What is the initial management for a patient with cirrhosis?

Initial Management of Cirrhosis

The initial management of cirrhosis must prioritize identifying and eliminating the causative factor, implementing dietary sodium restriction to 88 mmol/day (2000 mg/day), and initiating diuretic therapy with spironolactone 100 mg daily if ascites is present. 1, 2

Immediate Priority: Address the Underlying Cause

The cornerstone of cirrhosis management is removing the etiological factor causing liver injury, as this can prevent decompensation and potentially reverse early cirrhosis. 3, 1

Alcohol-Related Cirrhosis

• Complete abstinence from alcohol is essential and can lead to dramatic improvement in the reversible component of liver disease. 1, 2
• Some patients with decompensated alcoholic cirrhosis experience progressive "re-compensation" and excellent long-term outcomes with abstinence, though results vary based on disease severity at intervention. 3

Viral Hepatitis-Related Cirrhosis

• Initiate antiviral therapy for hepatitis B if HBV DNA ≥2,000 IU/mL regardless of ALT levels, using entecavir or tenofovir as first-line agents. 2
• All patients with decompensated cirrhosis should receive treatment regardless of HBV DNA level. 2
• Interferon-α is absolutely contraindicated in decompensated cirrhosis due to risk of serious complications including infection and hepatic failure. 2
• For hepatitis C, direct-acting antivirals can improve liver function and reduce portal hypertension. 2

Other Etiologies

• Address metabolic disorders (nonalcoholic fatty liver disease), autoimmune conditions, and other causative factors when identified. 1

Dietary and Lifestyle Modifications

Sodium Restriction

• Restrict sodium intake to 88 mmol/day (2000 mg/day), equivalent to a "no added salt" diet. 1, 4
• Greater dietary sodium restriction is not recommended as it may worsen malnutrition. 2
• Inadequate sodium restriction is a common cause of treatment failure. 1

Nutritional Requirements

• Provide 1.2-1.5 g/kg/day protein, 2-3 g/kg/day carbohydrate, and 35-40 kcal/kg/day total calories. 1, 4
• Smaller, frequent meals may be beneficial if three meals per day do not provide adequate nutrition. 4
• A late-evening snack of 200 kcal can improve nutritional status. 4
• Rapid nutritional screening should be performed in all patients, assuming high risk for malnutrition if BMI <18.5 kg/m² or Child-Pugh C. 2

Fluid Restriction

• Fluid restriction is not necessary unless serum sodium is less than 120-125 mmol/L. 1, 2, 4

Activity Level

• 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. 2

Pharmacological Management for Ascites

Initial Diuretic Therapy

• Start with spironolactone 100 mg once daily as the initial dose. 1, 4, 5
• Add furosemide 40 mg once daily if needed. 1, 4
• Doses can be increased simultaneously every 3-5 days (maintaining the 100 mg:40 mg ratio) if weight loss and natriuresis are inadequate. 4
• Maximum doses are typically 400 mg/day of spironolactone and 160 mg/day of furosemide. 1, 4
• 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%). 6

Tense Ascites Management

• For tense ascites, perform therapeutic abdominal paracentesis followed by sodium restriction and oral diuretics. 1, 2
• For large-volume paracentesis (>5L), administer albumin (8g/L of ascites removed) to prevent circulatory dysfunction. 1, 4
• Delaying paracentesis in patients with tense ascites is a common pitfall to avoid. 1

Medications to Avoid

Avoid nonsteroidal anti-inflammatory drugs as they can reduce urinary sodium excretion, induce azotemia, and convert diuretic-sensitive ascites to refractory ascites. 1, 2, 4

Discontinue ACE inhibitors and angiotensin receptor blockers. 2

Monitoring and Follow-up

• Monitor serum electrolytes, creatinine, and weight regularly. 1, 4
• Measure 24-hour urinary sodium excretion if weight loss is less than desired. 1, 4
• Initial follow-up should occur every 2-4 weeks, with frequency adjusted based on response to treatment and patient stability. 1, 4

Screening for Complications

Spontaneous Bacterial Peritonitis

• Perform diagnostic paracentesis without delay in all cirrhotic patients with ascites on hospital admission. 2
• Ascitic neutrophil count >250/mm³ is the gold standard for diagnosis. 2
• Immediate empirical antibiotic therapy should be initiated if SBP is suspected. 2

Variceal Screening

• Consider non-selective beta blockers (carvedilol or propranolol) for prevention of variceal bleeding, which reduced the risk of decompensation or death (16% vs 27% compared to placebo in a 3-year trial). 6
• Use with caution in patients with severe or refractory ascites. 2

Hepatocellular Carcinoma Surveillance

• Perform ultrasound screening every six months for patients with cirrhosis. 7

Liver Transplantation Evaluation

Consider liver transplantation for all patients with cirrhosis and ascites, as development of ascites is associated with poor prognosis—20% of patients die within the first year of diagnosis. 1, 4

Transplantation offers a definitive cure for cirrhosis and its complications. 1, 4

Common Pitfalls to Avoid

• Delaying paracentesis in patients with tense ascites. 1
• Inadequate sodium restriction due to diet non-compliance. 1
• Overly aggressive diuresis leading to electrolyte abnormalities or renal dysfunction. 1
• Failure to recognize and treat spontaneous bacterial peritonitis promptly. 1
• Using nephrotoxic agents or NSAIDs. 2, 4

Gastroenterology Referral Indications

Refer to gastroenterology when patients develop any decompensation events (ascites, variceal bleeding, hepatic encephalopathy), refractory ascites not responding to maximum diuretic therapy, or need evaluation for liver transplantation. 2