Treatment of Cirrhosis of the Liver
The treatment of cirrhosis should focus on addressing the underlying cause, preventing disease progression, and managing complications through a comprehensive approach that includes medication, lifestyle modifications, and regular monitoring to improve survival and quality of life. 1
Treatment of Underlying Etiology
- Alcoholic cirrhosis: Complete cessation of alcohol consumption is the cornerstone of treatment and can lead to dramatic improvement in the reversible component of alcoholic liver disease. Patients with Child-Pugh class C cirrhosis who stop drinking have approximately 75% 3-year survival, while those who continue drinking have 0% survival at 3 years 2
- Viral hepatitis-related cirrhosis:
- Nonalcoholic liver diseases: These are less reversible; by the time ascites is present, these patients may be better candidates for liver transplantation than protracted medical therapy 2
Nutritional Management
- Dietary sodium restriction (2000 mg/day or 88 mmol/day) is essential for managing ascites 2
- Recommended nutritional intake for cirrhotic patients:
- Carbohydrate: 2-3 g/kg/day
- Protein: 1.2-1.5 g/kg/day (higher in critically ill patients at 1.5 g/kg/day)
- Caloric intake: 35-40 kcal/kg/day 2
- Consider smaller, frequent meals if three meals per day don't provide adequate nutrition 2
- A late-evening 200 kcal snack can improve nutritional status in patients with intractable ascites 2
Management of Complications
Ascites Management
- Oral diuretics are the mainstay of treatment alongside sodium restriction 2
- Typical diuretic regimen: Single morning doses of oral spironolactone (100 mg) and furosemide (40 mg) 2
- For refractory ascites, large-volume paracentesis (LVP) with albumin replacement is recommended 1
- Fluid restriction is generally not necessary unless serum sodium is below 120-125 mmol/L 2
Portal Hypertension
- Nonselective β-blockers (carvedilol or propranolol) can reduce the risk of decompensation or death 5
- Enoxaparin may delay hepatic decompensation and improve survival in patients with Child-Pugh scores 7-10 3, 1
Hepatic Encephalopathy
- Managed with lifestyle and nutritional modifications 6
- Lactulose is associated with reduced mortality and reduced risk of recurrent overt hepatic encephalopathy 5
- Rifaximin may be added for patients who don't respond adequately to lactulose 5
Hepatorenal Syndrome
- Early identification and management of renal dysfunction is crucial for improving survival 3, 1
- Terlipressin has been shown to improve the rate of reversal of hepatorenal syndrome 5
Monitoring and Follow-up
- Calculate Child-Pugh and Model for End-stage Liver Disease (MELD) scores every 6 months 7
- Screen for hepatocellular carcinoma with ultrasound every six months 6
- Consider telemedicine and remote monitoring technologies to help with early detection of complications and reduce hospital readmissions 3, 1
Liver Transplantation
- Liver transplantation is the gold standard as a surgical curative treatment for end-stage liver disease 8
- Evaluation for liver transplantation is indicated for patients with a MELD score of 15 or greater, complications of cirrhosis, or hepatocellular carcinoma 7
- In patients with moderate to severe cirrhosis (Child-Pugh class B or C), transplantation is potentially optimal therapy for small-size, otherwise resectable hepatocellular carcinoma 2
Common Pitfalls and Caveats
- Only 10-30% of patients initially presenting with hepatocellular carcinoma will be eligible for surgery 2
- Surgery in patients with underlying cirrhosis can be associated with substantial morbidity and mortality (30-50% in Child-Pugh class B or C, but only 5-10% in Child-Pugh class A) 2
- Patients with MELD score < 9 have significantly lower mortality rates when undergoing resection of hepatocellular carcinoma 2
- Approximately 40% of people with cirrhosis are diagnosed only when they present with complications such as hepatic encephalopathy or ascites 5