What is the diagnosis for a 73-year-old male with cirrhosis (liver cirrhosis), dyspnea (trouble breathing), and peripheral edema (swollen legs)?

From the Guidelines

This patient likely has decompensated cirrhosis with ascites and peripheral edema causing respiratory difficulty, and I recommend immediate medical evaluation at an emergency department or with a hepatologist. The patient's symptoms of trouble breathing and swollen legs are consistent with complications of cirrhosis, such as hepatic hydrothorax or hepatopulmonary syndrome (HPS) 1.

Key Considerations

• The patient should be treated with sodium restriction (2000mg/day) and fluid restriction (1.5L/day) to reduce fluid retention, as recommended by the American Association for the Study of Liver Diseases 1.
• Diuretic therapy with spironolactone 100mg daily and furosemide 40mg daily should be initiated, with doses adjusted based on response and kidney function 1.
• The patient should be monitored for spontaneous bacterial peritonitis, hepatic encephalopathy, and hepatorenal syndrome, which are common complications of cirrhosis 1.
• Daily weight measurements and abdominal circumference tracking are helpful in assessing the efficacy of diuretics and preventing their adverse effects 1.
• If breathing difficulty is severe or not responding to diuretics, therapeutic paracentesis may be necessary to remove ascitic fluid and relieve symptoms 1.

Underlying Pathophysiology

The underlying pathophysiology involves portal hypertension leading to fluid retention, with low albumin contributing to fluid shifting into tissues and the peritoneal cavity 1. Reduced cardiac output from compression of the diaphragm by ascites and pleural effusions can worsen symptoms 1. The patient should avoid alcohol completely and needs evaluation for liver transplantation if not already underway. It is essential to assess the patient's cardiac function, as diastolic dysfunction may occur as an early sign of cardiomyopathy in the setting of normal systolic function 1. The patient's QTc interval should also be evaluated, as prolongation of the QTc interval is common in cirrhosis and can indicate a poor outcome 1.

From the FDA Drug Label

1. 3 Edema Associated with Hepatic Cirrhosis or Nephrotic Syndrome Spironolactone tablets are indicated for the management of edema in the following settings: Cirrhosis of the liver when edema is not responsive to fluid and sodium restriction Nephrotic syndrome when treatment of the underlying disease, restriction of fluid and sodium intake, and the use of other diuretics produce an inadequate response.

The patient has cirrhosis and edema (swollen legs), and spironolactone is indicated for the management of edema in patients with cirrhosis.

• The recommended initial daily dosage for edema in patients with cirrhosis is 100 mg of spironolactone tablets administered in either single or divided doses, but may range from 25 mg to 200 mg daily 2.
• Therapy should be initiated in a hospital setting and titrated slowly 2. Given the patient's symptoms, spironolactone may be a suitable treatment option for managing edema associated with cirrhosis.

From the Research

Patient Symptoms and Cirrhosis

• The patient is a 73-year-old male with cirrhosis, trouble breathing, and swollen legs.
• These symptoms can be related to complications of cirrhosis, such as ascites, which is the most common complication of cirrhosis, with a 5-year mortality rate of 30% 3.
• Ascites is driven by portal hypertension, systemic inflammation, and splanchnic arterial vasodilation, and its development can lead to further decompensation and worsen survival 3.

Ascites and Its Treatment

• The treatment of ascites is currently based on the management of fluid overload, including diuretics, sodium restriction, and/or paracenteses 3.
• In selected patients, long-term albumin use, norfloxacin prophylaxis, and transjugular intrahepatic portosystemic shunt can reduce the risk of further decompensation and improve survival 3.
• Large volume paracentesis associated with albumin infusion is the treatment of choice for tense ascites, as it is very effective and rapid, and is associated with fewer complications than traditional treatment (sodium restriction and diuretics) 4.
• Diuretics should be given after paracentesis to prevent reaccumulation of ascites, and patients with refractory ascites could be treated by paracentesis or percutaneous transjugular portacaval shunt (TIPS) 4.

Complications of Cirrhosis

• Cirrhosis can lead to various complications, including hepatic encephalopathy, hepatorenal syndrome, and hepatocellular carcinoma 5, 6.
• The annual incidence of spontaneous bacterial peritonitis in patients with ascites is 11%, and of hepatorenal syndrome is 8%, with a median survival of less than 2 weeks 6.
• Approximately 1% to 4% of patients with cirrhosis develop hepatocellular carcinoma each year, which is associated with a 5-year survival of approximately 20% 6.

Management of Cirrhosis and Its Complications

• The management of cirrhosis and its complications involves a multidisciplinary approach, including directed counseling, laboratory testing, and ultrasound monitoring 5.
• Treatment goals include preventing cirrhosis, decompensation, and death, and managing symptoms such as muscle cramps, poor-quality sleep, pruritus, and sexual dysfunction 6.
• First-line therapies include carvedilol or propranolol to prevent variceal bleeding, lactulose for hepatic encephalopathy, combination aldosterone antagonists and loop diuretics for ascites, and terlipressin for hepatorenal syndrome 6.
• All patients with ascites should be evaluated for eligibility for liver transplantation, as ascites impairs both quality of life and survival in patients with cirrhosis 7.