What is the management of liver cirrhosis?

Management of Liver Cirrhosis

The management of liver cirrhosis should focus on treating the underlying cause, preventing disease progression, and addressing complications through a comprehensive approach that includes medication, lifestyle modifications, and regular monitoring to improve survival and quality of life. 1

General Management Principles

• Management should prioritize preventing cirrhosis progression rather than simply treating complications as they occur 2, 1
• Removal of the causative factor is a cornerstone in cirrhosis management and can potentially reverse early cirrhosis 1
• Mechanistic approaches to counteract key pathophysiologic mechanisms may prevent or delay disease progression and complications 2

Treatment of Underlying Etiology

• In alcoholic cirrhosis, complete cessation of alcohol consumption may lead to "re-compensation" and improved outcomes in some patients 2, 1, 3
• For viral hepatitis-related cirrhosis:
  • HBV treatment with antivirals improves outcomes in selected patients 1, 3
  • HCV treatment with direct-acting antivirals can improve liver function and portal hypertension 1, 3
• Treatment effectiveness varies based on disease severity at the time of intervention 2, 1

Prevention of Disease Progression

• Enoxaparin may delay hepatic decompensation and improve survival in patients with Child-Pugh scores 7-10 by preventing portal vein thrombosis and reducing intestinal barrier damage 2, 3
• Pentoxifylline can reduce liver-related complications (infections, renal failure, encephalopathy) by preventing intestinal bacterial translocation 2, 3
• Propranolol reduces portal hypertension and decreases risk of various complications (variceal bleeding, ascites, hepatorenal syndrome, spontaneous bacterial peritonitis, encephalopathy) in responders 3, 4

Management of Specific Complications

Ascites

• Spironolactone is indicated for the management of edema in cirrhosis when not responsive to fluid and sodium restriction 5
• Initial daily dosage is 100 mg of spironolactone administered in either single or divided doses, but may range from 25 mg to 200 mg daily 5
• In cirrhotic patients, initiate therapy in a hospital setting and titrate slowly 5
• Combination aldosterone antagonist and loop diuretics are more effective than sequential initiation (76% vs 56% resolution) with lower rates of hyperkalemia (4% vs 18%) 4

Variceal Bleeding

• Nonselective β-blockers (carvedilol or propranolol) reduce the risk of decompensation or death compared with placebo (16% vs 27%) 4
• Regular endoscopic monitoring is necessary for varices management 6

Hepatic Encephalopathy

• Lactulose is associated with reduced mortality relative to placebo (8.5% vs 14%) and reduced risk of recurrent overt hepatic encephalopathy (25.5% vs 46.8%) 4
• Rifaximin may be added for management of hepatic encephalopathy when lactulose alone is insufficient 6

Spontaneous Bacterial Peritonitis

• Antibiotic prophylaxis is recommended for patients at high risk 3
• Ceftriaxone for up to seven days is recommended in patients with advanced cirrhosis and active bleeding 3

Hepatorenal Syndrome

• Early identification and management of renal dysfunction is crucial 1, 3
• Terlipressin improves the rate of reversal of hepatorenal syndrome from 39% to 18% 4
• Avoid nephrotoxic drugs, large volume paracentesis without albumin, beta-blockers during acute bleeding, and other hypotensive drugs 3

Monitoring and Follow-up

• Child-Pugh score is recommended for initial stratification of cirrhosis severity, with scores of 7-10 indicating decompensated disease 3
• MELD and MELD-Na scores are essential for transplant prioritization 3
• Regular laboratory testing and ultrasound monitoring every 6 months 6
• Hepatocellular carcinoma screening with ultrasound every 6 months for all cirrhotic patients 6
• Consider telemedicine and remote monitoring technologies to improve patient outcomes and reduce hospital readmissions 1, 3

Special Considerations

• Consider early referral for liver transplantation evaluation in appropriate candidates, especially with MELD score of 15 or greater, complications of cirrhosis, or hepatocellular carcinoma 3, 7
• A mean pulmonary arterial pressure ≥45 mmHg is an absolute contraindication to liver transplantation 3
• Manage common symptoms such as muscle cramps, poor-quality sleep, pruritus, and sexual dysfunction which affect quality of life 4
• Avoid drugs with potential for hepatotoxicity 7