What is the management plan for a patient with cirrhosis?

Management of Cirrhosis

For a patient with cirrhosis, the cornerstone of management involves treating the underlying etiology, preventing variceal bleeding with non-selective beta-blockers (preferably carvedilol), managing ascites with sodium restriction and diuretics, providing antibiotic prophylaxis when indicated, and monitoring for complications including hepatocellular carcinoma. 1

Remove the Underlying Cause

• Eliminating the etiological factor is associated with decreased risk of decompensation and increased survival 2
• Prioritize treatment of alcohol use disorder, hepatitis B or C virus infection, or other reversible causes 2
• Even in patients with established cirrhosis, treating the underlying cause (such as achieving sustained virologic response in hepatitis C) decreases the risk of long-term complications, though continuous monitoring remains necessary 1

Variceal Bleeding Prevention

Surveillance Strategy

• All patients with cirrhosis should undergo endoscopy at the time of diagnosis 2
• If no varices are present, repeat endoscopy every 3 years 2
• If small varices are present, repeat endoscopy yearly 2

Primary Prophylaxis

Non-selective beta-blockers are the preferred first-line treatment for preventing variceal bleeding 2, 1:

• Carvedilol is emerging as the non-selective beta-blocker of choice due to superior efficacy in lowering portal hypertension compared to traditional beta-blockers 3
• Target dose of carvedilol is 12.5 mg/day 3
• Traditional options include propranolol (starting 40 mg twice daily, increasing to 80 mg twice daily if necessary; long-acting formulations at 80-160 mg can improve compliance) 2
• The goal is to reduce hepatic venous pressure gradient to less than 12 mm Hg 2

Indications for primary prophylaxis 2:

• Grade 3 (large) varices regardless of liver disease severity
• Grade 2 (medium) varices with Child-Pugh class B or C disease

If beta-blockers are contraindicated or not tolerated, variceal band ligation is the treatment of choice 2

Important caveat: Beta-blockers should be used cautiously in patients with advanced decompensation as they may compromise renal function and hemodynamic stability 1

Ascites Management

Initial Approach

First-line treatment consists of sodium restriction (no more than 5-6.5 g or 87-113 mmol daily) combined with diuretic therapy 2, 1:

• For first presentation of moderate ascites, initiate spironolactone monotherapy at 100 mg daily, increasing up to 400 mg as needed 1
• For recurrent or severe ascites requiring faster diuresis, use combination therapy: spironolactone 100 mg plus furosemide 40 mg daily 1
• The FDA label recommends initiating spironolactone at 100 mg daily in cirrhotic patients (range 25-200 mg), administered for at least 5 days before dose escalation 4
• In cirrhotic patients, initiate therapy in a hospital setting and titrate slowly due to risk of sudden electrolyte shifts that may precipitate hepatic encephalopathy 4

Monitoring and Adjustments

• Nearly half of patients may require dose reduction or discontinuation due to adverse events 1
• Monitor closely for hyperkalemia, hyponatremia, and renal dysfunction 4
• Fluid restriction to 1-1.5 L/day should be reserved only for severe hyponatremia (serum sodium <125 mmol/L) 2, 1

Refractory Ascites

• Defined as fluid overload unresponsive to high-dose diuretics (400 mg/day spironolactone and 160 mg/day furosemide) or rapidly recurring after paracentesis 2
• Options include serial therapeutic paracenteses, TIPS, or liver transplantation 2
• Midodrine may benefit select patients with refractory ascites on a case-by-case basis 1

Tense Ascites

• Perform initial therapeutic paracentesis for symptomatic relief, then initiate sodium restriction and oral diuretics 2

Antibiotic Prophylaxis

Primary Prophylaxis for Spontaneous Bacterial Peritonitis

Indicated for patients with cirrhosis and ascites with ascitic fluid protein <1.5 g/dL 1:

• Options include norfloxacin 400 mg once daily, ciprofloxacin 500 mg once daily, or co-trimoxazole (800 mg sulfamethoxazole/160 mg trimethoprim daily) 1
• Consider local antibiotic resistance patterns when selecting agents 1

Prophylaxis During Gastrointestinal Bleeding

All patients with cirrhosis presenting with GI bleeding and underlying ascites should receive prophylactic antibiotics 1:

• Ceftriaxone is widely studied, though choice should be based on local resistance patterns 1
• Continue for duration of acute bleeding episode 2

Secondary Prophylaxis

Patients who have recovered from an episode of SBP require indefinite secondary prophylaxis 1 with the same antibiotic regimens listed above

Management of Acute Complications

Acute Variceal Hemorrhage

Initiate vasoactive drugs immediately when variceal bleeding is suspected, before endoscopic confirmation 2:

• Options include terlipressin (2 mg IV every 4 hours for 48 hours, then 1 mg every 4 hours), somatostatin (250 µg/h continuous infusion with 250 µg bolus), or octreotide (50 µg/h continuous infusion with 50 µg bolus) 2
• Continue vasoactive therapy for 2-5 days after endoscopic hemostasis to prevent early rebleeding 2, 1
• Perform endoscopy within 12 hours of presentation 2
• Endoscopic band ligation is the preferred endoscopic therapy (more effective than sclerotherapy with fewer adverse effects) 2
• Consider erythromycin 250 mg IV 30-120 minutes before endoscopy to improve visualization 2

Hepatorenal Syndrome

Treat promptly with terlipressin plus albumin 2:

• Terlipressin can be given as IV boluses (0.5-1 mg every 4-6 hours, increasing to maximum 2 mg every 4-6 hours) or continuous infusion (2 mg/day initially) 2
• Albumin at 20-40 g/day IV 2
• In patients with SBP and rising creatinine, administer albumin 1.5 g/kg within 6 hours of diagnosis 1
• Continue treatment until complete response (creatinine <1.5 mg/dL) or for maximum 14 days 2

Hepatic Encephalopathy

Initiate lactulose if hepatic encephalopathy develops 1

Medications to Avoid

Avoid the following agents in cirrhotic patients 1:

• NSAIDs (can precipitate renal failure and convert diuretic-sensitive to refractory ascites) 2, 1
• Aminoglycosides and other nephrotoxic drugs 1

Monitoring for Hepatocellular Carcinoma

• Patients with cirrhosis develop hepatocellular carcinoma at a rate of 1-4% per year 5
• Regular surveillance is essential even after successful treatment of underlying etiology 1

Liver Transplantation Consideration

Development of ascites as a complication of cirrhosis is associated with poor prognosis and should prompt evaluation for liver transplantation 2:

• Median survival after onset of ascites is 1.1 years 5
• Median survival after onset of hepatic encephalopathy is 0.92 years 5