Management of Chronic Liver Disease
The management of chronic liver disease must prioritize treating the underlying etiology to prevent progression and reduce mortality, while simultaneously addressing complications through evidence-based interventions including sodium restriction with diuretics for ascites, lactulose or rifaximin for hepatic encephalopathy, and vasoactive drugs with endoscopic therapy for variceal bleeding. 1, 2
Core Management Principles
Address the Underlying Cause First
Removing or treating the causative factor is the cornerstone of management and can potentially reverse early cirrhosis. 1, 2
For alcoholic liver disease: Complete alcohol cessation may lead to "re-compensation" and improved outcomes, with some patients experiencing reversal of early cirrhosis 1, 2
For hepatitis B-related cirrhosis: Initiate antiviral therapy with entecavir or tenofovir as first-line agents when HBV DNA ≥2,000 IU/mL regardless of ALT levels 1, 3
- In decompensated cirrhosis, treat all patients regardless of HBV DNA level 1
- Entecavir dosing: 0.5 mg daily for treatment-naïve patients; 1 mg daily for lamivudine-refractory patients or those with decompensated liver disease 3
- Never use interferon-α in decompensated cirrhosis due to risk of serious complications including infection and hepatic failure 1
For hepatitis C-related cirrhosis: Direct-acting antivirals can improve liver function and reduce portal hypertension 1, 2
For non-alcoholic fatty liver disease: Focus on controlling metabolic risk factors, though no specific drug cure exists beyond risk factor modification 4
Comprehensive Complication Management
Management of Ascites
First-line treatment consists of sodium restriction combined with spironolactone with or without furosemide. 1
Sodium restriction: Limit to 2 grams daily 1
Fluid restriction is NOT necessary unless serum sodium falls below 120-125 mmol/L 1
Diuretic therapy:
For tense ascites: Perform initial therapeutic paracentesis followed by sodium restriction and diuretic therapy 1
Avoid NSAIDs completely as they reduce urinary sodium excretion and can convert diuretic-sensitive ascites to refractory ascites 1
Refractory Ascites Management
Options include serial large-volume paracentesis with albumin replacement, transjugular intrahepatic portosystemic shunt (TIPS), or liver transplantation. 1, 2
- Patients requiring paracenteses more frequently than every 2 weeks likely have poor dietary compliance and need re-education 1
- Refer to gastroenterology when ascites becomes refractory to maximum diuretic therapy 1
- Offer palliative care referral to patients with refractory ascites who are not transplant candidates 1
Management of Hepatic Encephalopathy
Overt Hepatic Encephalopathy (OHE)
Use a four-pronged approach: initiate care for altered consciousness, exclude alternative causes, identify and correct precipitating factors, and commence empirical treatment. 6
Controlling precipitating factors is paramount as nearly 90% of patients can be treated with just correction of the precipitating factor 6
Lactulose is first-line treatment:
Rifaximin as alternative or adjunct:
Secondary prophylaxis after an episode is mandatory (Grade I, A, 1) 6
Patients with higher grades requiring airway protection need intensive care monitoring 6
Minimal Hepatic Encephalopathy (MHE)
Screen all cirrhotic patients actively, as MHE affects 30-84% and profoundly impacts daily functioning despite absent clinical symptoms. 7
Animal Naming Test is the preferred bedside screening tool: requires no equipment, takes 60 seconds, has limited variability 7
Treatment options:
Critical preventive measures:
- Maintain serum sodium >135 mmol/L (always >130 mmol/L) as hyponatremia is an independent risk factor for hepatic encephalopathy 7
- Systematically re-evaluate and discontinue proton pump inhibitors if no formal indication exists, as they increase hepatic encephalopathy risk through gastric pH elevation 7
- Benzodiazepines are contraindicated in decompensated cirrhosis 7
Nutritional management:
Management of Variceal Bleeding
Initiate vasoactive drugs immediately upon suspicion of variceal bleeding, even before endoscopic confirmation. 1
Antibiotic prophylaxis is essential in all cirrhotic patients with GI bleeding 1
Endoscopic band ligation should be performed within 12 hours of admission once hemodynamic stability is achieved 1
Use restrictive transfusion strategy: hemoglobin threshold of 7 g/dL, target 7-9 g/dL 1
TIPS as rescue therapy for persistent bleeding or early rebleeding 1
For primary prophylaxis: In a 3-year trial of 201 patients with portal hypertension, nonselective β-blockers (carvedilol or propranolol) reduced risk of decompensation or death from 27% to 16% compared with placebo 5
Avoid nephrotoxic drugs, large volume paracentesis without albumin, and hypotensive drugs during acute variceal hemorrhage 1
Management of Hepatorenal Syndrome
Terlipressin is the best available medical therapy for type 1 hepatorenal syndrome. 8, 5
- In a randomized trial of 300 patients, terlipressin improved reversal rate of hepatorenal syndrome from 18% to 39% 5
- Addition of albumin to terlipressin decreases mortality 8
Management of Common Symptoms
Many symptoms of cirrhosis are treatable and significantly impact quality of life. 5
- Muscle cramps (64% prevalence): Pickle brine or taurine supplementation 5
- Pruritus (39% prevalence): Hydroxyzine 5
- Poor-quality sleep (63% prevalence): Hydroxyzine 5
- Sexual dysfunction in men (53% prevalence): Tadalafil 5
Nutritional Support and Vitamin Supplementation
- Calcium supplementation: 1,000-1,200 mg/day 6
- Vitamin D supplementation: 400-800 IU/day 6
- Parenteral vitamin K prophylactically prior to invasive procedures in overt cholestasis and in bleeding contexts 6
Monitoring and Surveillance
Screen for varices when platelet count <200,000/mm³, serum albumin <40 g/L, or serum bilirubin >20 µmol/L 6
Hepatocellular carcinoma surveillance: 1-4% annual incidence in cirrhosis, with 5-year survival of approximately 20% 5
Consider telemedicine and remote monitoring technologies including heart rate variability monitoring to improve outcomes and reduce hospital readmissions 6, 2
Indications for Gastroenterology Referral
Refer to gastroenterology when: 1
- Any decompensation event occurs (ascites, variceal bleeding, hepatic encephalopathy)
- Refractory ascites not responding to maximum diuretic therapy
- Need for TIPS placement
- Evaluation for liver transplantation
Special Considerations
- Patient education is crucial: Teach salt restriction, medication adherence, and recognition of warning signs 1
- Monitor hepatic function closely for several months after discontinuing anti-hepatitis B therapy, as severe acute exacerbations can occur 3
- HIV/HBV co-infected patients: Entecavir is not recommended unless receiving concurrent highly active antiretroviral therapy (HAART) due to potential HIV resistance development 3
- Renal impairment: Adjust entecavir dosing based on creatinine clearance 3
Critical Pitfalls to Avoid
- Never restrict protein in hepatic encephalopathy—this worsens sarcopenia and outcomes 7
- Never use interferon in decompensated cirrhosis—risk of fatal complications 1
- Never continue NSAIDs in patients with ascites—converts to refractory ascites 1
- Never use benzodiazepines in decompensated cirrhosis—increases hepatic encephalopathy risk 7
- Never ignore precipitating factors—90% of hepatic encephalopathy can be managed by addressing these alone 6