What is the management approach for a patient with confirmed liver cirrhosis?

Management of Liver Cirrhosis

Primary Management Strategy: Treat the Underlying Cause First

The cornerstone of cirrhosis management is aggressive treatment of the underlying etiology, which can potentially reverse early cirrhosis, prevent decompensation, and dramatically improve survival—this takes priority over merely treating complications as they arise. 1, 2

Etiological Treatment by Cause

Alcoholic Cirrhosis:

• Complete and permanent alcohol cessation is mandatory and may lead to "re-compensation" with excellent long-term outcomes in some patients 1, 2, 3

Viral Hepatitis B:

• Initiate antiviral therapy immediately if HBV DNA ≥2,000 IU/mL regardless of ALT levels using entecavir or tenofovir as first-line agents due to their potent antiviral efficacy and high genetic barrier to resistance 1
• In decompensated cirrhosis, treat regardless of HBV DNA level with tenofovir plus lamivudine combination, or entecavir or tenofovir monotherapy 1
• Interferon-α is absolutely contraindicated in decompensated cirrhosis due to risk of serious complications including infection and hepatic failure 1
• Entecavir 1 mg/day demonstrates superior HBV DNA suppression (57% vs 20% undetectability at week 48 compared to adefovir) and improves Child-Pugh scores in almost half of treatment-naïve patients 1

Viral Hepatitis C:

• Start direct-acting antivirals immediately, as this improves liver function, reduces portal hypertension, and likely improves outcomes 1, 2, 3
• Continue monitoring for cirrhosis-related complications and hepatocellular carcinoma even after achieving sustained virologic response 1

Autoimmune Hepatitis:

• Immunosuppressive therapy shows clear beneficial effects even in decompensated cirrhosis 1, 3

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Management of Ascites

Grade 1 Ascites (Mild):

• Sodium restriction to less than 5 g/day (but not so excessive that it worsens malnutrition) 1, 3
• Discontinue NSAIDs, ACE inhibitors, and angiotensin receptor blockers 1
• Treat underlying disease 1
• Nutritional treatment and patient education 1
• Bed rest is not recommended as excessive bed rest causes muscle atrophy; manage outpatient unless complicated by bleeding, encephalopathy, infection, hypotension, or liver cancer 1

Grade 2 Ascites (Moderate):

• Sodium restriction to less than 5 g/day 1, 3
• Spironolactone 50-100 mg/day (maximum 400 mg/day) as the mainstay of diuretic treatment 1, 3, 4
• Add furosemide 20-40 mg/day (maximum 160 mg/day) if needed for rapid onset of action 1, 3
• In cirrhosis, initiate therapy in a hospital setting and titrate slowly 4
• Administer for at least five days before increasing dose to obtain desired effect 4
• Fluid restriction is not necessary unless serum sodium is less than 120-125 mmol/L 1

Grade 3 Ascites (Tense):

• Perform initial therapeutic paracentesis followed by sodium restriction and diuretic therapy 1, 3

Refractory Ascites:

• Serial large-volume paracentesis with albumin replacement 1, 2
• Consider transjugular intrahepatic portosystemic stent-shunt (TIPS) 1
• Evaluate for liver transplantation 1
• Patients requiring paracenteses more frequently than every 2 weeks likely have poor dietary compliance 1
• Offer palliative care referral to patients who are not transplant candidates 1

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Management of Variceal Bleeding

Acute Variceal Bleeding Protocol:

• Initiate vasoactive drugs immediately upon suspicion, even before endoscopic confirmation 1, 3
• Start antibiotic prophylaxis immediately (ceftriaxone 1 g/24h for up to 7 days in decompensated cirrhosis or quinolone-resistant settings; oral norfloxacin 400 mg twice daily in remaining patients) 1
• Use a restrictive transfusion strategy with hemoglobin threshold of 7 g/dL, target 7-9 g/dL 1
• Administer erythromycin 250 mg IV 30-120 minutes before endoscopy to improve visibility, unless QT prolongation is present 1
• Perform endoscopic band ligation within 12 hours of admission once hemodynamic stability is achieved 1
• Use TIPS as rescue therapy for persistent bleeding or early rebleeding 1

Prevention of First Variceal Bleeding:

• Perform screening endoscopy to assess for varices requiring prophylaxis in compensated cirrhosis 1
• Prophylactic band ligation is standard of care for varices 1
• Consider non-selective beta-blockers for prevention, but use with caution in patients with severe or refractory ascites 1

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Management of Spontaneous Bacterial Peritonitis (SBP)

• Perform diagnostic paracentesis without delay in all cirrhotic patients with ascites on hospital admission 1, 3
• Ascitic neutrophil count >250/mm³ is the gold standard for diagnosis 1
• Initiate immediate empirical antibiotic therapy, determined by context, severity, and local resistance patterns 1
• Patients with GI bleeding and ascites should receive prophylactic antibiotics such as ceftriaxone or based on local data 1

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Management of Hepatic Encephalopathy

• Use lactulose or lactitol as first-line therapy, as it reduces mortality and prevents recurrent overt hepatic encephalopathy 3
• Oral non-absorbable disaccharides may prevent the development of hepatic encephalopathy 1

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Nutritional Management

Screening and Assessment:

• Perform rapid nutritional screening in all patients, assuming high risk for malnutrition if BMI <18.5 kg/m² or Child-Pugh C 1, 3
• Assess sarcopenia using CT scan, anthropometry, DEXA, or BIA 1
• Evaluate muscle function with handgrip strength and/or short physical performance battery 1

Sodium Restriction:

• Restrict sodium to less than 5 g/day for controlling ascites 1, 3
• Greater dietary sodium restriction is not recommended as it may worsen malnutrition 1, 3

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Management of Diabetes in Decompensated Cirrhosis

• Screen all patients with decompensated cirrhosis for diabetes given high prevalence 1, 3
• Insulin therapy is the only evidence-based option for treating type 2 diabetes in decompensated cirrhosis 1, 3
• Do not use HbA1c for diagnosis or monitoring glycemic control 1
• Metformin is contraindicated due to lactic acidosis risk 1

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Medications to Avoid

Absolute Contraindications:

• NSAIDs are absolutely contraindicated as they reduce urinary sodium excretion, precipitate renal dysfunction, and convert diuretic-sensitive ascites to refractory ascites 1
• Discontinue ACE inhibitors and angiotensin receptor blockers 1
• Avoid nephrotoxic agents including aminoglycosides 3
• Avoid large volume paracentesis without albumin replacement 3
• Avoid hypotensive medications during acute variceal hemorrhage 1, 3

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Prevention of Disease Progression

Emerging Preventive Strategies:

• Non-selective beta-blockers decrease risk of ascites, hepatorenal syndrome, SBP, and hepatic encephalopathy beyond variceal bleeding prevention 3
• Enoxaparin may delay hepatic decompensation and improve survival in patients with Child-Pugh scores 7-10 2, 3
• Statins show promise in reducing portal hypertension and improving survival in patients with advanced cirrhosis, though these effects require validation in future studies 1

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Gastroenterology Referral Indications

Immediate Referral Required:

• Development of any decompensation events (ascites, variceal bleeding, hepatic encephalopathy) 1
• Refractory ascites not responding to maximum diuretic therapy 1
• Need for TIPS placement for refractory ascites or recurrent variceal bleeding 1
• Need for liver transplantation evaluation (mean pulmonary arterial pressure ≥45 mmHg is an absolute contraindication to transplantation) 3

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Patient Monitoring and Education

• Educate patients about disease management, including salt restriction, medication adherence, and recognition of warning signs 1
• Use Bluetooth-linked weighing scales and smartphone apps to monitor weight changes and intervene early 1, 2
• Implement remote monitoring technologies and telemedicine to improve outcomes and reduce hospital readmissions 1, 2, 3
• Heart rate variability monitoring may identify patients at risk of decompensation; loss of HRV is associated with decompensation and inflammation 1, 2, 3

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Common Pitfalls to Avoid

• Do not delay etiological treatment while only managing complications—this paradigm shift from reactive to preventive care is critical for improving outcomes 1, 2
• Do not initiate diuretic therapy in hepatic coma or states of electrolyte depletion until the basic condition is improved, as sudden alterations of fluid and electrolyte balance may precipitate hepatic coma 5
• Do not use rapid injection of furosemide—controlled intravenous infusion not exceeding 4 mg/minute is advisable to avoid ototoxicity 5
• Do not assume all patients with compensated cirrhosis have the same prognosis—1-year mortality ranges from 1% to 57% depending on the clinical stage 6, 7