What is the recommended management for a patient diagnosed with cirrhosis?

Management of Cirrhosis

The cornerstone of cirrhosis management is aggressive treatment of the underlying etiology to potentially reverse early disease and prevent decompensation, combined with systematic screening and prophylaxis for complications. 1

Immediate Assessment and Risk Stratification

• Determine whether the patient has compensated versus decompensated cirrhosis, as this fundamentally changes management priorities—decompensated cirrhosis carries a median survival of approximately 1 year without transplantation and requires immediate transplant evaluation. 2
• Calculate the MELD-Na score to assess mortality risk, with scores ≥15 warranting transplant referral and scores ≥22 indicating significant mortality risk requiring urgent evaluation. 2
• Perform diagnostic paracentesis immediately in any patient with new-onset ascites or clinical deterioration to rule out spontaneous bacterial peritonitis, sending fluid for cell count with differential, albumin, culture, total protein, and Gram stain. 2

Treat the Underlying Cause First

Addressing the underlying etiology is the only way to potentially reverse early cirrhosis and prevent progression—this takes priority over merely managing complications. 1, 2

Viral Hepatitis-Related Cirrhosis

• Initiate antiviral therapy 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
• All patients with decompensated cirrhosis should receive treatment regardless of HBV DNA level, with entecavir or tenofovir monotherapy as preferred first-line treatment. 1
• Interferon-α is absolutely contraindicated in decompensated cirrhosis due to risk of serious complications including infection and hepatic failure. 1
• For hepatitis C, direct-acting antivirals improve liver function and reduce portal hypertension, though continuous monitoring for cirrhosis complications and hepatocellular carcinoma is needed even after achieving sustained virologic response. 1, 3

Alcohol-Related Cirrhosis

• Complete and permanent cessation of alcohol consumption is mandatory, as this may lead to "re-compensation" of cirrhosis and excellent long-term outcomes in some patients. 1

Nonalcoholic Steatohepatitis

• Implement weight loss and metabolic management strategies. 2

Management of Ascites

First Presentation of Moderate Ascites

• Implement dietary sodium restriction to 5-6.5 g daily (87-113 mmol sodium), which translates to a no-added-salt diet with avoidance of precooked meals, and provide nutritional counseling on sodium content. 3, 2
• Initiate spironolactone monotherapy at 100 mg once daily, titrating up to 400 mg as needed based on response and tolerability. 1, 3
• Fluid restriction is NOT necessary unless serum sodium is less than 120-125 mmol/L—routine fluid restriction is not recommended for most cirrhotic patients with ascites. 1, 3

Recurrent or Severe Ascites

• Use combination therapy with spironolactone 100 mg plus furosemide 40 mg daily, increasing doses proportionally (up to spironolactone 400 mg and furosemide 160 mg) to maintain the 100:40 ratio. 3, 2
• For tense ascites, perform initial therapeutic paracentesis followed by sodium restriction and diuretic therapy. 1
• Monitor closely for adverse events—nearly half of patients require dose reduction or discontinuation due to electrolyte abnormalities, renal dysfunction, or hypotension. 3, 2

Refractory Ascites

• Options include serial large-volume paracentesis, transjugular intrahepatic portosystemic stent-shunt (TIPS), liver transplantation, or experimental medical therapy. 1
• Patients requiring paracenteses more frequently than every 2 weeks likely have poor dietary compliance. 1
• Offer palliative care referral to patients with refractory ascites who are not transplant candidates. 1

Prevention of Spontaneous Bacterial Peritonitis

Primary Prophylaxis

• Provide antibiotics to patients with ascitic fluid protein <1.5 g/dL using norfloxacin 400 mg daily, ciprofloxacin 500 mg daily, or co-trimoxazole 800/160 mg daily, though antibiotic choice should be guided by local resistance patterns. 3, 2

Secondary Prophylaxis

• All patients recovering from an episode of SBP require indefinite prophylaxis with norfloxacin 400 mg once daily, ciprofloxacin 500 mg once daily, or co-trimoxazole 800 mg/160 mg daily. 3

Gastrointestinal Bleeding Prophylaxis

• Patients presenting with gastrointestinal bleeding and underlying ascites should receive prophylactic antibiotic treatment—cefotaxime is widely studied, but choice should be based on local resistance patterns. 3
• In decompensated cirrhosis or quinolone-resistant settings, use ceftriaxone 1 g/24h for up to 7 days; in remaining patients, use oral norfloxacin 400 mg twice daily. 1

Management of Hepatic Encephalopathy

• Initiate lactulose 15-30 mL orally 2-3 times daily, titrating to achieve 2-3 soft bowel movements per day—this reduces mortality and prevents recurrence. 2
• Aggressively identify and treat precipitants: infection, constipation, gastrointestinal bleeding, electrolyte abnormalities, and offending medications. 2
• Add rifaximin 550 mg twice daily if recurrent episodes occur despite lactulose therapy. 2
• Do NOT restrict dietary protein—target 1.2-1.5 g/kg/day using dry or ideal body weight, and consider branched-chain amino acid supplementation. 2

Management of Variceal Bleeding

Acute Variceal Hemorrhage

• Initiate vasoactive drugs (terlipressin, somatostatin, or octreotide) immediately upon suspicion of bleeding, even before endoscopic confirmation, continuing for 2-5 days after endoscopic hemostasis to prevent early rebleeding. 1, 3
• Perform endoscopic band ligation within 12 hours of admission once hemodynamic stability is achieved. 1
• Use a restrictive transfusion strategy with a hemoglobin threshold of 7 g/dL, targeting 7-9 g/dL. 1
• Use TIPS as rescue therapy for persistent bleeding or early rebleeding. 1

Prevention

• Consider nonselective beta-blockers (carvedilol or propranolol) for prevention of variceal bleeding, but use with caution in patients with severe or refractory ascites as they may compromise renal function and hemodynamic stability. 1, 3
• Prophylactic band ligation is standard of care for varices. 1

Management of Acute Kidney Injury and Hepatorenal Syndrome

Stage 1 AKI

• Review all medications (including over-the-counter drugs), reduce or withdraw diuretic therapy, and withdraw all potentially nephrotoxic drugs, vasodilators, or NSAIDs. 4
• Provide plasma volume expansion in patients with clinically suspected hypovolemia using crystalloids, albumin, or blood (in patients with AKI from gastrointestinal bleeding). 4
• Promptly recognize and treat bacterial infections when diagnosed or strongly suspected. 4

Stage 2 and 3 AKI

• Withdraw diuretics (if not already done) and expand plasma volume with intravenous albumin at 1 g per kg bodyweight per day for two consecutive days. 4
• Target mean arterial pressure of 65 mmHg, using norepinephrine as first-line vasopressor if hypotension persists despite volume resuscitation. 2
• In patients with spontaneous bacterial peritonitis and increased or rising serum creatinine, administer albumin infusion 1.5 g/kg within 6 hours of diagnosis. 3

Nutritional Management

• Perform rapid nutritional screening in all patients, assuming high risk for malnutrition if BMI <18.5 kg/m² or Child-Pugh C. 1
• Assess sarcopenia using CT scan, anthropometry, DEXA, or BIA, and evaluate muscle function with handgrip strength and/or short physical performance battery. 1
• Bed rest is NOT recommended—excessive bed rest may cause muscle atrophy; patients can be managed on an outpatient basis unless complicated by bleeding, encephalopathy, infection, hypotension, or liver cancer. 1

Medications to Absolutely Avoid

• NSAIDs are absolutely contraindicated as they can reduce urinary sodium excretion, precipitate renal dysfunction, and convert diuretic-sensitive ascites to refractory ascites. 1, 3, 2
• Avoid aminoglycosides and other nephrotoxic drugs. 3, 2
• Discontinue ACE inhibitors and angiotensin receptor blockers as they aggravate hypotension and are not clinically useful. 1, 2

Screening and Monitoring

• Screen for hepatocellular carcinoma with ultrasound every 6 months in all patients with cirrhosis. 5, 6
• Perform screening endoscopy to assess for varices requiring prophylaxis in patients with compensated cirrhosis. 1
• Monitor complete blood count, comprehensive metabolic panel, and liver function tests at least twice weekly initially, then weekly once stable in decompensated patients. 2
• Assess daily weight, vital signs, mental status, intake/output, and volume status in decompensated patients. 2

Referral for Liver Transplantation

• Refer all patients with decompensated cirrhosis for liver transplant evaluation immediately, as transplantation is the only definitive cure and median survival without transplant is approximately 1 year. 2
• Development of any decompensation events (ascites, variceal bleeding, or hepatic encephalopathy) requires referral to gastroenterology. 1
• Refractory ascites not responding to maximum diuretic therapy requires referral to gastroenterology. 1

Common Pitfalls to Avoid

• Do NOT use fluid restriction routinely—reserve it only for severe hyponatremia (sodium <125 mmol/L) in clinically hypervolemic patients. 1, 3
• Do NOT restrict dietary protein in hepatic encephalopathy—this worsens malnutrition and outcomes. 2
• Do NOT use HbA1c for diagnosis or monitoring glycemic control in decompensated cirrhosis—it is unreliable in this population. 1
• Do NOT use metformin in decompensated cirrhosis due to lactic acidosis risk—insulin therapy is the only evidence-based option for treating type 2 diabetes in decompensated cirrhosis. 1
• Do NOT delay transplant evaluation—refer early when MELD-Na ≥15 rather than waiting for further deterioration. 2