What is the best course of treatment for a patient with liver cirrhosis (cirrhosis of the liver) experiencing vomiting?

Management of Vomiting in Liver Cirrhosis

The immediate priority is to determine whether vomiting represents variceal hemorrhage (a life-threatening emergency requiring urgent endoscopy and vasoactive drugs) versus other causes such as hepatic encephalopathy, gastropathy, or unrelated conditions. 1

Initial Assessment and Stabilization

Assess for signs of gastrointestinal bleeding immediately - examine for hematemesis (coffee-ground or bright red blood), melena, or hemodynamic instability (tachycardia, hypotension). 1, 2

• If active bleeding is suspected, start vasoactive drugs (octreotide, somatostatin, or terlipressin) immediately before endoscopic confirmation. 1
• Implement restrictive transfusion strategy with hemoglobin threshold of 7 g/dL and target range of 7-9 g/dL to avoid increasing portal pressure. 1
• Discontinue diuretics, beta-blockers, and other hypotensive medications during acute decompensation. 1
• Perform upper endoscopy within 12 hours once hemodynamically stable. 1
• Administer ceftriaxone 1g IV daily for up to 7 days as antibiotic prophylaxis, as infections are present in over 50% of patients with acute bleeding. 1

Evaluate for Hepatic Encephalopathy

Vomiting can be a presenting symptom of hepatic encephalopathy or brain edema, particularly when accompanied by headache, altered mental status, or confusion. 3

• Assess mental status using West Haven criteria and Glasgow Coma Scale. 3
• Look for precipitating factors: gastrointestinal bleeding, infection, constipation, excessive protein intake, dehydration, renal dysfunction, electrolyte imbalance, psychoactive medications, or acute hepatic injury. 3
• Start empiric lactulose therapy if hepatic encephalopathy is suspected, targeting 2-3 soft stools daily. 3, 4
• In severe hepatic encephalopathy (Grade 3-4), consider lactulose enema (300 mL lactulose in 700 mL water). 3
• If oral intake is inappropriate due to vomiting, insert nasogastric tube for lactulose administration (with caution if recent variceal band ligation). 3

Rule Out Other Causes

Hepatic encephalopathy is a diagnosis of exclusion - systematically evaluate for alternative etiologies. 3

• Screen for infections (spontaneous bacterial peritonitis, pneumonia, urinary tract infection) with complete blood count, C-reactive protein, chest X-ray, urinalysis, blood cultures, and diagnostic paracentesis if ascites present. 3
• Check for alcohol intoxication/withdrawal, drug toxicity, diabetic ketoacidosis, electrolyte disorders (particularly hyponatremia and hypokalemia), and renal dysfunction. 3
• Consider brain imaging (CT or MRI) if this is the first episode of altered mental status, if seizures or focal neurological signs present, or if inadequate response to therapy. 3
• Routine brain imaging is not warranted for presentations similar to prior episodes. 3

Address Portal Hypertensive Gastropathy

If chronic vomiting with iron-deficiency anemia but no active variceal bleeding, consider portal hypertensive gastropathy. 3

• Nonselective beta-blockers can be used to lower portal pressure and reduce chronic bleeding. 3
• Endoscopic treatment with argon plasma coagulation may be considered for active bleeding. 3
• Provide iron supplementation for associated anemia. 3

Manage Precipitating Factors

Identifying and treating precipitating factors is essential, as this alone can resolve symptoms in 80-90% of cases. 3

• For gastrointestinal bleeding: Perform endoscopy, provide transfusion as needed, endoscopic treatment, and vasoactive drugs. 3
• For infection: Administer appropriate antibiotics based on culture results. 3
• For constipation: Use enemas or laxatives. 3
• For dehydration/renal dysfunction: Stop or reduce diuretics, provide fluid therapy with intravenous albumin infusion. 3
• For electrolyte imbalances: Correct hyponatremia (maintain >135 mmol/L, always >130 mmol/L) and hypokalemia. 3, 4
• For medication-related causes: Discontinue benzodiazepines (contraindicated in decompensated cirrhosis), opioids, NSAIDs, and proton pump inhibitors if no formal indication. 3, 4

Additional Supportive Measures

• Provide airway protection if altered mental status with risk of aspiration. 2
• Monitor for secondary complications including fall-related injuries and aspiration pneumonia. 3
• Ensure adequate nutrition with 35-40 kcal/kg daily energy intake and 1.2-1.5 g/kg protein intake - do not restrict protein as this worsens outcomes. 3, 4
• Consider rifaximin as add-on therapy to lactulose for hepatic encephalopathy, though its role in acute settings requires further investigation. 3, 4

Critical Pitfalls to Avoid

• Never assume vomiting is benign - always rule out variceal hemorrhage first as it carries high mortality. 1, 2
• Do not restrict protein intake - this paradoxically worsens hepatic encephalopathy by promoting catabolism and sarcopenia. 3, 4
• Avoid routine ammonia level testing - levels are variable and not proportional to hepatic encephalopathy severity, though a normal level should prompt consideration of alternative diagnoses. 3
• Do not continue diuretics during acute decompensation - this worsens hemodynamic instability and renal function. 1