Discussion in 'Ask Dr. Decompression' started by ronski101, Jul 16, 2008.
my wife has had cerrosis of the liver for a number of years but still dives. Is there any risk?
DAN, divers alert network, says: http://www.diversalertnetwork.org/medical/articles/article.asp?articleid=41
OTHER CHRONIC INFLAMMATORY DISEASES
Condition: Liver cirrhosis, a destructive process resulting from fibrosis of liver tissue, is most commonly due to toxic substances (alcohol) or viral infections (hepatitis). Complications include bleeding from the esophagus or stomach, impaired blood coagulation, accumulation of fluid in the abdomen and impaired ability to detoxify medications.
Fitness and Diving: If otherwise fit, divers who, have a normal response to exercise, can dive if they have mild cirrhosis, with no symptoms or secondary complications. Before diving, they should be evaluated by their physicians. In cases where cirrhosis is more severe, the rigors of scuba and the effects of the disease could impair a diver’s ability. In such cases, scuba is not recommended.
Here is a question posed to scubdoc.com:
"Cirrhosis and Ascites
Here's a query from a scuba instructor:
57 year old male, history of alcoholism & suffering cirrohsis of the liver. Very large, distended belly ( has the largest "outie" belly button you've ever seen! ), but otherwise not obese. Passed the N.A.U.I. pool test better than most of his classmates. Claims his drinking days are past & has non-diving physician, unrestricted approval to participate. No other medical contraindications noted on the standard N.A.U.I. medical questionaire. He is an educated man ( prof. engineer ) with previous sport diving experience years ago... What is your advice?
It is highly likely that your diver has ascites (large quantities of free fluid in his abdomen surrounding his organs). In addition to his umbilical hernia (which can rupture easily under these circumstances) which has occurred in response to the excess pressure of the fluid - it is also highly likely that he has esophageal varices or dilated blood vessels in the lower end of his gullet.
Due to the effects of immersion on the blood supply of the body, during a dive blood is shunted from the periphery into the blood vessels of the gastrointestinal tract, liver and spleen. This would cause dilation and possible rupture of the esophageal varices with massive hemorrhage. Add to this the acid reflux changes that occur about the cardia (lower end of the gullet and upper stomach) due to the action of Boyle's law during ascent and we have a set up for rupture of not only the varices but the stomach.
This not just a theoretical possibility but has been reported.
Massive variceal bleeding caused by scuba diving.
Am J Gastroenterol. 2000 Dec;95(12):3677-8.
Nguyen MH, Ernsting KS, Proctor DD.
Finally, cirrhosis of the liver to the extent that it causes ascites can have significant mental effects of obtundation of the intellect. Hepatic encephalopathy can cause apathy, confusion, disorientation, drowsiness and slurred speech. This alone would be dangerous enough to disallow diving.
Because of what I consider significant risk, I would not certify this person as fit to dive. "
My concern is bleeding. If you slipped or fall, can you have a brain hemorrhage? I would be very caucious that you dive in easy gentle environment.
Second, some folks have very significant photosensitivity, also called porphyria (PCT - porphyria cutanea tarda). Wear good sunblock, as you skin is very fragile if exposed to the sun.
Third, the inciting cause of your cirrhosis, if it is viral hepatitis - it would be nice to inform your "rescuers" or folks who provide first aid for you - if you carry viral hepatitis. It is a courtesy, as universal precaution often is not practiced when one is urgently bleeding - as a courtesy for your helpers.
Here is a reply crafted from an answer I gave to a very recent question posed by a non-diving physician regarding cirrhosis of the liver and SCUBA. I have tried to phrase it in language that makes sense to the non-medical individual and to provide definitons of medical terms:
The cause of the cirrhosis is not indicated in your post and this is important information. If viral, such as from hepatitis, there are additional considerations beyond the commonly seen scarring of (cirrhosis) and increased blood pressure within the system of veins around (portal hypertension) the liver. If it is the result of alcohol or other substance abuse, there again are additional considerations, including those of a psychiatric nature.
The important matter of medications also is not remarked upon in your post. For example, if an antihypertensive of the beta blocker class were being used to control portal hypertension, the intended limitations in cardiac output might undesirably reduce exercise tolerance to the extent that the possible strenuous aspects of diving (e.g., very intense currents, a buddy rescue, a long surface swim in rough conditions) cannot be performed. As such, the diver taking a beta blocker should be able to attain, or closely approach, 13 mets upon exercise stress testing without chest pain, shortness of breath, EKG abnormality or other worrisome event. Or, if taking an antiviral agent known to weaken the immune system, the diver would be open to infection from the many germs that inhabit fresh and especially saltwater.
In the final analysis, the answer in large part depends upon the manifestations and implications the cirrhosis.
Individuals who can meet the exertional requirements of SCUBA; are otherwise medically, mentally and physically fit; and are not on any problematic medications generally can dive with mild cirrhosis. However, if they show such signs as significant and uncontrolled portal hypertension, enlargement of the spleen, abnormalities of blood coagulation, excess fluid in the abdominal space, bleeding veins in the walls of the lower part of the esophagus or upper part of the stomach, impaired cognitive processes, or are on medications with worrisome implications for SCUBA, then diving would be extremely unwise.
As you may know, every diver must complete a medical/health questionnaire before being taken out by any reputable dive op. An individual reporting clinically significant cirrhosis would almost certainly be required to present written medical clearance for SCUBA.
If you are so disposed, the question also could be discussed, either by your wife or her physician, with DAN at http://www.diversalertnetwork.org/medical/index.asp.
This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice.
As Doc Vikingo is pointing out, not only do you have to consider the cause of the cirrhosis, but the disease itself exists in a rather wide spectrum of manifestations. Some people simply have liver scarring, but without much systemic impact. People with severe cirrhosis can have life-threatening bleeding problems, kidney failure, and severe confusion and lethargy. It's pretty obvious that the latter sort have no business underwater, and the former group are probably fine. What's important is to know where an individual patient falls on that line, in order to be able to make rational risk assessments about any sort of activity, diving included.
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