From the Guidelines
The patient with cirrhosis and increasing hyperbilirubinemia over three months should be promptly referred to a hepatologist or gastroenterologist for comprehensive assessment and consideration for liver transplantation, while initial management includes laboratory testing, abdominal ultrasound, and possible upper endoscopy to evaluate for portal hypertension or hepatocellular carcinoma. The patient's presentation with scleral icterus and increasing hyperbilirubinemia suggests progressive liver dysfunction, which requires immediate attention to prevent further complications such as hepatic encephalopathy, variceal bleeding, or hepatorenal syndrome 1.
Initial Management
- Laboratory testing: complete liver panel, coagulation studies, CBC, renal function
- Abdominal ultrasound with Doppler to assess for portal hypertension or hepatocellular carcinoma
- Possible upper endoscopy to evaluate for varices
- Abstain from alcohol completely
- Avoid hepatotoxic medications including NSAIDs and acetaminophen doses exceeding 2g/day
- Follow a low-sodium diet (2g/day)
Additional Interventions
- Diuretic therapy with spironolactone 100mg daily and furosemide 40mg daily may be needed if ascites is present, with dose adjustments based on response
- Lactulose 25-30mL every 6-8 hours should be initiated if hepatic encephalopathy is suspected, titrating to achieve 2-3 soft bowel movements daily These interventions address the progressive liver dysfunction causing hyperbilirubinemia and jaundice, while the specialist evaluation will determine the best course of treatment, including consideration for liver transplantation based on disease severity and etiology 1.
Key Considerations
- The patient's bilirubin levels should be closely monitored, and any signs of hepatic encephalopathy, such as confusion or altered mental status, should be promptly addressed with lactulose therapy
- The patient's renal function should also be closely monitored, as hepatorenal syndrome is a potential complication of cirrhosis, and terlipressin plus albumin may be considered if hepatorenal syndrome is suspected 1
From the FDA Drug Label
The efficacy of XIFAXAN 550 mg taken orally two times a day was evaluated in a randomized, placebo-controlled, double-blind, multi-center 6-month trial of adult subjects from the U.S., Canada, and Russia who were defined as being in remission (Conn score of 0 or 1) from hepatic encephalopathy (HE). Eligible subjects had ≥2 episodes of HE associated with chronic liver disease in the previous 6 months. A total of 299 subjects were randomized to receive either XIFAXAN (n=140) or placebo (n=159) in this study Patients had a mean age of 56 years (range, 21-82 years), 81% <65 years of age, 61% were male and 86% White. At baseline, 67% of patients had a Conn score of 0 and 68% had an asterixis grade of 0. Patients had MELD scores of either ≤10 (27%) or 11 to 18 (64%) at baseline. No patients were enrolled with a MELD score of >25. Nine percent of the patients were Child-Pugh Class C Lactulose was concomitantly used by 91% of the patients in each treatment arm of the study.
The management for a 56-year-old patient with cirrhosis and scleral icterus presenting with increasing hyperbilirubinemia over three months may include rifaximin (XIFAXAN) 550 mg taken orally two times a day, as it has been shown to reduce the risk of hepatic encephalopathy (HE) breakthrough by 58% during a 6-month treatment period 2.
- Key considerations:
- The patient's MELD score and Child-Pugh class should be evaluated to determine the severity of their liver disease.
- Lactulose may be used concomitantly with rifaximin.
- The patient should be monitored for breakthrough HE episodes and HE-related hospitalizations.
From the Research
Management of Cirrhosis
The management of a 56-year-old patient with cirrhosis and scleral icterus presenting with increasing hyperbilirubinemia over three months involves a comprehensive approach to prevent complications and improve quality of life 3, 4, 5.
Diagnosis and Assessment
Diagnosis of cirrhosis can be made through liver biopsy, but non-invasive methods such as elastography can also confirm cirrhosis at levels of 15 kPa or greater 4. Assessment of liver function, including liver function tests and prothrombin time/international normalized ratio, is crucial in evaluating the severity of cirrhosis 5, 6.
Treatment Goals
Treatment goals for patients with cirrhosis include preventing decompensation, managing complications, and improving survival 3, 4, 5.
Management of Complications
- Ascites: Treatment includes diuresis, salt restriction, and antibiotic prophylaxis for spontaneous bacterial peritonitis, when indicated 4, 5.
- Hepatic Encephalopathy: Management involves lifestyle and nutritional modifications, and as needed, lactulose and rifaximin 4, 5, 7.
- Varices: Monitoring with endoscopy and prophylaxis with nonselective beta blockers are recommended 4, 5, 7.
- Hepatocellular Carcinoma: Screening with ultrasound every six months is recommended for patients with cirrhosis 5.
Pharmacological Interventions
- Nonselective β-blockers: Reduce the risk of decompensation or death in patients with portal hypertension 4.
- Lactulose: Associated with reduced mortality and risk of recurrent overt hepatic encephalopathy 4, 7.
- Terlipressin: Improves the rate of reversal of hepatorenal syndrome 4, 7.
Symptomatic Management
Symptoms such as muscle cramps, poor-quality sleep, pruritus, and sexual dysfunction can be managed with specific therapies, including hydroxyzine for sleep dysfunction, pickle brine and taurine for reducing muscle cramps, and tadalafil for improving sexual dysfunction in men 4.