Treatment for Decompensated Cirrhosis of the Liver
The treatment of decompensated cirrhosis requires a comprehensive approach targeting specific complications including ascites, variceal bleeding, hepatic encephalopathy, and spontaneous bacterial peritonitis, with the ultimate consideration of liver transplantation for eligible patients. 1, 2
Management of Ascites
First-line Treatment:
- Sodium restriction (80-120 mmol/day or 4.6-6.9 g salt/day) 1
- Diuretic therapy:
For Tense Ascites (Grade 3):
- Large volume paracentesis (LVP) with albumin replacement (8g per liter of ascites removed if >5L is removed) 1
- Continue diuretics after paracentesis to prevent reaccumulation 4
For Refractory Ascites:
- Consider transjugular intrahepatic portosystemic shunt (TIPS) evaluation or scheduled LVP with albumin replacement 1
- TIPS contraindications: age >70 years, serum bilirubin >50 μmol/L, platelet count <75×10^9/L, MELD score ≥18, or current hepatic encephalopathy 1
Management of Variceal Bleeding
Acute Variceal Bleeding:
- Initiate vasoactive drugs (terlipressin, somatostatin, or octreotide) as soon as bleeding is suspected and continue for 3-5 days 5
- Perform endoscopic variceal ligation within 12 hours after admission once hemodynamically stable 5
- Administer prophylactic antibiotics: Ceftriaxone (1 g/24 h) for up to 7 days in patients with advanced cirrhosis or oral quinolones (norfloxacin 400 mg twice daily) in other patients 5
- Volume replacement with colloids and/or crystalloids (avoid starch) to maintain hemodynamic stability 5
- Restrictive transfusion strategy with hemoglobin threshold of 7 g/dl and target range of 7-9 g/dl 5
- Consider early pre-emptive covered TIPS (within 24-72 hours) in high-risk patients 5
Primary Prophylaxis:
- Propranolol starting with 40 mg twice daily, increasing to 80 mg twice daily if necessary 1
- Goal: reduce portal pressure to less than 12 mm Hg 1
- Alternative: endoscopic variceal ligation or isosorbide mononitrate (20 mg twice daily) 1
Management of Hepatic Encephalopathy
- Lactulose or lactitol when encephalopathy develops 5, 2
- Rifaximin may be added for recurrent episodes 2
- Avoid nephrotoxic drugs, large volume paracentesis, beta-blockers, vasodilators, and other hypotensive drugs during acute variceal hemorrhage 5
- Discontinue medications that may worsen ascites (NSAIDs, ACE inhibitors, Angiotensin receptor blockers) 1
Management of Infections
Spontaneous Bacterial Peritonitis (SBP):
- Diagnostic paracentesis for new-onset ascites to rule out infection 1
- If SBP diagnosed, initiate antibiotics and albumin infusion (1.5 g/kg on day 1, followed by 1 g/kg on day 3) 1
- Third-generation cephalosporins are the antibiotics of choice 6
Monitoring and Screening
- Regular weight measurements and periodic ultrasound examinations to track fluid status 1
- Screen for hepatocellular carcinoma at diagnosis and then every 6 months 1, 7
- Endoscopic monitoring: every 3 years if no varices are present, annually if small varices are present 1
- Calculate Child-Pugh and MELD scores every 6 months 7
Liver Transplantation
- Consider evaluation for liver transplantation in patients with MELD score ≥15, complications of cirrhosis, or hepatocellular carcinoma 7
- Patients with ascites have a poor prognosis (40-50% mortality at 1-2 years) and should be considered for transplant evaluation 1
Cautions and Pitfalls
- Initiate diuretic therapy cautiously in patients with cirrhosis, preferably in a hospital setting 3, 8
- Monitor for electrolyte imbalances, particularly hypokalemia and hyponatremia 8
- Avoid overdiuresis as it can precipitate hepatic encephalopathy (occurs in ~26% of cases) 1
- Avoid nephrotoxic drugs such as aminoglycosides and NSAIDs 5, 1
- Monitor weight loss: should not exceed 0.5 kg/day in patients without peripheral edema and 1 kg/day in patients with peripheral edema 1