From the Guidelines
Patients with cirrhosis should be monitored regularly with follow-up visits every 3-6 months, depending on disease severity, and their care should be provided with palliative care principles, including assessment of symptoms, caregiver support, and goals of care discussions, as recommended by the most recent guidelines 1. The follow-up plan should include comprehensive laboratory testing, such as complete blood count, liver function tests, coagulation studies, and renal function tests, as well as periodic ultrasound surveillance for hepatocellular carcinoma every 6 months.
- Endoscopic screening for esophageal varices is recommended at diagnosis and then every 1-3 years based on initial findings and disease progression.
- Patients should undergo regular assessment of their nutritional status, with sodium restriction and protein intake optimization.
- Medication management includes diuretics for ascites, beta-blockers for varices, and lactulose for hepatic encephalopathy. The prognosis should be evaluated by gastroenterology/hepatology providers during routine care visits and at sentinel events, and goals of care discussions should be repeated at these events, including hospital or intensive care admission, before initiation of life-supporting therapies, before surgery, on new onset of cirrhosis-related complications, and after determination of transplant eligibility 1. Healthcare providers should consider how they can optimize efficiencies in palliative care delivery and work together with local specialist palliative care teams to establish clear triggers and pathways for referral 1. Patients who have comfort-oriented goals and prognosis of 6 months or less should be referred to hospice in a timely manner 1. The comprehensive approach is essential because cirrhosis is progressive and associated with numerous complications that can be detected early and managed effectively with regular monitoring, potentially improving quality of life and survival, as supported by previous guidelines 1.
From the Research
Follow-up Plan for Patients with Cirrhosis
The follow-up plan for patients with cirrhosis involves regular monitoring and surveillance for liver complications to reduce morbidity and mortality. Some key aspects of the follow-up plan include:
- Regular laboratory testing, such as complete blood count, comprehensive metabolic panel, and prothrombin time, at least every 6-12 months 2
- Hepatocellular carcinoma (HCC) surveillance with imaging studies every 6-12 months 3, 2
- Esophageal varices (EV) surveillance at least every 1-2 years 4, 2
- Monitoring for complications such as ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, portal hypertension, variceal bleeding, and hepatorenal syndrome 5, 4
Factors Associated with Adherence to Follow-up Plan
Several factors are associated with adherence to the follow-up plan, including:
- Age: patients aged 41-55 years are more likely to undergo regular monitoring and surveillance 2
- Insurance plan: patients with preferred provider organization insurance plans are more likely to undergo regular monitoring and surveillance 2
- Specialist care: patients receiving care from specialists are more likely to undergo regular monitoring and surveillance 2
- Diagnosis period: patients diagnosed between 2013-2016 are more likely to undergo regular monitoring and surveillance 2
- Type of cirrhosis: patients with decompensated cirrhosis are more likely to undergo regular monitoring and surveillance 2
- Comorbidities: patients with higher Charlson comorbidity index are more likely to undergo regular monitoring and surveillance 2
Treatment and Management
The treatment and management of cirrhosis involve a multidisciplinary approach, including:
- Nonselective β-blockers to prevent decompensation in patients with clinically significant portal hypertension 6, 5
- Lactulose and rifaximin for the treatment of hepatic encephalopathy 6, 5, 4
- Combination aldosterone antagonists and loop diuretics for the treatment of ascites 6
- Terlipressin for the treatment of hepatorenal syndrome 6, 5
- Transjugular intrahepatic portosystemic shunt (TIPS) for the treatment of refractory ascites and variceal bleeding 5, 4