What is the treatment plan for a patient with liver cirrhosis?

Treatment Plan for Liver Cirrhosis

The treatment of liver cirrhosis must prioritize addressing the underlying etiology while simultaneously managing complications, with the specific approach determined by whether the patient has compensated or decompensated disease. 1, 2

Initial Assessment and Risk Stratification

Determine disease stage immediately - patients with compensated cirrhosis (no ascites, variceal bleeding, or hepatic encephalopathy) have fundamentally different management priorities than those with decompensated disease, where median survival drops to approximately 1 year without transplantation. 3, 4

• Assess Child-Turcotte-Pugh class and calculate MELD-Na score to guide treatment intensity and transplant referral timing 3
• Screen for complications: perform diagnostic paracentesis if ascites present, endoscopy for varices, and cognitive testing for hepatic encephalopathy 5
• Identify the underlying cause through viral hepatitis serologies, ferritin, transferrin saturation, and abdominal ultrasonography 6

Treatment of Underlying Etiology (Primary Priority)

Treating the underlying disease is the first priority and can potentially reverse early cirrhosis or prevent progression. 1, 2

For Viral Hepatitis-Related Cirrhosis:

• Compensated cirrhosis (Child-Pugh A): Initiate entecavir or tenofovir monotherapy if HBV DNA ≥2,000 IU/mL regardless of ALT levels 1, 2
• Decompensated cirrhosis: Start entecavir (1 mg/day) or tenofovir immediately if HBV DNA is detectable by PCR, regardless of level 5, 1, 2
• Never use interferon/peginterferon in decompensated cirrhosis - it is absolutely contraindicated due to risk of infection and hepatic failure 5, 1, 2

For Alcohol-Related Cirrhosis:

• Mandate complete alcohol cessation - this can lead to dramatic improvement and "re-compensation" within months 1, 2

For Nonalcoholic Steatohepatitis:

• Address metabolic risk factors including obesity through dietary modification and weight loss 1

Management of Compensated Cirrhosis

Variceal Prevention:

• Perform screening endoscopy to assess for varices 2
• If varices present: Start nonselective beta-blockers (carvedilol or propranolol) - reduces risk of decompensation or death from 27% to 16% over 3 years 4
• Prophylactic endoscopic band ligation is standard of care for high-risk varices 2

Hepatocellular Carcinoma Surveillance:

• Perform imaging (preferably MRI, or CT, or ultrasound) every 6 months - HCC develops in 1-4% of cirrhotic patients annually with 5-year survival of only 20% 1, 4

Management of Decompensated Cirrhosis

Patients with decompensated cirrhosis should be managed in specialized liver units when possible and referred for transplant evaluation immediately. 2, 3

Ascites Management:

• Grade 1 ascites: Sodium restriction to <5 g/day (88 mmol sodium/day), discontinue NSAIDs/ACE inhibitors/ARBs 1, 2
• Grade 2 ascites: Add spironolactone 50-100 mg/day (maximum 400 mg/day) as primary diuretic 1, 7
  • Add furosemide 20-40 mg/day (maximum 160 mg/day) if inadequate response 1
  • Combination therapy is superior to sequential initiation - resolves ascites in 76% vs 56% with lower hyperkalemia rates (4% vs 18%) 4
• Grade 3 (tense) ascites: Perform therapeutic paracentesis first, then start diuretics 1, 2
  • Administer 6-8 g albumin IV per liter of ascites drained 1
• Critical pitfall: In patients with cirrhosis and ascites, initiate spironolactone in hospital setting with slow titration due to risk of sudden electrolyte shifts precipitating hepatic encephalopathy 7

Spontaneous Bacterial Peritonitis Prevention:

• Perform diagnostic paracentesis immediately on hospital admission in all cirrhotic patients with ascites 2
• Send ascitic fluid for cell count with differential, albumin, culture, total protein, and Gram stain 3
• If neutrophil count >250/mm³, start empirical antibiotics immediately 2
• Antibiotic prophylaxis: Ceftriaxone 1 g/24h for up to 7 days in decompensated cirrhosis or quinolone-resistant settings; norfloxacin 400 mg twice daily in remaining patients 2

Hepatic Encephalopathy Management:

• First-line therapy: Lactulose 15-30 mL orally 2-3 times daily, titrate to 2-3 soft bowel movements per day 1, 3
  • Reduces mortality from 14% to 8.5% and prevents recurrent episodes (25.5% vs 46.8%) 4
• Second-line: Add rifaximin if recurrent episodes occur despite lactulose 1, 3
• Identify and aggressively treat precipitants: infection (especially occult UTI), constipation, GI bleeding, electrolyte abnormalities 3
• Do not restrict protein - maintain 1.2-1.5 g/kg/day to prevent sarcopenia and protein catabolism 1, 2

Acute Variceal Bleeding:

• Start vasoactive drugs immediately upon suspicion, before endoscopy (terlipressin, somatostatin, or octreotide) 1, 2
• Initiate antibiotic prophylaxis immediately (ceftriaxone 1 g/24h for up to 7 days) 1, 2
• Perform endoscopy within 12 hours once hemodynamically stable 1, 2
• Use restrictive transfusion strategy: Hemoglobin threshold 7 g/dL, target 7-9 g/dL 2
• Consider erythromycin 250 mg IV 30-120 minutes before endoscopy to improve visibility (unless QT prolongation present) 2
• Perform endoscopic band ligation during the same procedure when varices confirmed 2
• TIPS as rescue therapy for uncontrolled or recurrent bleeding 1, 2

Hepatorenal Syndrome:

• Immediately discontinue all diuretics, NSAIDs, ACE inhibitors, beta-blockers, and nephrotoxic drugs 2, 3
• Volume challenge with IV albumin 1 g/kg (maximum 100 g/day) over 2-4 hours for 48 hours 1, 3
• For Stage 2 or greater HRS-AKI: Start terlipressin 0.5-2.0 mg IV q6h (or continuous infusion) plus albumin 20-40 g/day 1
  • Terlipressin improves reversal rate from 18% to 39% 4
• Target mean arterial pressure ≥65 mmHg; use norepinephrine as first-line vasopressor if hypotension persists 3

Portal Hypertensive Gastropathy:

• For chronic bleeding: Use nonselective beta-blockers to lower portal pressure 5
• For active bleeding: Consider endoscopic argon plasma coagulation 5
• Provide iron supplementation as needed 5

Nutritional Management (Critical for All Patients)

• Protein: 1.2-1.5 g/kg/day using dry or ideal body weight - never restrict protein long-term 1, 2, 3
• Calories: 35-40 kcal/kg/day for non-obese patients; 25-35 kcal/kg/day for obese patients 1, 3
• Meal frequency: 4-6 small meals per day including a night snack to prevent catabolism 1
• Consider branched-chain amino acid supplementation 3
• Sodium restriction ≤5 g/day (88 mmol/day) for ascites control 1, 2
• Fluid restriction only if serum sodium <120-125 mmol/L 2

Monitoring and Follow-Up

For Decompensated Cirrhosis:

• Daily: Weight, vital signs, mental status, intake/output, assess for asterixis and orientation 3
• Twice weekly initially, then weekly once stable: Complete blood count, comprehensive metabolic panel, liver function tests 3
• Monitor for hypoglycemia (can mimic hepatic encephalopathy) and occult infections 3

For All Cirrhotic Patients:

• Screen for diabetes - use insulin therapy only in decompensated cirrhosis (metformin contraindicated due to lactic acidosis risk) 2, 3
• Do not use HbA1c for diagnosis or monitoring in decompensated cirrhosis 2
• Target fasting blood glucose ≤180 mg/dL 3

Liver Transplantation Evaluation

Refer immediately for transplant evaluation when: 1, 2, 3

• Any decompensation event occurs (ascites, variceal bleeding, hepatic encephalopathy)
• MELD-Na score ≥15 or Child-Pugh class B/C
• Refractory ascites requiring paracentesis more frequently than every 2 weeks
• Hepatorenal syndrome develops
• Recurrent variceal bleeding despite therapy
• Severe hepatic encephalopathy not responding to medical treatment

Without transplantation, median survival with decompensated cirrhosis is approximately 1 year; transplantation offers the only definitive cure. 3

Critical Pitfalls to Avoid

• Never use NSAIDs - they reduce urinary sodium excretion and convert diuretic-sensitive ascites to refractory ascites 2
• Avoid nephrotoxic agents, large volume paracentesis without albumin, and hypotensive drugs during acute variceal hemorrhage 2
• Do not recommend bed rest - excessive bed rest causes muscle atrophy; manage outpatients unless complicated by bleeding, encephalopathy, infection, hypotension, or liver cancer 2
• Platelets of 100,000 and WBC of 3,200 are consistent with hypersplenism from portal hypertension and do not require intervention 3
• INR elevation should not be used to gauge bleeding risk in cirrhosis 3
• Hypoglycemic symptoms can mimic hepatic encephalopathy - educate staff and family about overlapping symptoms 3