Management of Cirrhosis
Cirrhosis management requires a systematic approach targeting the underlying etiology, preventing decompensation, and treating complications with specific evidence-based therapies including diuretics for ascites, lactulose for hepatic encephalopathy, beta-blockers for variceal prophylaxis, and early transplant evaluation for decompensated disease. 1, 2, 3
Initial Assessment and Risk Stratification
Determine if the patient has compensated or decompensated cirrhosis, as this fundamentally changes management priorities—decompensated cirrhosis (presence of ascites, hepatic encephalopathy, variceal bleeding, or jaundice) carries a median survival of approximately 1 year without transplantation and requires immediate transplant evaluation. 2
Calculate the MELD-Na score to assess mortality risk and transplant priority—scores ≥15 warrant transplant referral, and scores ≥22 indicate significant mortality risk requiring urgent evaluation. 2
Perform diagnostic paracentesis immediately in any patient with new-onset ascites or clinical deterioration to rule out spontaneous bacterial peritonitis (SBP), sending fluid for cell count with differential, albumin, culture, total protein, and Gram stain. 1, 2
Etiology-Specific Treatment
Treat the underlying cause aggressively as this is the only way to potentially reverse early cirrhosis and prevent progression—antiviral therapy for hepatitis C, abstinence support and psychopharmacological therapy for alcohol-use disorder, and weight loss/metabolic management for nonalcoholic steatohepatitis. 3, 4, 5
Even after successful viral eradication (SVR in hepatitis C), continue monitoring for cirrhosis complications and hepatocellular carcinoma as the cirrhosis persists. 3
Ascites Management
Implement dietary sodium restriction to 5-6.5 g daily (87-113 mmol sodium), which translates to a no-added-salt diet with avoidance of precooked meals, and provide nutritional counseling on sodium content. 1, 3
For first presentation of moderate ascites, initiate spironolactone monotherapy at 100 mg once daily, titrating up to 400 mg as needed based on response and tolerability. 1, 3, 6
For recurrent severe ascites or hospitalized patients requiring faster diuresis, use combination therapy with spironolactone 100 mg plus furosemide 40 mg daily, increasing doses proportionally (up to spironolactone 400 mg and furosemide 160 mg) to maintain the 100:40 ratio. 1, 3
Monitor closely for adverse events—nearly half of patients require dose reduction or discontinuation due to electrolyte abnormalities, renal dysfunction, or hypotension. 1, 3
Fluid restriction to 1-1.5 L/day should only be used in patients with severe hyponatremia (sodium <125 mmol/L) who are clinically hypervolemic—routine fluid restriction is not necessary for most cirrhotic patients with ascites. 1, 3, 7
Large Volume Paracentesis
Use ultrasound guidance when available to reduce adverse events. 1
Do not routinely check prothrombin time/INR or platelet count before paracentesis, and do not transfuse blood products prophylactically—the INR does not accurately reflect bleeding risk in cirrhosis. 1, 2
Administer albumin 8 g per liter of ascites removed for paracentesis >5 L to prevent post-paracentesis circulatory dysfunction. 1
Consider albumin for paracentesis <5 L in patients with acute-on-chronic liver failure (ACLF) or high risk of acute kidney injury. 1
Spontaneous Bacterial Peritonitis Prophylaxis
Provide primary prophylaxis with norfloxacin 400 mg daily, ciprofloxacin 500 mg daily, or co-trimoxazole 800/160 mg daily to patients with ascitic fluid protein <1.5 g/dL, though antibiotic choice should be guided by local resistance patterns. 1, 3
All patients recovering from an episode of SBP require secondary prophylaxis indefinitely with the same antibiotic regimens to prevent recurrence. 1, 3
Patients with gastrointestinal bleeding and ascites should receive prophylactic antibiotics (cefotaxime is widely studied, but adjust based on local resistance). 3
SBP Treatment
- When SBP is diagnosed (ascitic fluid neutrophil count >250 cells/mm³), administer albumin 1.5 g/kg within 6 hours of diagnosis, followed by 1 g/kg on day 3, especially in patients with elevated or rising creatinine. 1, 2
Hepatic Encephalopathy Management
Initiate lactulose 15-30 mL orally 2-3 times daily, titrating to achieve 2-3 soft bowel movements per day—this reduces mortality (8.5% vs 14% with placebo) and prevents recurrence (25.5% vs 46.8%). 2, 5
Aggressively identify and treat precipitants: infection (including occult urinary tract infections which are common and may be asymptomatic), constipation, gastrointestinal bleeding, electrolyte abnormalities, and offending medications. 2
Add rifaximin 550 mg twice daily if recurrent episodes occur despite lactulose therapy. 2
Do not restrict dietary protein—target 1.2-1.5 g/kg/day using dry or ideal body weight, and consider branched-chain amino acid supplementation. 2
Monitor daily for asterixis and orientation to time to detect early encephalopathy. 2
Variceal Bleeding Prevention
Initiate nonselective beta-blockers (carvedilol or propranolol) in patients with portal hypertension to prevent decompensation—this reduces the risk of decompensation or death (16% vs 27% with placebo over 3 years). 5
Use beta-blockers cautiously in advanced decompensation as they may compromise renal function and hemodynamic stability. 3
For acute variceal hemorrhage, initiate vasoactive drugs (terlipressin, somatostatin, or octreotide) immediately when bleeding is suspected, continuing for 2-5 days after endoscopic hemostasis. 3
Hepatorenal Syndrome and Acute Kidney Injury
Immediately discontinue all diuretics, NSAIDs, ACE inhibitors, beta-blockers, and nephrotoxic drugs when acute kidney injury develops. 2
Expand plasma volume with albumin 1 g/kg (up to 100 g) over 2-4 hours if hypovolemia is suspected. 2
Target mean arterial pressure of 65 mmHg, using norepinephrine as first-line vasopressor if hypotension persists despite volume resuscitation. 2, 7
For hepatorenal syndrome, terlipressin improves reversal rates (39% vs 18% with placebo). 5
Hepatocellular Carcinoma Surveillance
- Perform ultrasound screening every 6 months in all patients with cirrhosis, as the annual incidence of hepatocellular carcinoma is 1-4% with a 5-year survival of only 20%. 4, 5
Medications to Avoid
Absolutely avoid NSAIDs as they precipitate renal failure in cirrhotic patients. 3, 8
Avoid aminoglycosides and other nephrotoxic drugs. 3
ACE inhibitors aggravate hypotension and are not clinically useful. 7
Monitoring in Decompensated Cirrhosis
Monitor complete blood count, comprehensive metabolic panel, and liver function tests at least twice weekly initially, then weekly once stable. 2
Assess daily weight, vital signs, mental status, intake/output, and volume status. 2
Special Considerations for Hospitalized Patients
Initiate diuretic therapy in hospitalized cirrhotic patients under close observation, as sudden alterations in fluid and electrolyte balance may precipitate hepatic coma. 6, 8
For patients with hypotension and cirrhosis, use balanced crystalloids (Ringer's lactate) as first-line for fluid resuscitation, reserving albumin for specific indications (sepsis-induced hypotension, large volume paracentesis). 7
Consider relative adrenal insufficiency in patients with refractory shock requiring high-dose vasopressors—empiric hydrocortisone 50 mg IV every 6 hours may be beneficial. 7
Bedside echocardiography is essential to distinguish between hypovolemic, vasodilatory, and cardiogenic shock, as cirrhotic cardiomyopathy prevents adequate cardiac output compensation in advanced disease. 2, 7
Symptom Management
For muscle cramps (affecting 64% of patients), consider pickle brine or taurine supplementation. 5
For pruritus (39% prevalence), hydroxyzine can improve symptoms and sleep dysfunction. 5
For sexual dysfunction in men (53% prevalence), tadalafil has demonstrated efficacy. 5
Transplant Evaluation
Refer all patients with decompensated cirrhosis for liver transplant evaluation immediately, as transplantation is the only definitive cure and median survival without transplant is approximately 1 year. 2, 9
Discuss prognosis and treatment goals with patient and family, ensure advance directives are in place, and consider palliative care consultation if transplant is not feasible. 2