What is the initial approach to managing liver cirrhosis?

Initial Management of Liver Cirrhosis

The initial approach to managing liver cirrhosis should focus on identifying and treating the underlying cause, preventing complications through sodium restriction (88 mmol/day) and diuretic therapy (spironolactone with or without furosemide), and evaluating patients for liver transplantation. 1, 2

Etiology Assessment and Management

• Identify and address the underlying cause:

  • Alcohol cessation for alcoholic liver disease 1
  • Antiviral therapy for hepatitis B or C 1
  • Weight loss and metabolic control for non-alcoholic steatohepatitis 2
  • Management of autoimmune diseases, cholestatic diseases, or iron/copper overload 3

• Remove hepatotoxic medications:

  • Discontinue NSAIDs, ACE inhibitors, and angiotensin receptor blockers 4
  • Review all medications for potential hepatotoxicity 5

Management of Ascites

1. Grade 1 (mild) ascites:

   • Sodium restriction (88 mmol/day or 2000 mg/day) 1, 4
   • No diuretics initially required 4

2. Grade 2 (moderate) ascites:

   • Sodium restriction plus diuretic therapy 1, 4
   • Start spironolactone 100 mg daily (can range from 25-200 mg) 1, 6
   • Add furosemide if needed 1

3. Grade 3 (tense) ascites:

   • Initial therapeutic paracentesis followed by sodium restriction and diuretics 1
   • For patients with cirrhosis, initiate spironolactone therapy in a hospital setting and titrate slowly 6

Prevention of Complications

1. Portal hypertension management:

   • Nonselective β-blockers (carvedilol or propranolol) reduce risk of decompensation or death (16% vs 27% in 3-year RCT) 2
   • Screen for esophageal varices with endoscopy 5

2. Infection prevention:

   • Antibiotic prophylaxis for spontaneous bacterial peritonitis when indicated 7
   • Norfloxacin reduces risk of SBP and hepatorenal syndrome 1

3. Hepatic encephalopathy prevention:

   • Lactulose reduces mortality (8.5% vs 14%) and recurrent overt hepatic encephalopathy (25.5% vs 46.8%) 2
   • Rifaximin may reduce risk of developing complications beyond hepatic encephalopathy 1

Nutritional Support

• Ensure adequate caloric intake (35-40 kcal/kg/day) 4
• Maintain protein intake (1.2-1.5 g/kg/day) 4
• Consider smaller, more frequent meals and a late-evening 200 kcal snack 4
• Avoid extreme sodium restriction (<40 mmol/day) as it may worsen nutritional status 4

Monitoring and Follow-up

• Regular weight measurements and periodic ultrasound examinations 4
• Laboratory monitoring every 6 months: liver function tests, complete blood count, and prothrombin time/INR 5
• Calculate Child-Pugh and MELD scores every 6 months 5
• Screen for hepatocellular carcinoma with ultrasound every 6 months 7, 5

Liver Transplantation Evaluation

• Consider liver transplantation for patients with:
  • MELD score ≥15 2, 5
  • Complications of cirrhosis 5
  • Hepatocellular carcinoma 5

Common Pitfalls to Avoid

1. Failing to identify and address the underlying cause of cirrhosis
2. Overdiuresis in patients with ascites, leading to renal dysfunction
3. Excessive sodium restriction worsening malnutrition
4. Using NSAIDs, which can convert patients from diuretic-sensitive to refractory ascites 1
5. Delaying transplantation evaluation in appropriate candidates
6. Neglecting screening for hepatocellular carcinoma

The management of liver cirrhosis requires a comprehensive approach addressing the underlying cause, preventing complications, and providing supportive care. Early referral for liver transplantation evaluation is crucial for patients with decompensated cirrhosis to improve long-term outcomes.