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 ideally focus on preventing cirrhosis progression rather than just 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
• Patient education about disease management, including salt restriction, medication adherence, and recognition of warning signs is crucial for improved outcomes 3

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
• For viral hepatitis-related cirrhosis:
  • HBV treatment with antivirals improves outcomes in some patients 2, 1
  • HCV treatment with direct-acting antivirals can improve liver function and reduce portal hypertension 2, 1
• Treatment effectiveness in decompensated cirrhosis varies based on disease severity at the time of intervention 2, 1

Management of Specific Complications

Ascites Management

• First-line treatment consists of sodium restriction and diuretic therapy with spironolactone with or without furosemide 3
• Spironolactone is indicated for the management of edema in cirrhosis of the liver when edema is not responsive to fluid and sodium restriction 4
• For cirrhosis patients, initiate spironolactone therapy in a hospital setting and titrate slowly with an initial daily dosage of 100 mg (range 25-200 mg) 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 include serial large-volume paracentesis (LVP) with albumin replacement, transjugular intrahepatic portosystemic stent-shunt (TIPS), liver transplantation, or peritoneovenous shunt 1, 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 immediately upon suspicion, even before endoscopic confirmation 3
• Antibiotic prophylaxis is essential in cirrhotic patients with GI bleeding 3
• Endoscopic band ligation should be performed within 12 hours of admission once hemodynamic stability is achieved 3
• Use a restrictive transfusion strategy, with a 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

Portal Hypertension Management

• Consider non-selective beta blockers (carvedilol or propranolol) for prevention of variceal bleeding and to reduce the risk of decompensation 3, 5
• Enoxaparin may delay hepatic decompensation and improve survival in some patients 2, 1

Hepatic Encephalopathy Management

• Lactulose is the first-line treatment, which has been shown to reduce mortality compared to placebo and reduce risk of recurrent overt hepatic encephalopathy 5
• Rifaximin can be added for patients with recurrent episodes despite lactulose therapy 3
• Lifestyle and nutritional modifications are important components of management 3

Monitoring and Follow-up

• Clinical assessment with laboratory tests and calculation of the Child-Pugh and Model for End-stage Liver Disease (MELD) scores should occur every 6 months 6
• Screen for hepatocellular carcinoma with ultrasound every six months 7
• Consider telemedicine and remote monitoring technologies to improve patient outcomes and reduce hospital readmissions 1

Indications for Specialist Referral

• Development of any decompensation events, such as ascites, variceal bleeding, or hepatic encephalopathy 3
• Refractory ascites not responding to maximum diuretic therapy 3
• Need for TIPS placement for refractory ascites or recurrent variceal bleeding 3
• Evaluation for liver transplantation is indicated for patients with a MELD score of 15 or greater, complications of cirrhosis, or hepatocellular carcinoma 6

Common Pitfalls to Avoid

• Avoid nephrotoxic drugs, large volume paracentesis without albumin, and hypotensive drugs during acute variceal hemorrhage 3
• Use beta blockers with caution in patients with severe or refractory ascites 3
• Recognize that cirrhosis management is not just about treating complications but should focus on preventing disease progression 2, 1
• Be aware that treatment of the underlying cause may not be sufficient in advanced decompensated cirrhosis 2