The main findings of this study indicated that experiencing SOB was associated with a reduction in exercise; experiencing nausea and vomiting was associated with adopting exercise, and experiencing RUQ pain was associated with consuming F&V. In addition, the QOL of LC patients was negatively affected by experiencing muscle cramps, anorexia, RUQ pain and body pain, itching, ascites or edema, bruising, and change in appearance. Our results suggest that the types of symptoms experienced by a patient with LC affect the patient’s adoption of exercise, dietary behavior, and QOL.
The current study indicated that experiencing SOB was associated with a decrease in exercise performance. SOB can be complicated by ascites or pleural effusion in patients with cirrhosis. Dyspnea is well-known to induce exercise intolerance and individuals with daily-life dyspnea have more limited exercise capacity [19]. SOB may have inhibited exercise in cirrhosis population because this symptom becomes worse during exercise. Patients who perceive a temporary worsening of symptoms during physical activity may be less physically active [20]. Previous studies of the relationship between dyspnea and exercise intolerance were conducted in patients with pulmonary disease and multiple sclerosis. Therefore, further study is required to determine the impact of SOB on exercise levels in LC patients.
On the other hand, we found that experiencing nausea correlated with engaging in exercise and experiencing RUQ pain correlated with greater F&V consumption. According to the Health Belief Model, patients will perform healthy behaviors if they believe there is a high risk that the symptoms and complications could adversely affect their lives, and that the performance of healthy behaviors is an effective method to these symptoms. When symptoms and complications are already present, this may prompt patients to adopt healthy behaviors. The positive association between development of nausea and performing exercise may be because exercise can induce gastrointestinal symptoms, such as nausea, heartburn, and abdominal pain [21]. This is because exercise can increase the level of catecholamine, which activates adrenergic receptors and induces nausea and vomiting [22]. In contrast, most longitudinal studies of patients with cancer have reported that those who exercise experienced significantly less intense nausea and greater alleviation of other symptoms [23]. The current study had a cross-sectional design, so we cannot determine whether nausea led to increased exercise or if increased exercise led to nausea. However, it is unlikely that patients with LC would exercise so intensely as to cause gastrointestinal symptoms. Thus, we believe that the experience of gastrointestinal symptoms has been a cue that increased the performance of exercise, according to the Health Belief Model. Further longitudinal studies are required to make a definitive conclusion on the causal relationship between symptom and the adoption of healthy behaviors.
Our results indicated that symptoms that were more frequent, intense, and distressing, differed from the symptoms that affected QOL. In particular, patients whose symptoms were more frequent, intensive, and distressing experienced fatigue, muscle cramps, and decreased memory, respectively. The findings are in line with those of a previous integrative review, which reported that fatigue was common among populations with chronic liver disease [24]. The general findings from the current study, which found an association of symptoms with poor QOL in patients with LC, agree with the findings of previous studies [25].
Experiencing muscle cramps can negatively influence physical functioning and increase role limitations. Patients with LC frequently report painful muscle cramps [26], and typically describe them as abrupt, uncomfortable squeezing or contraction of a muscle, that last seconds to minutes. Our finding supports a previous study, which reported that although muscle cramps are not life-threatening, they are a major concern and closely associated with perception of a poor health status perception among patients with LC [27]. Another previous study also showed that muscle cramps are related with significantly decreased QOL in patients with LC [28]. Because muscle cramps are often intermittent and subjective, and predisposition to cramping is difficult to measure using a diagnostic tool, clinicians and researchers often overlook this symptom [28]. Although muscle cramps are easy to ignore, they can significantly impact the QOL of patients with LC, so professional clinical nurses should help in the assessment of this symptom.
Experiencing anorexia can negatively impact physical and social functioning and increase role limitations. The finding was consistent with previous studies, which reported that patients with LC and gastrointestinal symptoms had profound reductions in physical functioning based on the SF-36 [29], and that malnutrition due to anorexia was significantly associated with self-perception of lower QOL in patients with LC [30].
RUQ pain and body pain can also negatively impact physical and social functioning. Our rating of symptoms according to their frequency, intensity, and distress indicated that RUQ pain ranked eleventh and body pain ranked fourteenth among all symptoms. Although pain is not among the most serious symptoms, a small change in patients’ pain experience may significantly impact QOL, so it is important that professional clinical nurses carefully assess each patient’s individual experience of pain. This finding supports a previous study that compared age and gender-matched controls and found that patients with LC were impaired in all QOL domain scores [27].
Itching and ascites/edema had a negative impact on physical functioning. Pruritus is an extrahepatic symptom that is the greatest burden for patients with LC, and our study rated it as the fourth-most serious symptom overall. Persistent itching may lead to severe sleep loss, depression, and suicidal thoughts in patients with LC [31]. Assessment of itching severity allows objective assessment of its influence on a patient’s health and QOL, so that different therapies can be implemented. According to previous studies, ascites, serum sodium levels, and lower extremity edema were independently associated with impaired physical functioning [32] and decreased QOL in patients with LC [33]. Thus, professional clinical nurses should perform systematic assessments of patients with LC who present with itching, ascites, and edema.
Role limitations due to emotional problems were greater in those who experienced changes in appearance. We speculate that a patient with LC who has readily visible symptoms (itching, edema, and ascites) may experience greater problems with body self-image and consequently greater emotional distress. Previous clinical studies of patients with cancer reported that changes in physical appearance that resulted from disease progression or treatment produce psychological distress [34, 35]. The development of changes in appearance can have a profound impact on multiple functions such as working with others [36]. The present study of patients with LC indicated that emotional problems due to a poor body self-image seemed to be associated with greater role limitations. Healthcare professionals should be aware of a patient’s body self-image as a potential indicator of poor role functioning when referring a patient with LC for psychosocial care.
Being employed was positively associated with social functioning [37], and being married was negatively associated with role limitations [38]. These results are in line with the common idea that a patient who is married or in a common-law relationship has better health-related QOL. Previous studies also found that socioeconomic factors affected QOL, in those patients with HCV who were married or had a cohabitant had significantly better QOL than their single counterparts [39]. This is presumably because a spouse can provide social and emotional support that increases QOL.
This study indicated that symptoms had an impact QOL, yet performing exercise and consuming F&V did not. Although some studies have reported exercise-induced improvement in the metabolic profile [40], a randomized controlled trial on home-based physical activity and diet intervention showed no improvement in QOL [41]. Thus, more evidence addressing the benefits of exercise and diet in relation to cirrhosis is still needed, with emphasis on individuals with cardiovascular risk, musculoskeletal disorders, and complications related to cirrhosis. Cirrhosis patients need certified exercise and diet professionals who can perform a detailed functional assessment and design an individualized exercise and diet regimen in order to improve their QOL [6].
The symptom scores of our patients were lower than in previous studies [15], possibly because the symptoms of patients with LC may be a wide range of symptom development in those with advanced disease, whereas patients with LC may be asymptomatic for years. Importantly, professional clinical nurses should keep in mind that although a symptom score may be low, the symptoms may still negatively affect QOL and health-related behaviors.
Clinical nurses play pivotal roles in the systematic assessment of symptoms and the implementation of treatments in the management of patients with LC. Identification of symptoms that occur during the different stages of LC may inform the development of interventions that target multiple symptoms at once, thereby improving the effectiveness of symptom management. Knowledge of the impact of symptom on QOL during the different stages of LC can guide best practices for symptom assessment. Our findings suggest that professional clinical nurses require a deep understanding of the symptoms of patients with LC.
The major limitations of this study are the use of cross-sectional design and the small sample size. However, because many previous studies of this topic also examined about 100 individuals, we believe it is reasonable to compare our results with those of previous studies. In addition, our results suggest that the adoption of healthy behaviors had no significant effect on QOL. Therefore, further longitudinal or experimental studies for patients with LC are required to identify the causal relationship between the adoption of healthy behaviors and QOL. Despite these limitations, very few previous studies have identified the various types of symptom and QOL in patients with LC.
In conclusion, this study of patients with LC indicated that the type of symptoms experienced by a patient can lead to the adoption or rejection of healthy behaviors and that the symptom of a patient can also negatively impact QOL. Patients with LC have symptom that differ in frequency, intensity, and distress, and that have different effects on QOL. Professional clinical nurses should carefully assess patients who have symptoms of anorexia, RUQ pain and body pain, ascites/edema, and change of appearance because these can negatively impact QOL, even in patients who appear to be asymptomatic. Patients with LC require specialized support for the assessment and management of symptoms. Identification of the association of symptom with the intention of adopting healthy behaviors and QOL provides a basis for the development of symptom management strategies and other interventions that may improve the QOL of patients with LC.