What are the key components of a cirrhosis care bundle as recommended by the British Society of Gastroenterology (BSG)?

Cirrhosis Care Bundle: British Society of Gastroenterology Recommendations

The British Society of Gastroenterology endorses a structured care bundle approach for managing patients with cirrhosis, particularly during the critical first 24 hours of admission for decompensated disease, to ensure comprehensive assessment and reduce mortality. 1, 2

Core Components of the BSG Cirrhosis Care Bundle

Initial Assessment and Investigations (First 24 Hours)

For patients presenting with decompensated cirrhosis, the care bundle mandates immediate comprehensive evaluation:

• Diagnostic paracentesis must be performed in all patients with ascites to rule out spontaneous bacterial peritonitis and determine etiology 3, 4
• Infection screening including blood cultures, urine cultures, chest radiograph, and ascitic fluid analysis should be completed urgently 2
• Baseline laboratory investigations encompassing full blood count, renal function, electrolytes, liver function tests, coagulation profile, and serum albumin 2
• Precipitant identification through careful assessment for gastrointestinal bleeding, alcohol intake, drug-induced liver injury, or infections 2

Complication-Specific Management

Ascites Management:

• Initiate sodium restriction to 88 mmol/day (2000 mg/day) as first-line dietary intervention 3, 4
• Start diuretic therapy with spironolactone 100 mg daily plus furosemide 40 mg daily for patients with preserved renal function 3, 4
• Avoid NSAIDs as they convert diuretic-sensitive ascites to refractory ascites 3
• For large-volume paracentesis (>5L), administer albumin 8g per liter of ascites removed 4

Infection Prevention and Treatment:

• Provide antibiotic prophylaxis for all cirrhotic patients with gastrointestinal bleeding 3
• Initiate empiric antibiotics immediately if spontaneous bacterial peritonitis is suspected 2

Variceal Bleeding Protocol:

• Start vasoactive drugs immediately upon suspicion, before endoscopic confirmation 3
• Use restrictive transfusion strategy with hemoglobin threshold of 7 g/dL, targeting 7-9 g/dL 3
• Perform endoscopic band ligation within 12 hours once hemodynamically stable 3

Surveillance and Prevention in Compensated Cirrhosis

The compensated cirrhosis care bundle includes:

• Hepatocellular carcinoma surveillance with 6-monthly ultrasound to enable early diagnosis and improve survival 5, 1
• Variceal screening via endoscopy to identify patients requiring primary prophylaxis 1
• Osteoporosis screening given increased fracture risk in cirrhotic patients 1
• Vaccination against hepatitis A, hepatitis B, influenza, and pneumococcus 1
• Lifestyle modification counseling including complete alcohol cessation and dietary sodium restriction 1

Palliative Care Integration

Palliative care principles should be incorporated throughout the disease spectrum, not reserved for end-stage disease:

• Assess physical, psychological, social, and spiritual symptoms at every visit 5
• Conduct goals of care discussions at sentinel events: hospital admission, ICU transfer, new decompensation, before surgery, and upon transplant eligibility determination 5
• Evaluate prognosis routinely during clinic visits and at sentinel events 5
• Screen for caregiver burden and provide support, particularly in decompensated disease 5
• Refer to specialty palliative care when symptoms exceed scope of hepatology management 5
• Offer palliative care referral to patients with refractory ascites who are not transplant candidates 3, 4
• Provide timely hospice referral for patients with comfort-oriented goals and prognosis ≤6 months 5

Gastroenterology Referral Triggers

Immediate referral to gastroenterology is required for:

• Any decompensation event (ascites, variceal bleeding, hepatic encephalopathy) 3
• Refractory ascites unresponsive to maximum diuretic therapy 3, 4
• Need for TIPS placement for refractory ascites or recurrent variceal bleeding 3
• Consideration for liver transplantation when decompensation occurs 3

Care Coordination Model

The EASL guidelines emphasize that care coordination programs improve survival and reduce emergent readmissions: 5

• Implement multidisciplinary teams including hepatologists, nurses, dietitians, and care coordinators 5
• Develop patient and caregiver educational programs to optimize adherence 5
• Plan invasive procedures in day hospital settings when possible 5
• Transfer real-time information to primary care physicians to improve care coordination 5
• Optimize billing codes and use prescreening surveys by ancillary staff to address time barriers 5

Common Pitfalls to Avoid

Critical errors that worsen outcomes include:

• Failing to perform diagnostic paracentesis in new-onset ascites, missing spontaneous bacterial peritonitis 3, 4
• Using nephrotoxic drugs or performing large-volume paracentesis without albumin replacement 3
• Delaying vasoactive drugs until endoscopic confirmation of variceal bleeding 3
• Continuing NSAIDs in patients with ascites 3
• Overlooking caregiver burden assessment, leading to poor adherence and readmissions 5

Despite endorsement by the BSG, care bundle utilization remains poor across the UK (only 11.44% of admissions), representing a significant quality gap that requires interdisciplinary efforts to improve implementation and outcomes. 6