What are the appropriate tests and treatments for a patient with cirrhosis?

Appropriate Tests and Treatments for a Patient with Cirrhosis

For a female patient with cirrhosis, management should focus on assessing disease severity, monitoring for complications, and providing appropriate treatments to prevent decompensation and improve survival.

Diagnostic Tests

• Initial assessment should include liver function tests (ALT, AST, bilirubin, albumin), complete blood count, prothrombin time/INR, and renal function tests to determine disease severity 1
• Calculate Child-Pugh and Model for End-Stage Liver Disease (MELD) scores every 6 months to assess prognosis and need for transplantation 2, 1
• Abdominal ultrasound is recommended as the initial imaging procedure to assess liver morphology and detect ascites 3
• Consider elastography (FibroScan) for non-invasive assessment of liver stiffness, with values >15 kPa strongly suggesting advanced liver disease 3
• Screen for hepatocellular carcinoma with ultrasound every 6 months 4, 2
• Endoscopy to screen for esophageal varices 1, 5

Management of Ascites

• Salt restriction to 5 g/day or less (sodium 2 g/day) 4
• Protein supplementation of 1.2-1.5 g/kg/day is recommended 4
• Start spironolactone as primary diuretic at 100 mg/day (can be increased to 400 mg/day) 4, 6
• Furosemide can be added at 20-40 mg/day (can be increased to 160 mg/day) to enhance diuretic effect and maintain normal potassium levels 4
• For therapeutic large-volume paracentesis (>5L), administer 8 g albumin per liter of ascites removed 4
• Routine measurement of prothrombin time and platelet count before paracentesis is not recommended 4

Management of Portal Hypertension

• Consider non-selective beta-blockers (carvedilol or propranolol) to reduce the risk of decompensation or death 1, 5
• Refractory ascites should not be viewed as a contraindication to non-selective beta-blockers 4
• For patients with refractory ascites, consider transjugular intrahepatic portosystemic shunt (TIPSS) 4
• Use caution with TIPSS in patients with age >70 years, serum bilirubin >50 μmol/L, platelet count <75×10⁹/L, MELD score ≥18, current hepatic encephalopathy, or active infection 4

Management of Hepatic Encephalopathy

• Identify and manage precipitating factors (constipation, infection, gastrointestinal bleeding, electrolyte imbalances) 7
• Treat with lactulose, which has been shown to reduce mortality and recurrent episodes of hepatic encephalopathy 1
• Consider adding rifaximin for recurrent episodes 1, 5

Special Considerations for Cirrhosis in Women

• Females with established cirrhosis due to hepatitis B virus (HBV), hepatitis C virus (HCV), or genetic hemochromatosis should be considered for hepatocellular carcinoma surveillance 4
• For women with primary biliary cirrhosis or autoimmune hepatitis, the risk of hepatocellular carcinoma is generally lower than in men 4

Liver Transplantation Evaluation

• Consider liver transplantation evaluation for patients with MELD score ≥15, complications of cirrhosis, or hepatocellular carcinoma 8, 2
• Liver transplantation should be considered in patients with cirrhosis and small hepatocellular carcinoma (single nodule ≤5 cm or up to three lesions ≤3 cm) 4, 8

Coagulation Management

• Routine use of blood products (fresh frozen plasma or platelets) for bleeding prophylaxis before common procedures is not recommended in stable cirrhosis 4
• Clinical prediction scores can be used to assess risk of developing deep vein thrombosis or pulmonary embolism 4
• For patients at risk of venous thromboembolism, low molecular weight heparin can be recommended as it has a reasonable safety profile 4

Medication Considerations

• Spironolactone should be initiated in a hospital setting for patients with cirrhosis and ascites, with slow titration 6
• Clearance of spironolactone and its metabolites is reduced in patients with cirrhosis, so start with the lowest initial dose 6
• Avoid medications with potential for hepatotoxicity 2

Regular monitoring every 6 months with clinical assessment, laboratory tests, and imaging is essential for early detection and management of complications in this female patient with cirrhosis.