Management of Liver Cirrhosis

Core Management Principle

Treatment must immediately address the underlying etiology of cirrhosis, as this is the single most important intervention associated with decreased risk of further decompensation and increased survival. 1, 2

Treatment of Underlying Causes

Alcohol-Related Cirrhosis

Complete and permanent cessation of alcohol is the cornerstone of treatment and can lead to dramatic improvement in reversible components of liver disease 3, 4
Patients with Child-Pugh class C cirrhosis who stop drinking have approximately 75% 3-year survival, while those who continue drinking have 0% survival at 3 years 3

Viral Hepatitis-Related Cirrhosis

Initiate antiviral therapy if HBV DNA ≥2,000 IU/mL regardless of ALT levels using entecavir or tenofovir as first-line agents 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
Entecavir (1 mg/day) demonstrates superior HBV DNA suppression compared to adefovir (57% vs 20% undetectability at week 48) 1

Nonalcoholic Fatty Liver Disease

Address obesity through weight management and metabolic optimization 4, 5

Nutritional Management

Dietary Requirements

Sodium restriction to less than 5 g/day (sodium: 2 g/day, 88 mmol/day) is essential for controlling ascites 6, 3
Greater dietary sodium restriction is not recommended as it may worsen malnutrition 6
Protein intake: 1.2-1.5 g/kg/day 3
Carbohydrate intake: 2-3 g/kg/day 3
Total caloric intake: 35-40 kcal/kg/day 3
Fluid restriction is not necessary unless serum sodium drops below 120-125 mmol/L 1, 2

Nutritional Assessment

Perform rapid nutritional screening in all patients with cirrhosis 6
Assume high risk for malnutrition if BMI <18.5 kg/m² or Child-Pugh C 6
Always include assessment of sarcopenia within nutritional evaluation 6
Assess muscle mass using CT scan when available, or use anthropometry, DEXA, or BIA as alternatives 6
Evaluate muscle function with handgrip strength and/or short physical performance battery 6

Management of Ascites

Initial Treatment by Grade

Grade 1 (Mild - detectable only by ultrasound):

Sodium restriction 6
Treat underlying disease 6
Nutritional treatment and education 6
Discontinue NSAIDs, ACE inhibitors, or angiotensin receptor blockers 6

Grade 2 (Moderate - moderate symmetrical abdominal distension):

Sodium restriction 6
Oral diuretics: spironolactone with or without furosemide 6, 1, 3
Treat underlying disease 6
Discontinue NSAIDs, ACE inhibitors, or angiotensin receptor blockers 6

Grade 3 (Large - marked abdominal distension):

Therapeutic paracentesis followed by sodium restriction and diuretic therapy 6, 1
Treat underlying disease 6
Discontinue NSAIDs, ACE inhibitors, or angiotensin receptor blockers 6

Diuretic Therapy

Spironolactone (Aldosterone Antagonist):

Starting dose: 50-100 mg/day, maximum dose: 400 mg/day 6
Requires 3-4 days to achieve stable concentration 6
Side effects include hyperkalemia, gynecomastia, mastalgia, hyposexuality, and erectile dysfunction 6
Aldosterone antagonist is the mainstay of diuretic treatment 6

Furosemide (Loop Diuretic):

Starting dose: 20-40 mg/day, maximum dose: 160 mg/day 6
Has rapid onset of action 6
Can correct hyperkalemia caused by aldosterone antagonists 6
Monotherapy with loop diuretics is not recommended 6

Combination Therapy:

Combination aldosterone antagonist and loop diuretics are more effective than sequential initiation (76% vs 56% resolution of ascites) with lower rates of hyperkalemia (4% vs 18%) 4
Oral administration is standard; intravenous use is not recommended due to risk of kidney damage from sudden fluid loss 6

Refractory Ascites

Options include serial large-volume paracentesis, transjugular intrahepatic portosystemic stent-shunt (TIPS), liver transplantation, peritoneovenous shunt, or experimental medical therapy 1
Large-volume paracentesis with albumin replacement is recommended 3
Patients requiring paracenteses more frequently than every 2 weeks likely have poor dietary compliance 1
Offer palliative care referral to patients who are not transplant candidates 1

Management of Spontaneous Bacterial Peritonitis (SBP)

Diagnosis

Perform diagnostic paracentesis without delay in all cirrhotic patients with ascites on hospital admission 6
Perform diagnostic paracentesis in patients with GI bleeding, shock, fever, systemic inflammation, gastrointestinal symptoms, hepatic encephalopathy, or worsening liver/renal function 6
Ascitic neutrophil count >250/mm³ is the gold standard for diagnosis 6
Perform ascitic fluid culture with bedside inoculation of blood culture bottles 6

Treatment

Initiate immediate empirical antibiotic therapy determined by context (community-acquired vs healthcare-associated), severity, and local resistance patterns 6
Cefotaxime has been widely studied, but choice should be guided by local protocols 6
Consider second diagnostic paracentesis at 48 hours to check treatment efficacy 6

Prophylaxis

Patients with GI bleeding and ascites should receive prophylactic antibiotics (cefotaxime or based on local data) 6
Use ceftriaxone 1 g/24h for up to 7 days in decompensated cirrhosis or quinolone-resistant settings 1, 2
Use oral norfloxacin 400 mg twice daily in remaining patients 1, 2
Patients who recovered from SBP should receive norfloxacin 400 mg once daily or ciprofloxacin 500 mg once daily 6

Management of Hepatic Encephalopathy

Lactulose is first-line therapy and reduces mortality (8.5% vs 14% compared to placebo) and recurrent overt hepatic encephalopathy (25.5% vs 46.8%) 2, 4
Oral non-absorbable disaccharides may prevent development of hepatic encephalopathy 1
Rifaximin can be used as adjunctive therapy 5
Implement lifestyle and nutritional modifications 5

Management of Variceal Bleeding

Acute Management

Initiate vasoactive drugs immediately upon suspicion, even before endoscopic confirmation 1, 2
Antibiotic prophylaxis is mandatory: ceftriaxone 1 g/24h for up to 7 days in decompensated cirrhosis or quinolone-resistant settings; oral norfloxacin 400 mg twice daily in remaining patients 1, 2
Perform endoscopic band ligation within 12 hours of admission once hemodynamic stability is achieved 1
Use restrictive transfusion strategy with hemoglobin threshold of 7 g/dL, target 7-9 g/dL 1
Consider erythromycin 250 mg IV 30-120 minutes before endoscopy to improve visibility (unless QT prolongation present) 1
TIPS should be used as rescue therapy for persistent bleeding or early rebleeding 1

Prevention

Prophylactic band ligation is standard of care for varices 1
Non-selective beta-blockers (carvedilol or propranolol) reduce risk of decompensation or death (16% vs 27% compared to placebo) 4
Propranolol in responders decreases risk of ascites, hepatorenal syndrome, SBP, and hepatic encephalopathy beyond variceal bleeding prevention 2
Use caution with beta-blockers in patients with severe or refractory ascites 1

Management of Hepatorenal Syndrome

Terlipressin improves rate of reversal of hepatorenal syndrome from 18% to 39% 4
Median survival without treatment is less than 2 weeks 4
Annual incidence in patients with ascites is 8% 4

Prevention of Disease Progression

Anticoagulation

Enoxaparin may delay hepatic decompensation and improve survival in patients with Child-Pugh scores 7-10 by preventing portal vein thrombosis and reducing intestinal barrier damage 1, 2

Avoid Nephrotoxic Agents

NSAIDs should be avoided as they reduce urinary sodium excretion and can convert diuretic-sensitive ascites to refractory ascites 6, 1
Avoid nephrotoxic drugs, large volume paracentesis without albumin, and hypotensive drugs during acute variceal hemorrhage 1
Discontinue ACE inhibitors and angiotensin receptor blockers 6

Monitoring and Surveillance

Regular Assessment

Clinical assessment with laboratory tests and calculation of Child-Pugh and MELD scores should occur every 6 months 7
Hepatocellular carcinoma screening with ultrasound every 6 months for all patients with cirrhosis 5
Annual incidence of hepatocellular carcinoma is 1-4% in patients with cirrhosis 4

Remote Monitoring

Consider telemedicine and remote monitoring technologies for early detection of complications and reduction of hospital readmissions 1, 3
Bluetooth-linked weighing scales and smartphone apps enable providers to monitor weight changes and intervene early 1
Heart rate variability monitoring may identify patients at risk of decompensation 1

Indications for Gastroenterology Referral

Development of any decompensation events (ascites, variceal bleeding, hepatic encephalopathy) 1
Refractory ascites not responding to maximum diuretic therapy 1
Need for TIPS placement for refractory ascites or recurrent variceal bleeding 1
MELD score of 15 or greater for liver transplantation evaluation 7

Liver Transplantation

Early referral for liver transplantation evaluation is essential for appropriate candidates, as decompensation significantly worsens prognosis 2
Evaluation indicated for patients with MELD score ≥15, complications of cirrhosis, or hepatocellular carcinoma 7
Mean pulmonary arterial pressure ≥45 mmHg is an absolute contraindication 2
Liver transplantation is potentially optimal therapy for small-size hepatocellular carcinoma in patients with moderate to severe cirrhosis (Child-Pugh class B or C) 3

Management of Common Symptoms

Hydroxyzine for sleep dysfunction 4
Pickle brine and taurine for muscle cramps 4
Tadalafil for sexual dysfunction in men 4
These symptoms are common (muscle cramps 64%, pruritus 39%, poor sleep 63%, sexual dysfunction 53%) and treatable 4

Vaccination

Vaccinations against pneumococcus, hepatitis A, and hepatitis B are well tolerated and effective in disease prevention 8
Vaccination rates remain suboptimal and should be improved through EMR reminders and increased awareness 8

Common Pitfalls

Bed rest is not recommended as excessive bed rest may cause muscle atrophy; patients can be managed on an outpatient basis unless complicated by bleeding, encephalopathy, infection, hypotension, or liver cancer 6
Only 10-30% of patients initially presenting with hepatocellular carcinoma will be eligible for surgery 3
Surgery in patients with underlying cirrhosis has substantial morbidity and mortality (30-50% in Child-Pugh class B or C, but only 5-10% in Child-Pugh class A) 3
Approximately 40% of people with cirrhosis are diagnosed when they present with complications; median survival after onset of hepatic encephalopathy and ascites is 0.92 and 1.1 years, respectively 4

What are the management guidelines for liver cirrhosis?

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