What is the recommended comprehensive management for a patient with cirrhosis, including evaluation of etiology, abstinence from alcohol, low‑sodium diet, weight control, vaccinations, surveillance for hepatocellular carcinoma, variceal screening and therapy, ascites treatment, hepatic encephalopathy management, spontaneous bacterial peritonitis prophylaxis, hepatorenal syndrome care, safe analgesia, nutritional supplementation, and criteria for liver transplant referral?

Comprehensive Management of Cirrhosis

All patients with cirrhosis require a systematic approach addressing etiology, prevention of decompensation, surveillance for complications, and timely evaluation for liver transplantation when indicated.

Initial Evaluation and Etiology Management

Identify and treat the underlying cause of cirrhosis immediately, as this is the most important factor affecting prognosis and mortality. 1

• Alcohol abstinence is mandatory for all patients with any alcohol-related component, as continued drinking is the most important factor increasing risk of complications and death 1
• Evaluate for viral hepatitis (B and C), nonalcoholic fatty liver disease, autoimmune hepatitis, and other reversible causes 2
• Abstinence from alcohol can result in dramatic improvement even in advanced disease 3
• Screen for alcohol-induced damage in other organs including heart (cardiomyopathy), kidneys (IgA nephropathy), nervous system, and pancreas 1

Dietary Management

Implement sodium restriction to 88 mmol/day (2000 mg/day or approximately 5g salt/day), equivalent to a "no added salt" diet with avoidance of precooked meals. 1, 3

• Provide nutritional counseling on sodium content in diet 1
• Recommended nutritional intake: 1.2-1.5 g/kg/day protein, 2-3 g/kg/day carbohydrate, and 35-40 kcal/kg/day 3
• Consider smaller, frequent meals if three meals per day are inadequate 3
• Add a late-evening snack of 200 kcal to improve nutritional status 3
• Fluid restriction is NOT necessary unless serum sodium falls below 120-125 mmol/L 1, 3

Vaccinations

Vaccinate all cirrhotic patients against hepatitis A, hepatitis B (if not immune), pneumococcus, and influenza annually. 2

Hepatocellular Carcinoma Surveillance

Screen for hepatocellular carcinoma with ultrasound every 6 months, as the incidence ranges from 7-16% at 5 years and up to 29% at 10 years. 1, 2

Variceal Screening and Management

Perform upper endoscopy at diagnosis to screen for esophageal varices. 4

• If varices are identified, initiate prophylaxis with propranolol to prevent first bleeding episode 4
• For acute variceal bleeding, use endoscopic band ligation as standard treatment, combined with octreotide 4
• Patients with gastrointestinal bleeding and ascites require prophylactic antibiotics (cefotaxime or based on local resistance patterns) to prevent spontaneous bacterial peritonitis 1

Ascites Management

First-Line Treatment

Start spironolactone 100 mg once daily for first presentation of moderate ascites; for recurrent or severe ascites requiring hospitalization, use combination therapy with spironolactone 100 mg plus furosemide 40 mg daily. 1, 3

• Increase doses simultaneously every 3-5 days (maintaining 100:40 mg ratio) if weight loss inadequate, up to maximum of 400 mg spironolactone and 160 mg furosemide 1, 3, 5
• Monitor weight daily; target weight loss of 0.5 kg/day without peripheral edema, or up to 1 kg/day with edema 1
• Monitor serum electrolytes, creatinine, and renal function closely, as almost half of patients develop adverse events requiring dose adjustment 1

Monitoring Diuretic Response

• Measure 24-hour urinary sodium excretion if weight loss inadequate; sodium excretion <80 mmol/day indicates insufficient diuretic dose 1
• Alternatively, use spot urine sodium/potassium ratio: if >1, patient should be losing weight (if not, suspect dietary noncompliance); if ≤1, increase diuretics 1

Large Volume Paracentesis

For tense ascites, perform initial therapeutic paracentesis followed by sodium restriction and diuretics. 1, 5

• Use ultrasound guidance when available to reduce adverse events 1
• Do NOT routinely check PT/INR or platelet count before paracentesis, and do NOT transfuse blood products prophylactically 1
• Infuse albumin 20-25% solution at 8 g per liter of ascites removed when >5L is removed 1, 5
• Consider albumin for <5L removal in patients with acute-on-chronic liver failure or high-risk features 1

Refractory Ascites

Refractory ascites is defined as fluid unresponsive to sodium restriction and high-dose diuretics (400 mg spironolactone + 160 mg furosemide) or rapid recurrence after paracentesis. 1, 3

• Manage with serial therapeutic paracenteses every 2-3 weeks as needed 3, 5
• Consider transjugular intrahepatic portosystemic shunt (TIPS) in well-selected patients 3, 5
• Evaluate for liver transplantation regardless of MELD score 5

Spontaneous Bacterial Peritonitis (SBP) Management

Perform diagnostic paracentesis in all patients with new-onset ascites, hospitalized patients with ascites, or those with clinical deterioration. 1, 5

• Send ascitic fluid for: cell count with differential, total protein, albumin (calculate SAAG), Gram stain, and culture 1, 5
• Diagnose SBP when ascitic fluid polymorphonuclear leukocyte count ≥250 cells/mm³ 4
• Treat with cefotaxime or antibiotic chosen based on local resistance patterns 1
• Consider repeat paracentesis at 48 hours if inadequate response or secondary peritonitis suspected 1

SBP Prophylaxis

Secondary prophylaxis: After recovering from SBP, prescribe norfloxacin 400 mg daily, ciprofloxacin 500 mg daily, or trimethoprim/sulfamethoxazole 800/160 mg daily. 1, 4

Primary prophylaxis: Offer to high-risk patients with ascitic protein <1.5 g/dL, guided by local resistance patterns. 1

Hepatic Encephalopathy Management

Treat hepatic encephalopathy with lactulose to improve mental status; protein restriction is no longer recommended. 4

• Rule out alcoholic dementia, withdrawal syndrome, and Wernicke's encephalopathy in patients with impaired cognition 1

Hepatorenal Syndrome

Treat hepatorenal syndrome with vasoconstrictors plus albumin as the most appropriate medical therapy. 6

• Evaluate for TIPS or liver transplantation in appropriate candidates 5

Safe Analgesia

Avoid nonsteroidal anti-inflammatory drugs (NSAIDs) completely, as they reduce urinary sodium excretion, induce azotemia, and can convert diuretic-sensitive patients to refractory. 1, 7

• NSAIDs are prostaglandin inhibitors that worsen renal function in cirrhosis 1

Hyponatremia Management

For asymptomatic hypervolemic hyponatremia, implement both sodium and water restriction (1-1.5 L daily fluid intake), modify diuretics and laxatives, and monitor electrolytes. 5

• For severe or symptomatic hyponatremia, add intravenous albumin or oral vasoconstrictors 5
• Reserve hypertonic saline (3%) for severely symptomatic acute hyponatremia with slow correction 1
• Consider vaptans, intravenous vasoconstrictors, or renal replacement therapy for refractory cases with multidisciplinary approach 5

Liver Transplantation Evaluation

Evaluate for liver transplantation when MELD score ≥15, with any complication of cirrhosis (ascites, encephalopathy, variceal bleeding), hepatocellular carcinoma, or refractory ascites regardless of MELD score. 5, 2, 4

• Development of ascites is associated with poor prognosis: 20% mortality in first year 3
• Liver transplantation offers definitive cure for cirrhosis and its complications 3
• Survival rates have improved with advances in immunosuppression and proper risk stratification using MELD and Child-Pugh scoring 4

Monitoring Schedule

Assess patients clinically with laboratory tests and calculate Child-Pugh and MELD scores every 6 months. 2

• Monitor for development of complications at each visit 2
• Adjust monitoring frequency based on disease severity and stability 1