How is cirrhosis managed?

Management of Cirrhosis

Treat the Underlying Cause First

The cornerstone of cirrhosis management is addressing the underlying etiology, which can potentially reverse early cirrhosis and prevent progression to decompensation. 1, 2

• Alcoholic cirrhosis: Complete alcohol cessation may lead to "re-compensation" and improved outcomes 1, 2
• Viral hepatitis-related cirrhosis:
  • For HBV, initiate antiviral therapy with entecavir or tenofovir as first-line agents if HBV DNA ≥2,000 IU/mL, regardless of ALT levels 1
  • All patients with decompensated cirrhosis should receive treatment regardless of HBV DNA level 1
  • Interferon-α is absolutely contraindicated in decompensated cirrhosis due to risk of infection and hepatic failure 1
  • For HCV, direct-acting antivirals can improve liver function and reduce portal hypertension 1, 2
• Nonalcoholic fatty liver disease: Address obesity through lifestyle modifications 3

Management of Ascites

First-line treatment consists of sodium restriction combined with spironolactone with or without furosemide. 1

• Fluid restriction is unnecessary unless serum sodium drops below 120-125 mmol/L 1
• For tense ascites, perform initial therapeutic paracentesis followed by sodium restriction and diuretic therapy 1
• Critical caveat: NSAIDs must be avoided as they reduce urinary sodium excretion and can convert diuretic-sensitive ascites to refractory ascites 1, 4

Refractory Ascites Management

• Options include serial large-volume paracentesis with albumin replacement, transjugular intrahepatic portosystemic stent-shunt (TIPS), or liver transplantation 1, 2
• Patients requiring paracenteses more frequently than every 2 weeks likely have poor dietary compliance 1
• Offer palliative care referral to non-transplant candidates with refractory ascites 1

Management of Variceal Bleeding

Initiate vasoactive drugs immediately upon suspicion of variceal bleeding, even before endoscopic confirmation. 1

• Start antibiotic prophylaxis immediately in all cirrhotic patients with GI bleeding 1
  • Use ceftriaxone 1 g/24h for up to 7 days in decompensated cirrhosis or quinolone-resistant settings 1
  • Use oral norfloxacin 400 mg twice daily in remaining patients 1
• Perform endoscopic band ligation within 12 hours of admission once hemodynamic stability is achieved 1
• Use a restrictive transfusion strategy with hemoglobin threshold of 7 g/dL, targeting 7-9 g/dL 1
• Consider erythromycin 250 mg IV 30-120 minutes before endoscopy to improve visibility, unless QT prolongation is present 1
• Use TIPS as rescue therapy for persistent bleeding or early rebleeding 1

Prevention of Complications

Prophylactic band ligation is standard of care for varices. 1

• Consider non-selective beta blockers for prevention of variceal bleeding, but use with caution in patients with severe or refractory ascites 1
• Provide antibiotic prophylaxis for spontaneous bacterial peritonitis when indicated 1
• Oral non-absorbable disaccharides may prevent development of hepatic encephalopathy 1

Patient Education and Monitoring

Patient education about disease management is crucial for improved outcomes. 1

• Educate patients on salt restriction, medication adherence, and recognition of warning signs 1
• Perform clinical assessment with laboratory tests and calculate Child-Pugh and MELD scores every 6 months 3
• Screen for hepatocellular carcinoma regularly 3

Emerging Technologies for Monitoring

• Remote monitoring technologies and telemedicine can improve outcomes and reduce hospital readmissions 1, 2
• Heart rate variability monitoring may identify patients at risk of decompensation 1, 2
• Bluetooth-linked weighing scales and smartphone apps enable providers to monitor weight changes and intervene early 5

When to Refer to Gastroenterology

Refer to gastroenterology when patients develop any decompensation event. 1

• Development of ascites, variceal bleeding, or hepatic encephalopathy requires referral 1
• Refractory ascites not responding to maximum diuretic therapy requires referral 1
• Need for TIPS placement requires referral 1
• Evaluation for liver transplantation is indicated for patients with MELD score ≥15, complications of cirrhosis, or hepatocellular carcinoma 3

Critical Medications to Avoid

• Avoid nephrotoxic drugs, which can precipitate renal dysfunction 1, 4
• Avoid sedatives and benzodiazepines, which can precipitate hepatic encephalopathy 4
• Avoid NSAIDs due to risk of gastrointestinal bleeding, renal dysfunction, and conversion to refractory ascites 1, 4
• Avoid large volume paracentesis without albumin replacement and hypotensive drugs during acute variceal hemorrhage 1