What are the management options for cirrhosis and when to refer to a gastroenterologist?

Management of Cirrhosis and Referral to Gastroenterology

Patients with cirrhosis should be managed comprehensively with specific interventions for complications and referred to gastroenterology when they develop decompensation, refractory ascites, or need evaluation for liver transplantation. 1

General Management Principles

• Treatment should focus on addressing the underlying cause of cirrhosis (alcohol cessation, viral hepatitis treatment) to potentially reverse early cirrhosis and prevent disease progression 1
• Regular monitoring for complications is essential, with laboratory testing and ultrasound surveillance every 6 months 2
• Patient education about disease management, including salt restriction, medication adherence, and recognition of warning signs is crucial for improved outcomes 1

Management of Specific Complications

Ascites Management

• First-line treatment consists of sodium restriction (88 mmol/day [2000 mg/day]) and diuretic therapy with spironolactone with or without furosemide 3
• For cirrhotic ascites, spironolactone should be initiated at 100 mg daily (range 25-200 mg) and titrated slowly in hospital settings 4
• Fluid restriction is not necessary unless serum sodium is less than 120-125 mmol/L 3
• For tense ascites, perform initial therapeutic paracentesis followed by sodium restriction and diuretic therapy 3
• NSAIDs should be avoided as they can reduce urinary sodium excretion and convert diuretic-sensitive ascites to refractory ascites 3

Refractory Ascites

• Options for refractory ascites include serial large-volume paracentesis (LVP), transjugular intrahepatic portosystemic stent-shunt (TIPS), liver transplantation, peritoneovenous shunt, or experimental medical therapy 3
• Patients requiring paracenteses more frequently than every 2 weeks likely have poor dietary compliance 3
• Palliative care referral should be offered to patients with refractory ascites who are not transplant candidates 3

Gastrointestinal Bleeding Management

• For acute variceal bleeding, initiate vasoactive drugs (terlipressin, somatostatin, octreotide) immediately upon suspicion, even before endoscopic confirmation 3, 5
• Antibiotic prophylaxis is essential in cirrhotic patients with GI bleeding (ceftriaxone 1g/24h for up to 7 days) 3
• Endoscopic band ligation should be performed within 12 hours of admission once hemodynamic stability is achieved 3, 5
• Use a restrictive transfusion strategy (hemoglobin threshold of 7 g/dl, target 7-9 g/dl) 3
• TIPS should be used as rescue therapy for persistent bleeding or early rebleeding 3

Indications for Gastroenterology Referral

• Development of any decompensation events (ascites, variceal bleeding, hepatic encephalopathy) 1, 6
• Refractory ascites not responding to maximum diuretic therapy (spironolactone 400 mg/day and furosemide 160 mg/day) 3
• Evaluation for liver transplantation in patients with MELD score ≥15 or complications of cirrhosis 7
• Need for TIPS placement for refractory ascites or recurrent variceal bleeding 3
• Hepatocellular carcinoma surveillance and management 2
• Management of hepatorenal syndrome, which has a median survival of less than 2 weeks without treatment 6

Monitoring and Follow-up

• Calculate Child-Pugh and MELD scores every 6 months to assess disease progression 7
• Screen for hepatocellular carcinoma with ultrasound every 6 months 2
• Monitor for development of varices with endoscopy and consider prophylaxis with non-selective beta blockers when indicated 2
• Regularly assess nutritional status and address malnutrition or obesity as needed 8

Prevention of Complications

• Avoid nephrotoxic drugs (aminoglycosides, NSAIDs), large volume paracentesis, and hypotensive drugs during acute variceal hemorrhage 3
• Consider non-selective beta blockers for prevention of variceal bleeding, but use with caution in patients with severe or refractory ascites 5, 6
• Provide antibiotic prophylaxis for spontaneous bacterial peritonitis when indicated 3