What are the initial management steps for cirrhosis?

Initial Management of Cirrhosis

The initial management of cirrhosis should focus on sodium restriction (88 mmol/day or 2000 mg/day), diuretic therapy with spironolactone (starting at 100 mg/day) with or without furosemide, and addressing the underlying cause of liver disease. 1, 2

Assessment and Diagnosis

• Perform diagnostic paracentesis in all patients with new-onset ascites to:

  • Rule out spontaneous bacterial peritonitis
  • Determine ascitic fluid protein and cell count
  • Differentiate cirrhotic from non-cirrhotic causes of ascites 1, 2

• Identify and address the underlying cause of cirrhosis:

  • Alcohol abstinence for alcohol-related cirrhosis
  • Antiviral therapy for viral hepatitis
  • Weight loss for nonalcoholic fatty liver disease 2, 3, 4

Management of Ascites

Dietary Modifications

• Restrict sodium intake to 88 mmol/day (2000 mg/day) 1, 2
• Maintain adequate protein intake (1.2-1.5 g/kg/day) 2
• Fluid restriction is not necessary unless serum sodium is less than 120-125 mmol/L 1

Pharmacological Management

First-line Diuretic Therapy

1. For first episode of ascites:

   • Start with spironolactone 100 mg/day as monotherapy 1, 5
   • Titrate dose upward every 7 days (in 100 mg steps) to maximum of 400 mg/day if needed 1

2. For recurrent ascites:

   • Combination therapy with spironolactone and furosemide 1, 3
   • Start with spironolactone 100 mg/day and furosemide 40 mg/day 1, 2
   • Titrate doses upward every 3-5 days while maintaining a spironolactone:furosemide ratio of approximately 2.5:1 to 5:1 1, 2
   • Maximum doses: spironolactone 400 mg/day and furosemide 160 mg/day 1

Monitoring During Diuretic Therapy

• Target weight loss: 0.5 kg/day in patients without peripheral edema; 1 kg/day in those with peripheral edema 1
• Monitor serum creatinine, sodium, and potassium frequently, especially during the first weeks of treatment 1
• Adjust diuretic doses to maintain minimal or no ascites once mobilized 1

Management Based on Ascites Grade

1. Grade 1 (mild) - Only detected by ultrasound:

   • Sodium restriction alone 2

2. Grade 2 (moderate) - Moderate abdominal distension:

   • Sodium restriction + diuretic therapy 1, 2

3. Grade 3 (tense) - Marked abdominal distension:

   • Initial large-volume paracentesis for immediate relief 1, 2
   • Follow with sodium restriction and diuretic therapy 1
   • Administer albumin (8 g/L of fluid removed) if >5L is removed 2

Management of Refractory Ascites

Refractory ascites is defined as:

• Ascites unresponsive to sodium restriction and high-dose diuretics (spironolactone 400 mg/day and furosemide 160 mg/day) 1
• Ascites that recurs rapidly after therapeutic paracentesis 1

Treatment options include:

1. Serial therapeutic paracenteses 1
2. Transjugular intrahepatic portosystemic shunt (TIPS) 1, 2, 6
3. Liver transplantation evaluation 1, 2

Prevention and Management of Complications

Spontaneous Bacterial Peritonitis (SBP)

• Perform diagnostic paracentesis in all patients with new-onset ascites and at every hospital admission 1
• Initiate antibiotics promptly if SBP is diagnosed 2

Hepatic Encephalopathy

• Monitor for signs of encephalopathy, especially during diuretic therapy 1
• Reduce or temporarily discontinue diuretics if encephalopathy develops 2
• First-line treatment is lactulose 3, 6

Variceal Bleeding

• Initiate non-selective beta-blockers (propranolol or carvedilol) for prevention 2, 3
• Perform endoscopic screening and monitoring 2, 7

Common Pitfalls and Caveats

• Avoid NSAIDs as they can reduce urinary sodium excretion, induce azotemia, and convert diuretic-sensitive patients to refractory 1, 2
• Avoid over-diuresis which can precipitate renal failure, hepatic encephalopathy, and electrolyte disorders 1
• Discontinue diuretics temporarily if serum sodium decreases to less than 120-125 mmol/L, serum creatinine exceeds 2.0 mg/dL, or serum potassium exceeds 6.0 mmol/L 1
• Use caution with spironolactone in renal impairment due to increased risk of hyperkalemia 5
• Initiate spironolactone in a hospital setting for patients with hepatic impairment and titrate slowly to avoid sudden alterations in fluid and electrolyte balance 5

Long-term Management

• Consider liver transplantation evaluation for all patients with decompensated cirrhosis 1, 2
• Screen for hepatocellular carcinoma with ultrasound every 6 months 2, 7
• Regular follow-up every 2-4 weeks initially, then every few months once stable 1