What are the steps involved in diagnosing and managing cirrhosis?

Diagnosis and Management of Cirrhosis

Diagnostic Approach

The diagnosis of cirrhosis requires a combination of clinical, laboratory, imaging, and sometimes histological findings, with non-invasive methods increasingly replacing liver biopsy as the first-line diagnostic approach.

Initial Assessment

• Laboratory evaluation:

  • Complete blood count (look for thrombocytopenia)
  • Liver function tests (AST, ALT, alkaline phosphatase, bilirubin)
  • Albumin and prothrombin time/INR
  • Transferrin saturation and ferritin 1
  • Viral hepatitis serologies (HBV, HCV) 2

• Non-invasive fibrosis assessment:

  • Serum-based markers:

    • FIB-4 score (age, AST, ALT, platelet count)
    • APRI (AST to platelet ratio index)
    • FibroTest/FibroSure 2

  • Imaging-based assessment:

    • Transient elastography (FibroScan): Cirrhosis typically confirmed at ≥15 kPa 3
    • Standard ultrasonography (look for nodular liver surface, coarse echotexture) 2

Definitive Diagnosis

• Liver biopsy: Still the gold standard for diagnosis and staging of cirrhosis 4
  • Indications:
    • Indeterminate results from non-invasive testing
    • Unknown etiology of liver disease
    • When results would alter management 5
  • A biopsy core of at least 2.5-3.0 cm should be obtained for adequate assessment 1

Etiological Workup

• Alcohol use history
• Viral hepatitis (HBV, HCV)
• Metabolic factors (diabetes, obesity, dyslipidemia)
• Autoimmune markers
• Iron studies for hemochromatosis 1
• Copper studies for Wilson's disease
• Alpha-1 antitrypsin levels

Management of Cirrhosis

General Management

1. Treat underlying cause:

   • Abstinence from alcohol
   • Antiviral therapy for viral hepatitis
   • Weight loss and metabolic control for NAFLD 1

2. Nutrition and lifestyle:

   • Adequate caloric intake (35-40 kcal/kg/day)
   • Protein intake (1.2-1.5 g/kg/day)
   • Sodium restriction (5-6.5g salt/day) 6
   • Avoid nephrotoxic drugs (NSAIDs, aminoglycosides, ACE inhibitors) 6

3. Monitoring:

   • Clinical assessment with laboratory tests every 6 months
   • Calculate Child-Pugh and MELD scores regularly 5
   • Hepatocellular carcinoma screening with ultrasound every 6 months 2

Management of Complications

1. Portal Hypertension and Varices:

   • Endoscopic screening for varices
   • Prophylaxis with non-selective beta-blockers (propranolol or carvedilol) 6
   • Acute variceal bleeding: Volume resuscitation, vasoactive drugs, endoscopic band ligation within 12 hours 6

2. Ascites Management:

   • Grade 1 (mild): Sodium restriction
   • Grade 2 (moderate): Sodium restriction + diuretics (spironolactone 100 mg/day, can increase up to 400 mg/day)
   • Grade 3 (large): Sodium restriction + diuretics + large volume paracentesis with albumin replacement (8g/L of ascites removed) 6

3. Hepatic Encephalopathy:

   • Identify and treat precipitating factors (infection, GI bleeding, electrolyte imbalances)
   • First-line therapy: Lactulose (reduces mortality from 14% to 8.5%) 3
   • Second-line: Rifaximin (particularly for recurrent episodes) 6
   • Avoid sedatives and medications that may precipitate encephalopathy 6
   • Consider branched-chain amino acid supplementation 6

4. Spontaneous Bacterial Peritonitis:

   • Diagnostic paracentesis for ascites with neutrophil count >250/mm³ 6
   • Immediate broad-spectrum antibiotics (third-generation cephalosporin) 6
   • Antibiotic prophylaxis for high-risk patients

5. Hepatorenal Syndrome:

   • Albumin infusion plus vasoactive drugs (terlipressin, octreotide, midodrine) 6
   • Terlipressin improves reversal rates from 18% to 39% 3
   • Expedited referral for liver transplantation 6

6. Hepatocellular Carcinoma:

   • Ultrasound screening every 6 months 1
   • Alpha-fetoprotein may be used in combination with ultrasound 1

Liver Transplantation Referral

Referral for liver transplantation evaluation should be considered for patients with:

• MELD score ≥15
• Complications of cirrhosis (refractory ascites, recurrent variceal bleeding, hepatorenal syndrome, hepatic encephalopathy)
• Hepatocellular carcinoma 5, 6

Prognosis

• Median survival after onset of complications:

  • Hepatic encephalopathy: 0.92 years
  • Ascites: 1.1 years
  • Hepatorenal syndrome: less than 2 weeks 3

• Approximately 40% of people with cirrhosis are diagnosed only when they present with complications 3

Common Pitfalls to Avoid

1. Delayed diagnosis: Only one in three people with cirrhosis knows they have it 2
2. Overreliance on liver enzymes: Normal liver enzymes do not exclude cirrhosis
3. Missing hepatocellular carcinoma: Ensure regular screening every 6 months
4. Inappropriate medication use: Avoid sedatives, NSAIDs, and other hepatotoxic medications
5. Inadequate monitoring: Regular follow-up is essential to detect and manage complications early

Remember that early cirrhosis may be reversible with appropriate management of the underlying cause, making timely diagnosis and intervention crucial for improving outcomes 2.