The liver is the second largest organ in the body. It is located in the right upper abdomen under the rib cage. The liver has many important jobs. It filters harmful substances from the blood and converts food and fluid into the nutrients and energy the body needs. It also helps clot the blood.

Causes of liver disease include viral hepatitis, autoimmune disorders, cancer, obesity, alcohol, drugs, toxins and genetics. Changes that can occur with end-stage liver disease include:

• jaundice;
• increased risk of bleeding;
• buildup of fluid in the abdomen; and
• reduced brain function.

Jaundice is a buildup of bile in the body that causes the skin and eyes to turn yellow. Bile contains a pigment called bilirubin that causes this yellow colour. Jaundice is a sign that the liver can’t move bile to the intestine, which removes it from the body. Sometimes the buildup of bilirubin can be treated with a stent to keep the bile duct open. The person’s health care team may also suggest inserting an external tube to drain bile out of the liver. A buildup of bile can also cause itchiness. Itchiness can be very distressing and difficult to treat. But the person’s doctor can prescribe medications that may help manage this symptom.

When the liver can no longer make proteins to help clot the blood, the person’s risk of bleeding and bruising may increase. Changes may also occur along the person’s gastrointestinal tract, such as the development of enlarged veins in the lower part of the esophagus. These enlarged veins can rupture and pose an increased risk of bleeding. As a result, the health care team needs to consider the risks of bleeding in the person’s care plan. 

Fluid buildup in the abdomen can develop and be uncomfortable. It may cause shortness of breath if there’s pressure on the diaphragm. Fluid buildup may also cause nausea, loss of appetite, and abdominal and back pain. The person may also be at risk of developing an infection when this fluid is present. But the health care team can often drain the fluid. This will temporarily reduce abdominal and back discomfort, shortness of breath and nausea. The fluid may come back in a few weeks (occasionally sooner). But the team can drain it again. The person’s doctor may prescribe a diuretic. This is a medication that helps the body get rid of unwanted fluid. The doctor may also prescribe an opioid (pain medication) to help relieve discomfort and shortness of breath and an anti-nausea medication. Fluid buildup may also occur in the person’s feet and legs.

Another complication of end-stage liver failure is reduced brain function. This is because toxins (such as ammonia) build up in the blood, causing confusion. The person may be unable to tell night from day. He or she may also display irritability and personality changes, or have memory problems. As brain function continues to decline, he or she will become sleepy and increasingly confused. This state can progress to unresponsiveness and coma. Although there is medication that may help reduce confusion, in the final days of liver failure, it will be less useful. The doctor may then prescribe medications to calm the person and maintain his or her comfort and dignity.

Other symptoms of end-stage liver disease include:

• muscle cramps;
• trouble sleeping at night;
• fatigue;
• decreased appetite and intake of food; and
• depression.

As liver function declines, certain medications can further harm the liver or build up in the bloodstream, causing side effects. This concern requires extra attention from the person’s health care team.