From the Guidelines
Management of cirrhosis should prioritize treating the underlying cause, preventing complications, and providing supportive care, with a focus on individualized weight loss for obese patients, as stated in the 2021 AGA clinical practice update 1. The primary approach includes addressing the specific etiology, such as alcohol abstinence for alcoholic cirrhosis, antiviral therapy for viral hepatitis, weight loss for non-alcoholic steatohepatitis, and specific treatments for autoimmune or metabolic causes.
- For obese patients with cirrhosis, weight loss of ≥10% total body weight via lifestyle modification or bariatric surgery, such as laparoscopic sleeve gastrectomy, may decrease portal hypertension and histologic progression 1.
- Complications require targeted management:
- For ascites, sodium restriction and diuretics (spironolactone with furosemide) are recommended.
- For hepatic encephalopathy, lactulose and rifaximin are used.
- For variceal bleeding, endoscopic band ligation, non-selective beta-blockers, and TIPS procedure for refractory cases are considered.
- Portal hypertension management includes beta-blockers and nitrates.
- Nutritional support with 1.2-1.5g/kg/day protein intake and vitamin supplementation is essential.
- Regular screening for hepatocellular carcinoma with ultrasound every 6 months is recommended, as emphasized in the 2018 EASL clinical practice guidelines for the management of patients with decompensated cirrhosis 1.
- For end-stage disease, liver transplantation evaluation should be considered when complications become difficult to manage or liver function significantly deteriorates. This comprehensive approach aims to slow disease progression, improve quality of life, and extend survival in cirrhotic patients.
From the Research
Management Options for Cirrhosis
The management of cirrhosis involves a multifaceted approach, including lifestyle modifications, pharmacological therapies, and surveillance for complications.
- Lifestyle modifications: Patients with cirrhosis should be encouraged to adopt a healthy lifestyle, including a balanced diet, regular physical activity, and avoidance of alcohol and smoking 2.
- Pharmacological therapies: Various medications are available to manage the complications of cirrhosis, such as non-selective beta-blockers for variceal bleeding, diuretics for ascites, and lactulose for hepatic encephalopathy 3, 4, 5, 6.
- Surveillance for complications: Regular monitoring for complications such as varices, ascites, hepatic encephalopathy, and hepatocellular carcinoma is crucial to prevent and manage these conditions effectively 3, 5.
Treatment of Complications
The treatment of complications of cirrhosis depends on the specific condition.
- Varices: Non-selective beta-blockers, such as carvedilol or propranolol, are used to prevent variceal bleeding 5, 6.
- Ascites: Diuretics, such as spironolactone and furosemide, are used to manage ascites, and patients with refractory ascites may require serial therapeutic paracentesis, transjugular intrahepatic stent-shunt (TIPS), or peritoneovenous shunt 4.
- Hepatic encephalopathy: Lactulose is used to manage hepatic encephalopathy, and rifaximin may be used for secondary prophylaxis 5, 6.
- Hepatocellular carcinoma: Surveillance with ultrasound every six months is recommended for patients with cirrhosis, and treatment options include surgical resection, liver transplantation, and ablative therapies 3, 5.
Pharmacological Therapies
Various pharmacological therapies are available to manage cirrhosis and its complications.
- Non-selective beta-blockers: Effective in reducing variceal re-bleeding risk and may have protective effects on fibrosis progression and decompensation 5, 6.
- Diuretics: Remain the mainstay of uncomplicated ascites treatment, and early trials suggest alpha-adrenergic receptor agonists may improve diuretic response in refractory ascites 4, 6.
- Statins: May have protective effects on fibrosis progression, decompensation, and mortality, and their safety has been demonstrated in compensated cirrhosis 6.
- Anticoagulation therapy: May reduce incidence and increase recanalisation rates of non-malignant portal vein thrombosis, and may impede hepatic fibrogenesis and decompensation 6.