What is the initial evaluation and treatment approach for a patient with cirrhosis?

Initial Evaluation and Treatment Approach for Cirrhosis

The initial evaluation of a patient with cirrhosis should include diagnostic paracentesis for new-onset ascites, assessment of liver disease severity using Child-Turcotte-Pugh and MELD scores, screening for varices, and implementation of sodium restriction with appropriate diuretic therapy. 1, 2

Diagnostic Evaluation

Laboratory Assessment

• Complete blood count, liver function tests (bilirubin, albumin, AST, ALT)
• Coagulation studies (INR, prothrombin time)
• Renal function (creatinine, BUN)
• Serum and urine electrolytes
• Etiologic workup:
  • Viral hepatitis serologies (HBV, HCV)
  • Ferritin and transferrin saturation
  • Autoimmune markers if suspected

Imaging

• Abdominal ultrasound to:
  • Assess liver morphology
  • Evaluate for ascites
  • Screen for hepatocellular carcinoma (HCC)
  • Assess portal vein patency
• Transient elastography (FibroScan) to quantify liver stiffness if diagnosis uncertain

Ascites Evaluation

• Diagnostic paracentesis is mandatory for all new-onset ascites 1
• Ascitic fluid analysis should include:
  • Total protein concentration
  • Serum-ascites albumin gradient (SAAG)
  • Neutrophil count to rule out spontaneous bacterial peritonitis (SBP)
  • Ascitic fluid culture (bedside inoculation in blood culture bottles)
  • Additional tests as indicated: cytology, amylase, BNP, adenosine deaminase 1

Disease Severity Assessment

• Calculate Child-Turcotte-Pugh (CTP) score using:

  Parameter	1 point	2 points	3 points
  Bilirubin (mg/dL)	<2	2-3	>3
  Albumin (g/dL)	>3.5	2.8-3.5	<2.8
  INR	<1.7	1.7-2.3	>2.3
  Ascites	None	Mild/Moderate	Severe
  Encephalopathy	None	Grade 1-2	Grade 3-4

• Calculate MELD score (uses bilirubin, creatinine, INR) 1

Treatment Approach

General Management

1. Treat underlying cause:

   • Antiviral therapy for viral hepatitis
   • Alcohol cessation for alcoholic liver disease
   • Weight management for NAFLD/NASH

2. Nutritional support:

   • Adequate caloric intake (35-40 kcal/kg/day)
   • Adequate protein intake (1.2-1.5 g/kg/day)
   • Avoid unnecessary protein restriction, even with hepatic encephalopathy 2

3. Sodium restriction:

   • Limit to 5-6.5 g salt/day (87-113 mmol sodium)
   • No added salt diet with avoidance of precooked meals
   • Nutritional counseling on sodium content 1, 2

4. Medication management:

   • Avoid hepatotoxic medications
   • Adjust dosages for medications metabolized by liver
   • Avoid NSAIDs due to risk of renal impairment

Management of Ascites

• Grade 1 (mild): Sodium restriction alone
• Grade 2 (moderate):
  • Sodium restriction + diuretics
  • Start with spironolactone 100 mg/day
  • If inadequate response, add furosemide 40 mg/day
  • Titrate doses (spironolactone up to 400 mg/day, furosemide up to 160 mg/day) 1, 2, 3
• Grade 3 (large):
  • Large volume paracentesis + albumin replacement (8g/L of ascites removed)
  • Followed by sodium restriction and diuretics 2

Screening and Prophylaxis

1. Variceal screening:

   • Upper endoscopy to screen for esophageal/gastric varices
   • If varices present, initiate prophylaxis with non-selective beta-blockers

2. Spontaneous bacterial peritonitis (SBP) prophylaxis:

   • For patients with prior SBP: norfloxacin (400 mg daily), ciprofloxacin (500 mg daily), or co-trimoxazole
   • For high-risk patients (ascitic protein <1.5 g/dL): consider antibiotic prophylaxis 1

3. Hepatocellular carcinoma surveillance:

   • Ultrasound every 6 months
   • Consider alpha-fetoprotein in combination with ultrasound 2

Management of Complications

Spontaneous Bacterial Peritonitis

• Diagnostic paracentesis if suspected (fever, abdominal pain, encephalopathy)
• Immediate empirical antibiotic therapy (cefotaxime or based on local resistance patterns)
• Albumin administration to prevent hepatorenal syndrome 1

Hepatic Encephalopathy

• Identify and treat precipitating factors
• Lactulose as first-line therapy
• Rifaximin as add-on therapy for recurrent episodes 4

Refractory Ascites

• Serial large volume paracentesis with albumin replacement
• Consider transjugular intrahepatic portosystemic shunt (TIPS)
• Evaluate for liver transplantation 2

Transplant Evaluation

• Refer for transplant evaluation when:
  • MELD score ≥15
  • CTP score ≥7
  • First major complication occurs (ascites, variceal bleeding, encephalopathy)
  • Hepatocellular carcinoma develops 1, 2

Follow-up Monitoring

• Clinical assessment every 3-6 months
• Laboratory tests and calculation of CTP and MELD scores every 6 months
• Ultrasound for HCC surveillance every 6 months
• Endoscopic surveillance for varices based on initial findings

The comprehensive approach to cirrhosis management requires ongoing vigilance for complications and prompt intervention when they occur, with the ultimate goal of improving survival and quality of life while preparing appropriate candidates for liver transplantation.