Review: Fatigue in Cirrhosis, 2022, Bhandari and Kapoor

Fatigue is a common symptom in patients with liver disease and has a significant impact on the health-related quality of life (HR-QoL). Its pathogenesis is poorly understood and is considered multifactorial. The liver is central in the pathogenesis of fatigue because it uniquely regulates much of the production, storage, and release of substrate for energy generation. Also, the liver “cross-talks” with the key organs that are responsible for this symptom complex—gut, skeletal muscle, and brain. Fatigue can have both peripheral (i.e., neuromuscular) and central (i.e., resulting from changes in neurotransmission within the brain) components. The treatment strategies for the management of fatigue are behavioral changes and pharmacotherapy, along with dietetic intervention and exercise. However, there is no consensus on management strategies for fatigue in patients with liver disease. This article gives an overview of fatigue as a concept, its pathophysiology, measures to evaluate fatigue in patients with liver disease, the impact of fatigue on chronic liver disease, assessment of fatigue in an appropriate clinical setting, and various interventions to manage fatigue.

Open access, https://www.jcehepatology.com/article/S0973-6883(21)00234-6/fulltext

 

Excerpts from the paper that mention ME. My bolding.

"The concept that fatigue could be a disease entity in itself and not just a symptom of pathological/clinical conditions gained traction after acceptance of ME/CFS [meningo-encephalomyelitis/chronic fatigue syndrome] as a chronic complex systemic disease. ME/CFS has distinct diagnostic criteria [Institute of Medicine criteria, iom.nationalacademies.org/reports/2015/me-cfs aspx], case definition, and biological abnormalities. These are post-exertional malaise, unrefreshing sleep, cognitive impairment, and orthostatic intolerance.4"

"There is extensive literature regarding the management of fatigue in patients with chronic fatigue syndrome and cancer-related fatigue.19 With regards to managing fatigue in patients with liver disease, few specific interventions have shown promise. The TrACE model was developed for patients with PBC and has been used in the management of patients with liver disease of other etiologies too. It includes Treating the treatable causes of fatigue, Ameliorating the modifiable symptoms, Coping, and Empathizing 20 patients’ thoughts and beliefs also contribute profoundly to central fatigue. Cognitive behaviour therapy works better in chronic fatigue syndrome, and it can be used in liver disease-associated fatigue also.21 The authors use a similar kind of approach called TRACES for patients with advanced fibrosis, cirrhosis, and liver decompensation"

"Since its first elaborate description by Angelo Mosso in 1891, fatigue continues to be easy to understand the concept of a diminution in muscular force, although not as much an abnormal sensation for perceived effort. Strict criteria as described in the meningoencephalitis chronic fatigue syndrome [ME/CFS] do not exist for patients with chronic liver disease, although this problem is quite prevalent, persistent, and perplexing in this cohort of patients. Biomarkers to define the symptom complex have remained elusive. Hepatic encephalopathy and dysautonomia confound the interpretation of the cognitive and affective domains of this symptom in chronic liver disease patients. The authors have noted in their experience that there is a physical differential in fatigue in patients with chronic liver disease—upper limb <lower limbs, recumbent < upright. This is different from other disease conditions where fatigue is an important feature. The mainstay of therapy has been adequate substrate provision and building good quality muscle mass through physical exercise. Study of bio-energetics and tissue-specific energy substrate assessment [OXPHOS/ETC] hold promise as future research tools."

 

The lack of attention to details is incredible. ME is not "fatigue, but as a disease", what an ignorant thing to say. But of course that's what's generally believed so this is basically systemic incompetence.

What I don't get is on what basis these people think they actually understand fatigue enough to talk about it, when they so obviously show they have no clue about the basic concepts. This comes off as inept as the oldest Catholic priest you can imagine giving marital advice to a newlywed couple. Decades of getting it wrong without being told it's wrong looks exactly the same, whether in religion, or as a weird type of medical religion.

 

"The concept that fatigue could be a disease entity in itself and not just a symptom of pathological/clinical conditions gained traction after acceptance of ME/CFS"

Fatigue is just a symptom of a pathological/clinical condition in ME too. It was psychologists who dropped all the other symptoms and would not talk about them. We always had them for anyone who cared to ask.