What is the management of suspected decompensated liver cirrhosis?

From the Guidelines

Management of suspected decompensated liver cirrhosis requires prompt evaluation and treatment to prevent further deterioration and address complications, with a focus on identifying and treating precipitating factors such as infections, gastrointestinal bleeding, medications, or alcohol consumption, as recommended by the EASL clinical practice guidelines 1. The initial management should include admission to the hospital for close monitoring of vital signs, mental status, and laboratory parameters. Diagnostic workup includes comprehensive blood tests, abdominal ultrasound with Doppler, and possibly endoscopy to assess for varices. For ascites management, sodium restriction and diuretic therapy with spironolactone and furosemide should be initiated, with doses adjusted based on response, as outlined in the EASL guidelines 1. Some key points to consider in the management of decompensated liver cirrhosis include:

• Large-volume paracentesis may be necessary for tense ascites, with albumin replacement for volumes greater than 5 liters.
• Hepatic encephalopathy should be treated with lactulose and rifaximin for recurrent episodes.
• For variceal bleeding, terlipressin or octreotide should be administered along with prophylactic antibiotics, such as ceftriaxone, as recommended by the EASL guidelines 1.
• Endoscopic band ligation should be performed within 12 hours.
• Spontaneous bacterial peritonitis requires antibiotics, such as ceftriaxone, plus albumin.
• Hepatorenal syndrome may require vasoconstrictors like terlipressin with albumin.
• Nutritional support with 1.2-1.5g/kg/day of protein and 35-40 kcal/kg/day is essential, as emphasized in the EASL guidelines 1.
• Abstinence from alcohol is crucial, and patients should be evaluated for liver transplantation if appropriate, as noted in the KASL clinical practice guidelines for management of chronic hepatitis B 1.

From the FDA Drug Label

In patients with cirrhosis, initiate therapy in a hospital setting and titrate slowly [see Use in Specific Populations (8. 7)] WARNINGS In patients with hepatic cirrhosis and ascites, Furosemide tablets therapy is best initiated in the hospital.

The management of suspected decompensated liver cirrhosis involves:

• Initiating therapy in a hospital setting
• Slow titration of spironolactone 2
• Monitoring for potential complications, such as hepatic coma and electrolyte depletion 3
• Consideration of supplemental potassium chloride and aldosterone antagonist to prevent hypokalemia and metabolic alkalosis 3

From the Research

Management of Suspected Decompensated Liver Cirrhosis

The management of suspected decompensated liver cirrhosis involves a comprehensive approach to identify and treat the underlying cause of decompensation, as well as manage the associated complications. Key aspects of management include:

• Identifying the precipitating cause of decompensation, such as infections, gastrointestinal bleeding, high alcohol intake, or drug-induced liver injury 4
• Conducting a careful history, examination, and investigations to guide management 4
• Implementing a 'care bundle' to ensure all aspects of care are addressed in the first 24 hours 4
• Managing complications, such as infections, gastrointestinal bleeding, hepatic encephalopathy, and hepatorenal syndrome 4, 5, 6, 7

Treatment of Variceal Bleeding

Variceal bleeding is a common complication of decompensated liver cirrhosis, and treatment goals include:

• Correcting hypovolemia and achieving rapid hemostasis 6
• Preventing early rebleeding and complications related to bleeding 6
• Maintaining hemodynamic stability, with a hemoglobin level >8 g/dL, systolic blood pressure >90 to 100 mm Hg, heart rate <100/min, and central venous pressure from 1 to 5 mm Hg 6
• Using endoscopic variceal ligation or obturation to achieve hemostasis, with salvage therapy as needed 6

Comparison of Treatments for Variceal Bleeding

A network meta-analysis compared the benefits and harms of different treatments for variceal bleeding, including:

• Endoscopic sclerotherapy, variceal band ligation, somatostatin analogues, vasopressin analogues, and balloon tamponade 8
• The analysis found that somatostatin analogues alone and vasopressin analogues alone had higher mortality than sclerotherapy, while vasopressin analogues alone and variceal band ligation had fewer adverse events than sclerotherapy 8
• The evidence suggests considerable uncertainty about the effect of the interventions in the remaining comparisons, highlighting the need for further research to guide treatment decisions 8