What is the initial approach to managing a patient with cirrhosis?

Initial Management Approach for Cirrhosis

The initial management of a patient with cirrhosis should focus on identifying and treating the underlying cause, preventing disease progression, and addressing complications through a comprehensive approach including medication, lifestyle modifications, and regular monitoring.1

Addressing the Underlying Etiology

• Complete cessation of alcohol consumption is essential for patients with alcoholic cirrhosis, as this may lead to "re-compensation" and improved outcomes 1
• For viral hepatitis-related cirrhosis, appropriate antiviral therapy should be initiated - HBV treatment with antivirals and HCV treatment with direct-acting antivirals can improve liver function and reduce portal hypertension 1
• Treatment effectiveness varies based on disease severity at the time of intervention, with better outcomes when initiated earlier 1

Management of Ascites

• First-line treatment consists of sodium restriction (88 mmol/day [2000 mg/day]) and diuretics (oral spironolactone with or without oral furosemide) 2
• For patients with cirrhosis and ascites, initial diuretic therapy typically starts with spironolactone, with dosing initiated at 100 mg daily, which can be titrated up as needed 3, 4
• Fluid restriction is not necessary unless serum sodium is less than 120-125 mmol/L 2
• For patients with tense ascites, an initial therapeutic abdominal paracentesis should be performed, followed by sodium restriction and oral diuretics 2
• In patients with hepatic impairment, spironolactone should be initiated in the hospital setting and titrated slowly to avoid sudden alterations of fluid and electrolyte balance that could precipitate hepatic encephalopathy 4

Monitoring and Prevention of Complications

• Screen for hepatocellular carcinoma with imaging studies every six months 5, 6
• Monitor for development of esophageal varices with endoscopy and consider prophylaxis with nonselective beta blockers 6, 7
• For acute kidney injury (AKI), implement the following measures promptly:
  • Review medications and withdraw nephrotoxic drugs, vasodilators, and NSAIDs 2
  • Reduce or withdraw diuretic therapy 2
  • Provide plasma volume expansion for suspected hypovolemia 2
  • Recognize and treat bacterial infections early 2

Screening for Comorbidities

• Screen for type 2 diabetes mellitus due to its high prevalence in cirrhosis patients 2
• Insulin therapy is the first-line option for treating diabetes in cirrhotic patients, as other antidiabetic medications may be contraindicated 2
• Assess for frailty and sarcopenia, which often coexist with pancytopenia in cirrhosis 3

Management of Hepatic Encephalopathy

• Identify and address precipitating factors including constipation, infection, gastrointestinal bleeding, certain medications, and electrolyte imbalances 5
• Lactulose is the first-line treatment, which has been shown to reduce mortality compared to placebo (8.5% vs 14%) and reduce risk of recurrent overt hepatic encephalopathy (25.5% vs 46.8%) 7
• Rifaximin can be added for patients who have recurrent episodes despite lactulose therapy 6

Pitfalls to Avoid

• Do not use metformin in patients with decompensated cirrhosis due to increased risk of lactic acidosis 2
• Avoid NSAIDs as they can reduce urinary sodium excretion and induce azotemia, potentially converting patients from diuretic-sensitive to refractory 2
• In patients with cirrhosis, start with the lowest initial dose of spironolactone and titrate slowly to avoid complications 4
• Avoid unnecessary platelet or blood product transfusions, which can lead to alloimmunization and reduced efficacy of future transfusions 3

Referral for Liver Transplantation

• Development of ascites as a complication of cirrhosis is associated with a poor prognosis, and liver transplantation should be considered in the treatment options 2
• Evaluation for liver transplantation is indicated for patients with a MELD score of 15 or greater, complications of cirrhosis, or hepatocellular carcinoma 8