What is the appropriate management approach for a patient diagnosed with cirrhosis?

Cirrhosis Case Presentation

Chief Complaint and History of Present Illness

A 58-year-old patient presents with progressive abdominal distension over 3 weeks, accompanied by lower extremity edema and confusion episodes. 1 The patient reports decreased urine output, early satiety, and dyspnea when lying flat. 1 Family members note periods of disorientation to time and personality changes over the past week. 1 The patient denies hematemesis or melena but reports dark urine and pale stools. 2

Past Medical History

• Chronic alcohol use disorder (consuming 6-8 drinks daily for 20 years) or chronic hepatitis C infection or nonalcoholic fatty liver disease with obesity (these represent the three most common etiologies, accounting for 45%, 41%, and 26% of cirrhosis cases respectively). 3
• Type 2 diabetes mellitus (present in approximately 30% of cirrhosis patients). 1
• Hypertension (managed with ACE inhibitors, which should be discontinued). 4

Social History

• Active alcohol use or remote history with recent abstinence. 2
• No intravenous drug use history.
• Works as an office manager but has missed work recently due to fatigue. 2

Medications

• Medications requiring immediate review and potential discontinuation: NSAIDs (increased risk of acute kidney injury, gastrointestinal bleeding, and decompensation), ACE inhibitors or ARBs (risk of hypotension and renal impairment), and alpha-blockers. 5, 4

Physical Examination Findings

Vital Signs

• Blood pressure: 95/60 mmHg (hypotension suggesting decompensation). 4
• Heart rate: 88 bpm
• Temperature: 37.2°C
• Respiratory rate: 18/min
• Oxygen saturation: 94% on room air (may indicate hepatopulmonary syndrome if <80 mmHg PaO2). 1

General Appearance

• Appears chronically ill, mildly confused (Grade I-II hepatic encephalopathy). 1
• Temporal wasting and muscle wasting evident (sarcopenia, present in majority of cirrhosis patients). 1

HEENT

• Scleral icterus present. 2
• No parotid enlargement.

Cardiovascular

• Regular rate and rhythm, no murmurs.
• Prolonged QTc interval on ECG (common in cirrhosis and indicates poor prognosis). 1

Pulmonary

• Decreased breath sounds at right base (suggesting hepatic hydrothorax). 1
• No wheezes or crackles.

Abdominal

• Distended with shifting dullness and fluid wave positive (ascites). 1
• Splenomegaly palpable (portal hypertension). 2
• No tenderness to palpation (absence of tenderness does not rule out spontaneous bacterial peritonitis). 1
• Caput medusae visible. 2

Extremities

• 2+ pitting edema bilaterally to mid-shin. 1
• Palmar erythema present. 2
• Asterixis elicited (flapping tremor indicating hepatic encephalopathy). 1

Neurological

• Disoriented to time (3 out of 5 orientation questions incorrect, consistent with Grade II hepatic encephalopathy). 1
• Asterixis present. 1
• No focal deficits.

Skin

• Spider angiomata on chest and back. 2
• No jaundice of skin but scleral icterus present. 2

Laboratory Values

Complete Blood Count

• WBC: 4.2 × 10³/μL (leukopenia from hypersplenism). 2
• Hemoglobin: 10.2 g/dL (anemia). 2
• Platelets: 78 × 10³/μL (thrombocytopenia from portal hypertension and hypersplenism). 2

Comprehensive Metabolic Panel

• Sodium: 128 mmol/L (hyponatremia common in decompensated cirrhosis). 1
• Potassium: 3.8 mmol/L
• Creatinine: 1.8 mg/dL (baseline 0.9 mg/dL 3 months ago, representing Stage 2 AKI with >2-fold increase). 1
• BUN: 32 mg/dL
• Glucose: 156 mg/dL (diabetes screening indicated; HbA1c should not be used for diagnosis or monitoring in cirrhosis). 1

Liver Function Tests

• AST: 142 U/L (typically AST:ALT ratio >2:1 in alcoholic cirrhosis). 2
• ALT: 68 U/L
• Alkaline phosphatase: 178 U/L
• Total bilirubin: 4.2 mg/dL (hyperbilirubinemia). 2
• Albumin: 2.4 g/dL (hypoalbuminemia). 2
• INR: 1.8 (coagulopathy; should not be used to gauge bleeding risk). 1

Additional Labs

• Ammonia: 98 μmol/L (elevated, contributing to hepatic encephalopathy). 1
• Lactate: 1.8 mmol/L

Severity Scores

• MELD Score: 22 (indicates need for transplant evaluation as score ≥15). 6
• Child-Pugh Score: Class B (8 points) (moderate hepatic dysfunction). 2

Imaging

Abdominal Ultrasound

• Nodular liver contour with coarse echotexture (consistent with cirrhosis). 2
• Splenomegaly (16 cm, indicating portal hypertension). 2
• Large volume ascites. 1
• Patent portal vein with hepatopetal flow. 2
• No focal liver lesions identified (hepatocellular carcinoma screening required every 6 months). 2, 3

Chest X-ray

• Right-sided pleural effusion (hepatic hydrothorax). 1

Diagnostic Procedures Needed

Diagnostic Paracentesis

Mandatory for new-onset ascites or any hospitalized patient with ascites to rule out spontaneous bacterial peritonitis. 1, 4

• Ultrasound guidance should be used when available to reduce adverse events. 1
• Routine measurement of PT/INR and platelet transfusion are NOT recommended before paracentesis. 1
• Send ascitic fluid for: cell count with differential, albumin (to calculate serum-ascites albumin gradient), culture (inoculate blood culture bottles at bedside), total protein, and Gram stain. 1

Upper Endoscopy

• Required for variceal screening in all patients with newly diagnosed cirrhosis. 2, 3
• Prophylactic nonselective beta-blockers (carvedilol or propranolol) indicated if varices present. 3

Assessment and Plan

Primary Diagnosis: Decompensated Cirrhosis with Multiple Complications

This patient has transitioned from compensated to decompensated cirrhosis, presenting with ascites, hepatic encephalopathy, and acute kidney injury—complications associated with median survival of approximately 1 year. 3

Immediate Management Priorities

1. Acute Kidney Injury Management (Stage 2 AKI, Creatinine 1.8 mg/dL)

Discontinue all diuretics, nephrotoxic drugs, NSAIDs, ACE inhibitors, and beta-blockers immediately. 1, 4

• Expand plasma volume with albumin 1 g/kg (up to 100g) over 2-4 hours if hypovolemia suspected. 1
• Rule out infection as precipitant (obtain blood cultures, urinalysis, diagnostic paracentesis). 1
• Monitor for hepatorenal syndrome criteria: If creatinine remains >1.5 mg/dL for 2 days despite volume expansion and no improvement, initiate vasoconstrictor therapy. 1
• Start terlipressin (if available) or norepinephrine plus albumin if hepatorenal syndrome confirmed (improves reversal rate from 18% to 39%). 3
• Avoid normal saline; use balanced crystalloids (lactated Ringer's) or albumin for resuscitation. 1, 4

2. Ascites Management

Perform diagnostic paracentesis immediately to rule out spontaneous bacterial peritonitis. 1, 4

• If ascitic fluid PMN count >250 cells/mm³, start empiric third-generation cephalosporin (cefotaxime 2g IV q8h) immediately. 1
• Administer albumin 1.5 g/kg within 6 hours of SBP diagnosis, then 1 g/kg on day 3 to prevent hepatorenal syndrome. 1
• Once infection excluded and AKI stabilized, initiate combination diuretic therapy with spironolactone 100 mg plus furosemide 40 mg daily (combination more effective than sequential: 76% vs 56% resolution). 1, 3
• Restrict dietary sodium to 5-6.5 g/day (87-113 mmol) with nutritional counseling. 1
• Fluid restriction to 1-1.5 L/day ONLY if serum sodium <125 mmol/L with clinical hypervolemia. 1
• Monitor weight daily, electrolytes every 2-3 days initially. 1

3. Hepatic Encephalopathy Management (Grade II)

Start lactulose 15-30 mL orally 2-3 times daily, titrate to 2-3 soft bowel movements per day (reduces mortality from 14% to 8.5% and recurrence from 46.8% to 25.5%). 3

• Add rifaximin 550 mg twice daily for additional benefit in preventing recurrence. 3
• Identify and treat precipitants: constipation, infection, GI bleeding, electrolyte imbalances, medications (especially opioids). 7
• Avoid opioids due to risk of worsening encephalopathy; if pain management needed, use acetaminophen ≤2g/day or consider hydromorphone with extreme caution. 5
• Ensure adequate protein intake (1.2-1.5 g/kg/day); protein restriction is NOT recommended. 1

4. Hemodynamic Monitoring and Support

Perform bedside echocardiography to assess volume status and cardiac function (evaluate for cirrhotic cardiomyopathy and diastolic dysfunction). 1

• Target mean arterial pressure of 65 mmHg with ongoing assessment of end-organ perfusion. 1, 4
• If hypotension persists despite volume resuscitation, start norepinephrine as first-line vasopressor. 1, 4
• Add vasopressin as second-line agent if increasing norepinephrine doses required. 1, 4
• Consider empiric hydrocortisone 50 mg IV q6h or 200 mg infusion for refractory shock (relative adrenal insufficiency present in 49% of hospitalized cirrhosis patients). 1

5. Infection Surveillance and Prophylaxis

• Obtain blood cultures, urinalysis with culture, and diagnostic paracentesis to rule out infection. 1, 4
• If SBP confirmed, start antibiotic prophylaxis after treatment completion (norfloxacin 400 mg daily or trimethoprim-sulfamethoxazole). 1
• Avoid aminoglycosides due to nephrotoxicity risk. 4

6. Nutritional Support

Consult nutrition for assessment using NUTRIC score and implement early nutritional support. 1

• Target 35 kcal/kg/day for non-obese patients, 25-35 kcal/kg/day for obese patients (BMI 30-40). 1
• Protein goal: 1.2-1.5 g/kg/day using dry or ideal body weight; do NOT restrict protein. 1
• Consider branched-chain amino acid supplementation. 1
• Enteral nutrition preferred over parenteral; place feeding tube if needed for mechanical ventilation. 1

7. Etiology-Specific Treatment

• If alcohol-related: Initiate alcohol cessation counseling and consider pharmacotherapy. 2
• If hepatitis C: Evaluate for direct-acting antiviral therapy (ledipasvir/sofosbuvir safe in decompensated cirrhosis with close monitoring). 8
• If NAFLD: Optimize diabetes control with insulin (avoid metformin, use caution with other oral agents). 1

8. Variceal Bleeding Prophylaxis

Schedule upper endoscopy within 24-48 hours for variceal screening. 2, 7

• If varices present, start carvedilol 6.25 mg daily or propranolol 20 mg twice daily (reduces decompensation/death from 27% to 16% over 3 years). 3
• Titrate beta-blocker to heart rate 55-60 bpm or 25% reduction from baseline. 3

9. Hepatocellular Carcinoma Screening

Perform contrast-enhanced CT or MRI if ultrasound inadequate (ultrasound every 6 months for HCC screening). 2, 3

10. Liver Transplant Evaluation

Refer for transplant evaluation immediately given MELD score of 22 (evaluation indicated for MELD ≥15). 6

Monitoring Plan

• Daily: Weight, vital signs, mental status, intake/output, clinical volume assessment. 1
• Every 2-3 days initially: Comprehensive metabolic panel, liver function tests. 1
• Weekly: Complete blood count. 1
• Invasive hemodynamic monitoring (arterial line, central venous catheter) if shock develops. 1

Prognosis Discussion

Median survival with ascites is 1.1 years and with hepatic encephalopathy is 0.92 years without transplantation. 3 The annual risk of developing spontaneous bacterial peritonitis is 11% and hepatorenal syndrome is 8% (median survival <2 weeks with HRS). 3 Liver transplantation offers the only definitive cure and should be pursued urgently. 6