What is the management and treatment of cirrhosis?

Management and Treatment of Cirrhosis

Cirrhosis management centers on treating the underlying cause to prevent progression, managing complications systematically, and timely referral for liver transplantation when indicated. 1

Treating the Underlying Etiology

The most critical intervention is addressing the root cause of cirrhosis, as this can potentially reverse early disease and prevent decompensation 1:

• Alcohol-related cirrhosis: Complete alcohol cessation is essential and may lead to "re-compensation" with improved outcomes 1
• Viral hepatitis B: Initiate antiviral therapy with entecavir or tenofovir as first-line agents if HBV DNA ≥2,000 IU/mL, regardless of ALT levels 1. In decompensated cirrhosis, treat all patients regardless of HBV DNA level 1. Interferon-α is absolutely contraindicated in decompensated cirrhosis due to risk of infection and hepatic failure 1
• Hepatitis C: Direct-acting antivirals can improve liver function and reduce portal hypertension 1
• NAFLD/NASH: Address metabolic risk factors including diabetes, obesity, and hypertension 2

Management of Ascites

First-Line Treatment

Initiate combination therapy with spironolactone (starting 100 mg daily, up to 400 mg) plus furosemide (starting 40 mg daily, up to 160 mg) for patients with recurrent or severe ascites 2, 1. For first presentation of moderate ascites, spironolactone monotherapy may be reasonable 2. Combination therapy is superior to sequential initiation, resolving ascites in 76% vs 56% of patients with lower hyperkalemia rates (4% vs 18%) 3.

In cirrhotic patients, initiate diuretic therapy in a hospital setting and titrate slowly 4. For patients with eGFR 30-50 mL/min/1.73 m², consider starting at 25 mg every other day due to hyperkalemia risk 4.

Dietary Management

• Restrict sodium intake to 5-6.5 g daily (87-113 mmol), which translates to a no-added-salt diet with avoidance of precooked meals 2
• Fluid restriction to 1-1.5 L/day is only necessary when serum sodium <125 mmol/L with clinical hypervolemia 2
• Avoid NSAIDs as they reduce urinary sodium excretion and can convert diuretic-sensitive to refractory ascites 1

Refractory Ascites

When ascites persists despite maximum diuretic therapy (spironolactone 400 mg + furosemide 160 mg daily) and sodium restriction 2:

• Perform serial large-volume paracentesis (every 2-4 weeks) 1
• Consider transjugular intrahepatic portosystemic shunt (TIPS) 1
• Evaluate for liver transplantation 1
• Offer palliative care referral if not a transplant candidate 1

Patients requiring paracentesis more frequently than every 2 weeks likely have poor dietary compliance 1.

Prevention and Management of Variceal Bleeding

Primary Prophylaxis

Non-selective beta-blockers (carvedilol or propranolol) reduce the risk of decompensation or death (16% vs 27% over 3 years) in patients with portal hypertension 3. However, exercise caution in severe or refractory ascites 2, 1:

• Discontinue NSBBs if systolic BP <90 mmHg or during acute complications (bleeding, sepsis, spontaneous bacterial peritonitis, acute kidney injury) 2
• After recovery from acute events, reinstatement can be attempted 2
• High doses should be avoided 2
• Carvedilol cannot be recommended at present 2

Prophylactic endoscopic band ligation is standard of care for varices 1.

Acute Variceal Hemorrhage Management

This is a medical emergency requiring immediate intensive care 2:

Immediate Resuscitation (within minutes)

• Restore hemodynamic stability with crystalloids via two large-bore catheters 2
• Use restrictive transfusion strategy: transfuse at hemoglobin threshold of 7 g/dL, target 7-9 g/dL 2, 5, 3. Higher thresholds increase portal pressure and rebleeding risk 5
• Initiate vasoactive drugs immediately upon suspicion, before endoscopic confirmation: terlipressin 2 mg IV every 4 hours for 48 hours, then 1 mg every 4 hours; OR somatostatin 250 µg/h continuous infusion (up to 500 µg/h) with 250 µg bolus; OR octreotide 50 µg/h continuous infusion with 50 µg bolus 2
• Start antibiotic prophylaxis immediately: ceftriaxone 1 g IV daily (preferred in decompensated cirrhosis or quinolone-resistant settings) or norfloxacin 400 mg PO twice daily 1, 5

Endoscopic Management (within 12 hours)

• Consider erythromycin 250 mg IV 30-120 minutes before endoscopy to improve visibility (unless QT prolongation present) 2, 1
• Perform endoscopic band ligation within 12 hours once hemodynamically stable 2, 1, 5
• Continue vasoactive drugs for 5 days to prevent early rebleeding 2
• Continue antibiotics for up to 7 days 5

Rescue Therapy

Use TIPS for persistent bleeding or early rebleeding (~15% of cases) 2, 5. Balloon tamponade can serve as temporary bridge to definitive treatment 5.

Spontaneous Bacterial Peritonitis (SBP)

Diagnosis and Treatment

• Perform diagnostic paracentesis on all cirrhotic patients with ascites at hospital admission 2
• Also perform paracentesis with GI bleeding, shock, fever, systemic inflammation, GI symptoms, hepatic encephalopathy, or worsening liver/renal function 2
• Ascitic neutrophil count >250/mm³ confirms SBP diagnosis 2
• Inoculate blood culture bottles at bedside to guide antibiotic selection 2
• Initiate empirical antibiotics immediately based on local resistance patterns (cefotaxime widely studied) 2
• Consider repeat paracentesis at 48 hours if inadequate response 2

Prophylaxis

• Primary prophylaxis: Offer to high-risk patients with ascitic protein <1.5 g/dL, guided by local resistance patterns 2
• Secondary prophylaxis: After SBP recovery, use norfloxacin 400 mg daily, ciprofloxacin 500 mg daily, or co-trimoxazole 800/160 mg daily 2
• GI bleeding prophylaxis: All cirrhotic patients with ascites and GI bleeding should receive prophylactic antibiotics 2

Hepatic Encephalopathy

Lactulose reduces mortality (8.5% vs 14%) and recurrent overt hepatic encephalopathy (25.5% vs 46.8%) 3. Screen for precipitating factors including constipation, infection, GI bleeding, medications, electrolyte imbalances, and medication non-compliance before escalating therapy 2, 6.

Oral non-absorbable disaccharides may prevent development of hepatic encephalopathy 1. Consider rifaximin as adjunctive therapy 6.

Hepatorenal Syndrome

Terlipressin improves reversal of hepatorenal syndrome from 18% to 39% 3. Renal replacement therapy may bridge to transplantation in end-stage kidney disease 2.

Diabetes Management in Cirrhosis

Screen all patients with decompensated cirrhosis for diabetes given high prevalence (30%) 2. Do not use HbA1c for diagnosis or monitoring 2.

Insulin therapy is the only evidence-based treatment option for type 2 diabetes in decompensated cirrhosis 2:

• Initiate in hospital due to high glucose variability and hypoglycemia risk 2
• Target fasting blood glucose <10 mmol/L 2
• Metformin is contraindicated (lactic acidosis risk) 2
• Most other oral agents are not recommended due to hepatic/renal elimination 2

Chronic Kidney Disease Monitoring

Nearly half of cirrhotic patients may have CKD, particularly those with NASH 2. Measure GFR with exogenous markers in transplant candidates, as creatinine-based equations have poor accuracy 2. If measured GFR <30 mL/min, consider combined liver-kidney transplantation 2.

Indications for Gastroenterology Referral

Refer patients with 1:

• Any decompensation event (ascites, variceal bleeding, hepatic encephalopathy)
• Refractory ascites not responding to maximum diuretic therapy
• Need for TIPS placement
• Evaluation for liver transplantation

Emerging Technologies

Remote monitoring with Bluetooth-linked scales and smartphone apps enables early intervention for weight changes, potentially reducing hospital readmissions 1. Specialist cirrhosis nursing support improves care coordination and quality of life 2.