Initial Management of Liver Cirrhosis
The initial approach to managing liver cirrhosis should include staging the disease into compensated or decompensated categories, implementing sodium restriction, starting appropriate diuretic therapy with spironolactone as first-line treatment, and considering liver transplantation evaluation for patients with decompensated disease. 1
Diagnosis and Staging
- Classify cirrhosis as either compensated (asymptomatic) or decompensated (with complications)
- Decompensated cirrhosis is defined by the presence of:
- Ascites
- Variceal hemorrhage
- Hepatic encephalopathy 1
- Perform diagnostic paracentesis in all cirrhotic patients with ascites on hospital admission 2, 1
- Assess for complications that may require immediate management
Initial Management Approach
1. Treat the Underlying Cause
- Immediately start appropriate treatment for viral hepatitis if present:
- Nucleos(t)ide analogues for HBV
- Direct-acting antivirals for HCV (avoid protease inhibitors in decompensated disease) 1
- Complete alcohol cessation for alcoholic liver disease 3
- Weight management for non-alcoholic fatty liver disease 4
2. Dietary and Lifestyle Modifications
- Implement sodium restriction to 90 mmol/day (5.2 g salt/day) - "no added salt diet" 2
- Ensure adequate nutritional intake:
- Avoid unnecessary medications that can worsen liver function:
- NSAIDs
- ACE inhibitors
- Angiotensin receptor blockers 2
3. Management of Ascites Based on Grade
| Grade | Description | Treatment Approach |
|---|---|---|
| Grade 1 (mild) | Only detectable by ultrasound | Sodium restriction alone |
| Grade 2 (moderate) | Moderate abdominal distension | Sodium restriction + diuretics |
| Grade 3 (large) | Marked abdominal distension | Initial paracentesis + sodium restriction + diuretics [2,1] |
4. Diuretic Therapy
- First-line treatment: Spironolactone starting at 100 mg/day, can increase up to 400 mg/day 2, 1
- If inadequate response: Add furosemide 20-40 mg/day, can increase up to 160 mg/day 2
- Monitor for complications:
- Hyperkalemia (with spironolactone)
- Hypokalemia (with furosemide)
- Hyponatremia
- Renal impairment 2
5. Management of Large Volume Ascites
- Therapeutic paracentesis is first-line treatment for large or refractory ascites 2
- Volume expansion guidelines:
- <5 liters removed: Synthetic plasma expander (150-200 ml of gelofusine)
- Large volume paracentesis: Albumin (8g per liter of ascites removed) 2
6. Prevention of Complications
- Screen for varices with endoscopy 1
- Consider non-selective beta-blockers (carvedilol or propranolol) for portal hypertension 1, 5
- Vaccinate against hepatitis A, hepatitis B, pneumococcal disease, and influenza 1
- Screen for hepatocellular carcinoma with ultrasound every 6 months 1
7. Transplantation Evaluation
- All patients with decompensated cirrhosis should be considered for liver transplantation evaluation 2, 1
- Patients with spontaneous bacterial peritonitis should be referred for transplantation 2
Monitoring
- Regular clinical assessment every 3-6 months
- Laboratory tests and calculation of Child-Pugh and MELD scores every 6 months
- Ultrasound for HCC surveillance every 6 months 1
Common Pitfalls to Avoid
- Excessive bed rest is not recommended and may lead to muscle atrophy 2
- Fluid restriction is generally not necessary unless serum sodium is <120-125 mmol/L 2, 1
- Avoid monotherapy with loop diuretics; always start with spironolactone 2
- Don't restrict protein intake in patients with cirrhosis, even with hepatic encephalopathy 2
- Avoid rapid correction of hyponatremia (increase serum sodium by <12 mmol/L per 24 hours) 2
The development of ascites marks an important point in the natural history of cirrhosis and should be considered an indication for transplantation evaluation, as it significantly impacts quality of life and indicates advanced disease 2.