What is the treatment for pseudocirrhosis?

Treatment of Pseudocirrhosis

The primary treatment for pseudocirrhosis is discontinuation or modification of the causative chemotherapy regimen, combined with aggressive management of portal hypertension complications using the same evidence-based approaches as for true cirrhosis. 1, 2

Understanding Pseudocirrhosis

Pseudocirrhosis is a chemotherapy-induced condition that mimics cirrhosis radiologically and clinically but has distinct pathophysiology—it results from desmoplastic fibrotic response to chemotherapy in the setting of hepatic metastases, most commonly from breast cancer (88.2% luminal subtype predominance). 1, 2 The condition develops with extensive liver disease burden, particularly with 5-fluorouracil (22.9% of cases), cisplatin (18.8%), and their derivatives, often paradoxically following treatment response. 2

Immediate Management Priorities

Chemotherapy Modification

• Discontinue or modify the offending chemotherapy regimen immediately, as continued treatment with worsening liver function makes further chemotherapy difficult and potentially life-threatening. 1
• Recognize that 52.1% of patients showed partial response at the time pseudocirrhosis appeared, suggesting this may occur as a consequence of effective tumor treatment. 2

Portal Hypertension Complications

Variceal bleeding management (if present):

• Initiate vasoactive drug therapy (terlipressin, somatostatin, or octreotide) immediately upon suspicion of variceal hemorrhage, before endoscopy, and continue for 3-5 days. 3
• Perform endoscopic variceal ligation within 12 hours once hemodynamic stability is achieved. 3
• Administer ceftriaxone 1 g/24h for up to 7 days (or norfloxacin 400 mg twice daily in less advanced cases) as antibiotic prophylaxis. 3
• Use restrictive transfusion strategy with hemoglobin threshold of 7 g/dL and target range 7-9 g/dL. 3
• Consider pre-endoscopy erythromycin 250 mg IV 30-120 minutes before procedure to improve visibility (avoid if QT prolongation). 3

Ascites management (present in 58.3% of pseudocirrhosis patients):

• Implement moderate salt restriction to 5-6.5 g daily (87-113 mmol sodium). 3
• Initiate combination diuretic therapy with spironolactone (starting 100 mg, up to 400 mg) plus furosemide for faster diuresis in severe cases. 3
• Perform diagnostic paracentesis to rule out spontaneous bacterial peritonitis, particularly with fever, encephalopathy, or worsening renal/liver function. 3
• Note that 90% of ascites in pseudocirrhosis are transudative, similar to true cirrhosis. 2

Infection Prevention and Management

• Perform diagnostic paracentesis without delay in all hospitalized patients with ascites to rule out spontaneous bacterial peritonitis. 3
• If SBP diagnosed (ascitic neutrophil count >250/mm³), initiate empirical ceftriaxone based on local resistance patterns. 3
• Consider primary prophylaxis with norfloxacin, ciprofloxacin, or co-trimoxazole if ascitic protein <1.5 g/dL. 3

Critical Monitoring

• Avoid nephrotoxic drugs (aminoglycosides, NSAIDs) and hepatotoxic agents during acute complications. 3
• Discontinue beta-blockers, vasodilators, and other hypotensive drugs during acute variceal hemorrhage. 3
• Monitor for hepatic encephalopathy and treat with lactulose or lactitol if it develops. 3
• Preserve renal function through adequate fluid and electrolyte replacement. 3

Prognosis and Transplant Evaluation

• Assess for liver transplant candidacy, as pseudocirrhosis with severe complications indicates advanced disease with poor prognosis. 4
• Recognize that 23% of patients develop esophageal varices and 6.5% experience variceal rupture, similar to decompensated cirrhosis. 2
• Understand that early recognition is crucial, as pseudocirrhosis is life-threatening and non-invasive markers for early diagnosis are needed but currently lacking. 1

Important Caveats

• Pseudocirrhosis can occur even when intrahepatic metastases are absent on imaging, but liver biopsy shows cancer cell infiltration in fibrotic areas. 1
• The condition represents a distinct pathologic process from true cirrhosis despite similar clinical presentation. 5, 6
• While most common with breast cancer, pseudocirrhosis has been reported with ovarian, thyroid, and other carcinomas. 7, 6