What are the diagnosis and management strategies for cirrhosis?

Diagnosis and Management of Cirrhosis

The diagnosis and management of cirrhosis should focus on early identification, risk stratification, and aggressive management of complications to reduce morbidity and mortality, with all patients with decompensated cirrhosis being referred for liver transplantation evaluation. 1

Diagnosis of Cirrhosis

Diagnostic Approach

• Clinical Presentation:

  • Most patients with compensated cirrhosis are asymptomatic
  • Only 1 in 3 people with cirrhosis know they have it 2
  • Decompensated cirrhosis presents with:
    • Ascites
    • Variceal hemorrhage
    • Hepatic encephalopathy

• Laboratory Testing:

  • Initial workup:
    • Complete blood count
    • Liver function tests
    • Prothrombin time/INR
    • Viral hepatitis serologies
    • Ferritin and transferrin saturation
    • Specific tests based on suspected etiology 2

• Non-invasive Assessment:

  • Serum-based fibrosis scores:
    • Aspartate transaminase to platelet ratio index (APRI)
    • Fibrosis-4 (FIB-4) score
    • FibroTest/FibroSure
  • Imaging:
    • Abdominal ultrasound (first-line)
    • Transient elastography (≥15 kPa typically confirms cirrhosis) 3

• Liver Biopsy:

  • Reference standard for diagnosis
  • Indicated when:
    • Non-invasive evaluation results are indeterminate
    • Etiology remains unknown
    • Results may alter management 4

Risk Stratification

• Staging of Cirrhosis:

  • Compensated: No clinically evident complications
    • Further substaged into those with mild portal hypertension and those with clinically significant portal hypertension (CSPH, HVPG ≥10 mmHg) 5
  • Decompensated: Presence of complications (ascites, variceal hemorrhage, hepatic encephalopathy) 5

• Prognostic Scoring:

  • Child-Turcotte-Pugh (CTP) classification
  • Model for End-Stage Liver Disease (MELD) score
  • Regular calculation every 6 months 4

Management of Cirrhosis

General Management

• Treat Underlying Cause:

  • Viral hepatitis:
    • HBV: Immediate nucleos(t)ide analogues with high barrier to resistance (entecavir 1 mg daily or tenofovir) 1
    • HCV: Direct-acting antivirals without protease inhibitors in decompensated cirrhosis 1
  • Alcohol cessation
  • Weight management for NAFLD

• Preventive Measures:

  • Avoid hepatotoxic medications
  • Vaccinations (hepatitis A/B, pneumococcal, influenza)
  • Regular surveillance:
    • Clinical assessment every 3-6 months
    • Laboratory tests and CTP/MELD calculation every 6 months
    • Ultrasound for HCC surveillance every 6 months 1

Management of Complications

1. Portal Hypertension and Varices

• Screening:

  • All patients with cirrhosis should undergo endoscopic screening for varices 5

• Primary Prophylaxis:

  • Non-selective β-blockers (carvedilol or propranolol) reduce risk of decompensation or death compared with placebo (16% vs 27%) 3

2. Ascites

• Grade-based Management:

  • Grade 1 (mild): Sodium restriction alone
  • Grade 2 (moderate): Sodium restriction + diuretics
  • Grade 3 (large): Initial paracentesis + sodium restriction + diuretics 1

• Diuretic Therapy:

  • Start with spironolactone 100 mg/day (can increase to 400 mg/day)
  • Add furosemide 40 mg/day (can increase to 160 mg/day) if needed
  • Target weight loss: 0.5 kg/day without edema, 1 kg/day with edema 1
  • Combination therapy with spironolactone and furosemide is more effective than sequential therapy (76% vs 56% resolution) with lower rates of hyperkalemia (4% vs 18%) 3

• Large Volume Paracentesis (LVP):

  • Indicated for tense ascites (Grade 3)
  • Administer albumin (8g/L of ascites removed) when removing >5L 1

3. Spontaneous Bacterial Peritonitis (SBP)

• Diagnosis:

  • Diagnostic paracentesis should be performed:
    • In all cirrhotic patients with ascites on hospital admission
    • In patients with GI bleeding, shock, fever, systemic inflammation, GI symptoms, hepatic encephalopathy, or worsening liver/renal function 5
  • Diagnosis based on ascitic fluid neutrophil count >250 cells/μL 5

• Treatment:

  • Third-generation cephalosporins (e.g., ceftriaxone 1g/24h) for 5-7 days
  • Albumin administration (1.5 g/kg at diagnosis and 1 g/kg on day 3) to prevent hepatorenal syndrome 1

4. Hepatic Encephalopathy

• Management:
  • Identify and treat precipitating factors (constipation, infection, GI bleeding, medications, electrolyte imbalances)
  • Lactulose reduces mortality compared to placebo (8.5% vs 14%) and risk of recurrent overt hepatic encephalopathy (25.5% vs 46.8%) 3
  • Add rifaximin for recurrent episodes

5. Hepatorenal Syndrome

• Treatment:
  • Terlipressin improves reversal rates from 18% to 39% 3

6. Hepatocellular Carcinoma (HCC)

• Surveillance:
  • Ultrasound screening every 6 months for all patients with cirrhosis 4
  • High-risk groups for HCC development include:
    • Males and females with cirrhosis due to HBV, HCV, genetic hemochromatosis
    • Males with alcohol-related cirrhosis who are abstinent
    • Males with cirrhosis due to primary biliary cirrhosis 5

Liver Transplantation

• Indications:
  • MELD score ≥15
  • Complications of cirrhosis
  • Hepatocellular carcinoma 4

Nutritional and Lifestyle Considerations

• Nutritional Support:

  • Recommended intake: 35-40 kcal/kg/day and 1.2-1.5 g/kg/day protein 1
  • Sodium restriction (<2g/day)
  • Fluid restriction only if serum sodium <125 mmol/L (restrict to 1-1.5 L/day) 1

• Medications to Avoid:

  • NSAIDs
  • ACE inhibitors
  • Angiotensin receptor blockers 1

• Symptom Management:

  • Muscle cramps (64% prevalence): pickle brine and taurine
  • Pruritus (39% prevalence): antihistamines
  • Poor sleep (63% prevalence): hydroxyzine
  • Sexual dysfunction (53% prevalence): tadalafil for men 3

By following this comprehensive approach to diagnosis and management, clinicians can significantly improve outcomes for patients with cirrhosis, potentially reversing early disease and effectively managing complications to enhance quality of life and survival.