Chronic Monitoring of Alcoholic Cirrhosis
Patients with alcoholic cirrhosis require systematic surveillance every 6 months for hepatocellular carcinoma with ultrasound, routine laboratory monitoring every 6-12 months, and endoscopic screening for esophageal varices, with complete alcohol abstinence as the single most critical intervention to prevent decompensation and death. 1, 2
Alcohol Abstinence and Addiction Management
Complete and permanent alcohol abstinence is mandatory and represents the most important factor in reducing complications and mortality—even moderate alcohol consumption worsens portal hypertension and precipitates clinical decompensation. 1, 2, 3
Refer all patients to psychiatric consultation for evaluation, treatment planning, and long-term abstinence support. 1
Prescribe baclofen as the anti-craving medication of choice, as it is both effective and safe in patients with advanced liver disease. 1, 2
Avoid disulfiram due to hepatotoxicity risk in cirrhotic patients. 2, 4
Implement brief interventions using the FRAMES model (Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy) at every clinical encounter. 1
Laboratory Monitoring Schedule
Obtain complete blood count, comprehensive metabolic panel, and prothrombin time/INR every 6-12 months to assess liver synthetic function, hepatocellular injury, cholestasis, electrolyte balance, and renal function. 2, 5
Monitor serum creatinine, sodium, and potassium more frequently (weekly to monthly) during initial diuretic therapy or when adjusting doses. 4
Calculate MELD score at each visit to establish prognosis and determine transplant listing priority. 1, 2
Hepatocellular Carcinoma Surveillance
Perform abdominal ultrasound every 6 months for HCC screening in all patients with cirrhosis. 5
The annual incidence of HCC in alcoholic cirrhosis is approximately 2.6%, which decreases by 6-7% per year in abstinent patients. 2
Do not use alpha-fetoprotein alone for screening, though it may be added to ultrasound. 5
Variceal Screening and Prophylaxis
Perform upper endoscopy at diagnosis to screen for esophageal varices, then repeat every 1-2 years based on initial findings and degree of liver dysfunction. 1, 5
Patients with alcoholic cirrhosis have approximately 6% risk of variceal bleeding in the first year after diagnosis. 1
Initiate primary prophylaxis with non-selective beta blockers for medium to large varices. 1, 5
Implement secondary prophylaxis (beta blockers plus endoscopic band ligation) for patients with prior variceal bleeding. 1
Nutritional Assessment and Support
Implement aggressive nutritional therapy with 1.2-1.5 g/kg/day protein and high-calorie intake, as malnutrition affects up to 50% of patients with alcoholic liver disease. 1, 2, 4
Recommend frequent interval feedings with a nighttime snack and morning feeding to improve nitrogen balance. 4, 6
Never restrict protein intake, even in patients with hepatic encephalopathy. 4
Provide thiamine supplementation 100-300 mg/day for all patients, maintained for 2-3 months. 1
Refer to a dietitian for severe malnutrition cases and ongoing nutritional counseling. 1, 2
Management of Decompensation
Ascites
Start spironolactone 100 mg plus furosemide 40 mg orally each morning when ascites develops. 4
Adjust diuretic doses every 7 days to achieve weight loss of 0.5 kg/day without peripheral edema or 1 kg/day with peripheral edema. 4
Temporarily stop diuretics if serum sodium drops below 120-125 mmol/L. 4
Initiate antibiotic prophylaxis for spontaneous bacterial peritonitis when indicated (prior SBP, ascitic fluid protein <1.5 g/dL with advanced cirrhosis). 5
Hepatic Encephalopathy
Hepatic encephalopathy carries the highest mortality among all cirrhosis complications. 1, 2, 4
Treat with lactulose 30-45 mL three to four times daily, adjusted to produce 2-3 soft stools daily. 7
Add rifaximin 550 mg twice daily for recurrent or persistent encephalopathy. 1
Rule out alcoholic dementia, withdrawal syndrome, and Wernicke's encephalopathy in patients with impaired cognitive function. 1
Infection Surveillance
Maintain high clinical suspicion for bacterial infections, as patients with alcoholic cirrhosis are particularly prone to infections. 2, 4
Treat infections promptly with appropriate antibiotics. 2
Screening for Extrahepatic Complications
- Screen for alcohol-induced damage to other organ systems including:
- Heart (alcoholic cardiomyopathy)
- Kidneys (IgA-induced nephropathy)
- Nervous system (peripheral neuropathy, Wernicke-Korsakoff syndrome)
- Pancreas (chronic pancreatitis) 1
Management of Cofactors
- Identify and aggressively manage cofactors that accelerate disease progression:
Medication Safety
Use paracetamol with extreme caution, particularly in malnourished patients with alcoholic cirrhosis. 2, 4
Review all medications for hepatotoxicity potential and drug interactions. 2
Liver Transplantation Evaluation
Refer patients with decompensated cirrhosis (ascites, encephalopathy, variceal bleeding, MELD ≥15) to a liver transplant center. 1, 6
Most programs require documented 6-month abstinence period prior to transplant evaluation. 1
Graft and patient survival rates after transplantation for alcoholic cirrhosis are equivalent to other etiologies. 1
Common Pitfalls to Avoid
Do not delay HCC surveillance—only 8.78% of cirrhosis patients in the U.S. receive appropriate screening every 6-12 months. 8
Do not restrict protein intake in cirrhotic patients, even with encephalopathy, as this worsens malnutrition and outcomes. 4
Do not assume any level of alcohol consumption is safe—even low-level drinking increases mortality and decompensation risk in both ALD-cirrhosis and HCV-cirrhosis. 3
Do not use disulfiram for alcohol cessation in cirrhotic patients due to hepatotoxicity. 2