in two or three sessions was slow in coming.

After release from the hospital, my family and I started a hunt for low-ammonia foods. No luck — just try to find the low ammonia diet. There are horrifying stories about “pink slime” and the use of ammonia to control e coli in food processing plants (remember that? The “pink slime” Wikipedia entry hasn’t been updated since 2013, which doesn’t mean the stuff isn’t still around.). Red meats and rind cheeses were listed as items to avoid if you suffer from cirrhosis, but there wasn’t a clear indication of why. Finally, I contacted a food scientist I knew who provided the key.

I was not going to find low ammonia foods. Ammonia is a by-product of the breakdown of proteins, whether they be animal or plant-based. The thing is, red meats and rind cheeses (and to a lesser extent, chicken and fish) are more protein-intensive than vegetable-based proteins, so more ammonia is produced during their digestion.

For most people this isn’t a problem. The liver takes care of the problem, as it handles other toxins consumed.

But a cirrhotic liver isn’t up to the task. Think of all the drug labels and commercials that tell you to consult with your doctor before using if you have an impaired liver.

Red meat should contain a similar warning.

From the 1950s (at least) into the first years of this century, cirrhotics who had experienced hepatic encephalopathy [HE] were told to eat little protein, period, and malnourishment was common among cirrhotics. As their bodies consumed their own muscle and fat for protein, ammonia was released, and thus HE was not avoided by not eating meat.

Now the advice is for cirrhotics to consume more protein than than non-cirrhotics, and I have been told that while it is most important to get enough protein — to eat chicken and fish if I need to — non-animal sources of protein are less of a challenge to my liver. I am still looking for studies on whether vegetarian or vegan diets are superior for preventing HE in contrast to those that include some animal protein. If it were possible to eliminate the need for Lactolose or rifiximin (an antibiotic used to prevent HE), I would go vegan.

It was easier to give up red meat than I would have imagined. Back when severe anemia was one of my major issues,  I was a staunch defender of meat-eating, arguing that for some of us, a vegetarian diet was not an option, that we couldn’t otherwise get the iron needed to raise our hemoglobin from the 8’s to the 12’s without transfusions or infusions. And I still think that universal vegetarianism isn’t practical, unless you want to require all who live in regions inhospitable to agriculture to eat processed foods shipped in from other climes (are there any Sami, Inuits, or Eskimo thriving on locally-produced vegetarian foods?).

Now I eat far less chicken and fish; they don’t dominate the plate but are supplements to the grains and vegetables, and I eat them only a few times a week. I eat a lot of beans and rice, oatmeal, grains. No fast food — and I don’t miss that at all.

There’s a relief to being forced to do what I’ve known for a long time I should do but have been too lazy to bother doing.

So far, I’ve had no more problems with HE. There are other theories about what causes hepatic encephalopathy, but the prevailing one is that when the liver can’t handle the ammonia that is a by-product of protein digestion, the ammonia crosses the blood-brain barrier, and the brain becomes a sink for this noxious toxin.

Still, it is amazing to me that cirrhosis has been recognized as a disease for hundreds of years and yet so many questions remain about its treatment and effects, but I suspect that may be because it is largely linked to alcoholism, and the stigma of cirrhosis as a lifestyle and avoidable disease.

Advertisements

6 thoughts on “Protein, Ammonia, Cirrhosis, and Hepatic Encephalopathy: What I Learned

  1. I’m in Canada, and I know that when I was diagnosed in 2013, the FibroScan was quite new technology. I’ve read that liver biopsies are the gold standard for diagnosis of cirrhosis but luckily my hepatologist considers them to be too invasive.

    By the way, I believe my PBC was kicked off by me taking a Chinese herbal preparation called Jin Bu Huan anodyne (for insomnia) for over a decade. It turns out that Jin Bu Huan was banned in Canada because it can cause liver, brain, and nerve damage. Unknowingly, I was still taking it. So aside from taking Ursodiol, I stopped taking Jin Bu Huan and therefore stopped the damage to my liver.

    Well, I sure hope your bilirubin levels lower and all your other levels stay down. Wishing you all good health and happiness!

  2. I had not even heard of FibroScan before. I see now that although it has been available in Europe since 2003, it was only approved in the US in 2013. Pretty amazing lack. I need to talk with my hepatologists about it, although now since they saw a good deal of the liver when putting in the shunt it may not matter.

    Thank you so much for bringing this to our attention,

  3. That is an amazing and encouraging account, Peggy. My bloodwork was normal for years once I started on the Urso, but the upper GI bleeds I was having suggested the liver was very compromised. Now the ALP, AST, and alk phos are still in high normal range, but bilirubin is not. But it hasn’t worsened in 4 months, so we shall see!

  4. I sure feel for you…it sounds like you’ve been through hell and back. I admire your determination to dig for information and do whatever it takes to help yourself. You would’ve made an excellent doctor, I’ll bet!

    Over the years I’ve been switched back and forth from being a vegetarian to a meat-eater. My diet included meat since being diagnosed with cirrhosis in 2013…I would say on average I have meat 2-3 times a week.

    This past spring I had a Fibroscan done again and was told that my cirrhosis reversed from stage 4 to stage 2 (fibrosis). This is just anecdotal, but I’ve really only changed a few things about my diet since 2013: I drink green smoothies almost daily, I add about 1/2 tsp. of turmeric to my food on most days, and I add raw garlic to a lot of my meals (focussing on anti-inflammatories). I’ve read though that turmeric wouldn’t be a good idea for someone in the later stages of PBC because it thins the blood. My blood tests are all normal and my hepatologist tells me that he couldn’t even tell I have liver disease when he looks at my test results.

    I’m keeping my fingers crossed that I continue to improve. I hope your health improves as well. Sending healing vibes your way! 🙂

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s