What is the treatment for cirrhosis (scarring of the liver)?

Treatment of Cirrhosis

The treatment of cirrhosis should focus on addressing the underlying cause of liver disease, managing complications, and implementing sodium restriction (88 mmol/day [2000 mg/day]) with diuretic therapy (spironolactone with or without furosemide) as first-line treatment for ascites. 1, 2

Addressing the Underlying Cause

Treating the underlying cause of cirrhosis is crucial for preventing disease progression:

• Alcohol-related cirrhosis: Complete abstinence from alcohol is essential. Patients who stop drinking have approximately 75% 3-year survival, while those who continue drinking have significantly worse outcomes 1
• Viral hepatitis: Antiviral therapy for hepatitis B or C can improve liver function and potentially reverse fibrosis 1, 2
• Nonalcoholic fatty liver disease: Weight loss and metabolic control are primary interventions 2, 3
• Autoimmune hepatitis: Immunosuppressive therapy 2

Management of Ascites

Ascites is a common complication requiring prompt intervention:

1. Dietary sodium restriction:

   • Limit to 2000 mg/day (88 mmol/day) 1
   • Nutritional counseling is recommended 1

2. Diuretic therapy:

   • First presentation of moderate ascites: Start with spironolactone monotherapy (100 mg daily, can increase to 400 mg) 1, 4
   • Recurrent or severe ascites: Combination therapy with spironolactone (100-400 mg) and furosemide (40-160 mg) 1, 2
   • Monitor for adverse effects including hyponatremia, hyperkalemia, and renal dysfunction 1

3. Large volume paracentesis (LVP):

   • Indicated for tense/refractory ascites 1, 2
   • Administer albumin (8g/L of ascites removed) when removing >5L 2
   • Perform diagnostic paracentesis to rule out spontaneous bacterial peritonitis (SBP) 1

Management of Other Complications

Spontaneous Bacterial Peritonitis (SBP)

• Diagnostic paracentesis should be performed in all cirrhotic patients with ascites on hospital admission 1
• Immediate empirical antibiotic therapy when SBP is suspected 1
• Prophylactic antibiotics (norfloxacin 400 mg daily or ciprofloxacin 500 mg daily) for high-risk patients 1, 2

Esophageal Varices

• Regular endoscopic surveillance (every 1-3 years depending on cirrhosis severity) 1, 2
• Non-selective beta-blockers (propranolol or carvedilol) for prophylaxis 1, 3

Hepatic Encephalopathy

• Lactulose is first-line therapy 2, 3
• Rifaximin can be added for refractory cases 3, 5
• Identify and treat precipitating factors (infection, GI bleeding, electrolyte imbalances) 6

Monitoring and Follow-up

• Regular assessment of liver function tests every 6 months 7, 5
• Calculate Child-Pugh and MELD scores to assess disease severity 7
• Screen for hepatocellular carcinoma with ultrasound every 6 months 2, 5
• Consider referral for liver transplantation evaluation for decompensated cirrhosis 2, 3

Important Precautions

• Avoid nephrotoxic medications, especially NSAIDs 1, 2
• Fluid restriction is only necessary for severe hyponatremia (serum sodium <125 mmol/L) 1, 2
• Avoid starch-based volume expanders 1
• Use a restrictive transfusion strategy (hemoglobin threshold of 7 g/dl) in patients with GI bleeding 1

Nutritional Support

• Ensure adequate caloric intake (35-40 kcal/kg/day) and protein intake (1.2-1.5 g/kg/day) 2
• Consider branched-chain amino acid supplementation for patients with hepatic encephalopathy 2

The management of cirrhosis requires a comprehensive approach targeting the underlying cause while preventing and treating complications. Early intervention is critical to prevent disease progression and improve quality of life and survival.