What is the initial management for a patient with cirrhosis (scarring of the liver)?

Initial Management of Cirrhosis

The initial management of cirrhosis should focus on treating the underlying cause, preventing disease progression, and addressing complications through medication, lifestyle modifications, and regular monitoring to improve survival and quality of life. 1, 2

Identification and Treatment of Underlying Cause

• Complete cessation of alcohol consumption is essential for patients with alcoholic cirrhosis and can lead to dramatic improvement in the reversible component of liver disease, with patients with Child-Pugh class C cirrhosis who stop drinking having approximately 75% 3-year survival, compared to 0% survival at 3 years for those who continue drinking 1
• Antiviral therapy with tenofovir, entecavir, or peginterferon-α should be initiated for HBV-related cirrhosis 1
• Direct-acting antivirals for HCV-related cirrhosis can improve liver function and reduce portal hypertension 2
• Treatment of other causative factors (autoimmune diseases, metabolic disorders) should be pursued when possible 3

Nutritional and Lifestyle Management

• Restrict sodium intake to 2000 mg/day (88 mmol/day), equivalent to a "no added salt" diet 1, 3
• Nutritional intake should include:
  • Protein: 1.2-1.5 g/kg/day
  • Carbohydrate: 2-3 g/kg/day
  • Total caloric intake: 35-40 kcal/day 1, 3
• Fluid restriction is generally not necessary unless serum sodium is less than 120-125 mmol/L 3
• Counsel patients about alcohol cessation, obesity management, and infection prevention 4

Pharmacological Management of Ascites

• Start with spironolactone 100 mg once daily as initial therapy 3
• Add furosemide 40 mg once daily if response is inadequate 3
• Maximum doses are typically 400 mg/day of spironolactone and 160 mg/day of furosemide 3
• For tense ascites, perform therapeutic paracentesis followed by sodium restriction and oral diuretics 3
• For large-volume paracentesis (>5L), administer albumin (8g/L of ascites removed) to prevent circulatory dysfunction 3

Management of Hepatic Encephalopathy

• Lactulose is indicated for the prevention and treatment of portal-systemic encephalopathy, including hepatic pre-coma and coma 5
• Lactulose therapy reduces blood ammonia levels by 25-50%, which generally parallels improvement in mental state and EEG patterns 5
• Clinical response has been observed in about 75% of patients 5
• Identify and treat precipitating factors such as constipation, infection, gastrointestinal bleeding, certain medications, and electrolyte imbalances before initiating lactulose 6

Screening and Monitoring

• Surveillance for hepatocellular carcinoma should be considered in high-risk groups:
  • Males and females with established cirrhosis due to HBV, particularly with ongoing viral replication
  • Males and females with established cirrhosis due to HCV
  • Males and females with established cirrhosis due to genetic hemochromatosis
  • Males with alcohol-related cirrhosis who are abstinent or likely to comply with treatment
  • Males with cirrhosis due to primary biliary cirrhosis 7
• Screening should include six-monthly abdominal ultrasound assessments in combination with serum AFP estimation 7
• Monitor serum electrolytes, creatinine, and weight regularly 3
• Calculate Child-Pugh and Model for End-stage Liver Disease (MELD) scores every 6 months 4

Liver Transplantation Evaluation

• Consider liver transplantation for all patients with cirrhosis and ascites 3
• Liver transplantation should be considered in any patient with cirrhosis and a small (5 cm or less single nodule or up to three lesions of 3 cm or less) hepatocellular carcinoma 7
• Evaluation for liver transplantation is indicated for patients with a MELD score of 15 or greater, complications of cirrhosis, or hepatocellular carcinoma 4

Common Pitfalls to Avoid

• Delaying paracentesis in patients with tense ascites 3
• Inadequate sodium restriction (diet non-compliance is a common cause of treatment failure) 3
• Overly aggressive diuresis leading to electrolyte abnormalities or renal dysfunction 3
• Using NSAIDs, which can reduce urinary sodium excretion and induce azotemia 3
• Failure to recognize and treat spontaneous bacterial peritonitis 3
• Delaying hepatocellular carcinoma screening, which should be performed with ultrasound every six months 8