What is the initial approach to managing liver cirrhosis?

Initial Management of Liver Cirrhosis

The initial approach to managing liver cirrhosis should focus on identifying and treating the underlying cause, implementing nutritional therapy, restricting sodium intake, and monitoring for complications. 1

Etiology-Based Management

Identify and Treat Underlying Cause

• Alcoholic cirrhosis: Complete abstinence from alcohol is essential as it improves liver fibrosis, lowers portal pressure, and increases survival rates 1, 2
• Viral hepatitis:
  • HBV-related cirrhosis: Antiviral therapy if HBV DNA ≥2,000 IU/mL regardless of AST/ALT levels 1
  • HCV-related cirrhosis: Direct-acting antiviral agents can improve liver function and portal hypertension 3, 1
• Nonalcoholic steatohepatitis: Weight management, diabetes control, and lifestyle modifications 4
• Autoimmune hepatitis: Immunosuppressive therapy 3

Nutritional Management

• Caloric intake: 35-40 kcal/kg/day 1
• Protein intake: 1.2-1.5 g/kg/day (avoid protein restriction even with hepatic encephalopathy) 3, 1
• Carbohydrate intake: 2-3 g/kg/day 1
• Meal pattern recommendations:
  • Smaller, more frequent meals
  • Late-evening snack of 200 calories to prevent overnight starvation 3, 1
  • BCAA supplementation if hepatic encephalopathy is present 1

Important: Perform nutritional screening in all cirrhotic patients and complete detailed assessment in those at risk of malnutrition 3

Sodium and Fluid Management

• Sodium restriction: Limit to less than 5 g/day (sodium: 2 g/day, 88 mmol/day) 3, 1
• Fluid restriction: Generally not necessary unless serum sodium <120-125 mmol/L 3, 1

Screening and Monitoring for Complications

Portal Hypertension and Varices

• Upper endoscopy screening for esophageal varices 1
• Prophylaxis with non-selective beta-blockers (carvedilol or propranolol) for patients with varices 1, 4
  • Beta-blockers reduce risk of decompensation or death compared to placebo (16% vs 27%) 4

Ascites Management

• Grade 1 (mild): Sodium restriction 3, 1
• Grade 2 (moderate): Sodium restriction + diuretics 3, 1
  • Start with spironolactone 100 mg/day, increasing to 400 mg/day if needed 3
  • Add furosemide up to 160 mg/day if spironolactone alone is insufficient 3
  • Combination aldosterone antagonist and loop diuretics are more effective than sequential therapy (76% vs 56% resolution) with lower rates of hyperkalemia (4% vs 18%) 4
• Grade 3 (large/tense): Therapeutic paracentesis followed by sodium restriction and diuretics 3, 1
  • Volume expansion with albumin (8 g/L of ascites removed) for large volume paracentesis 3

Hepatic Encephalopathy

• Lactulose is first-line therapy 1, 4
  • Reduces mortality compared to placebo (8.5% vs 14%) 4
  • Reduces risk of recurrent overt hepatic encephalopathy (25.5% vs 46.8%) 4
• Add rifaximin for recurrent episodes despite lactulose 4

Spontaneous Bacterial Peritonitis (SBP)

• Diagnostic paracentesis for all cirrhotic patients with ascites on hospital admission 3
• Antibiotic prophylaxis for high-risk patients (previous SBP or low protein ascites) 3, 1
  • Ciprofloxacin 500 mg daily or norfloxacin 400 mg daily 3

Hepatocellular Carcinoma

• Ultrasound screening every 6 months 1, 5

Medication Management

• Avoid nephrotoxic drugs (NSAIDs, ACE inhibitors, angiotensin receptor blockers) 1, 4
• Adjust medication dosages due to altered pharmacokinetics 1

Liver Transplantation Consideration

• Consider for patients with decompensated cirrhosis 3, 1
• All patients with spontaneous bacterial peritonitis should be considered for referral 3
• Also recommended for patients with small hepatocellular carcinoma (single nodule ≤5 cm or up to three lesions ≤3 cm) 1

Pitfall to avoid: Delaying treatment of the underlying cause. Early intervention can potentially reverse fibrosis in early cirrhosis and prevent further decompensation 5.