Cirrhosis and its complications

Cirrhosis and its complications:

• Liver cirrhosis leads to portal hypertension, categorized into three stages:

• Compensated cirrhosis (mild PH, HVPG 5-10 mmHg)

• Decompensated cirrhosis (CSPH, HVPG 10-12 mmHg)

• Late decompensation (HVPG >= 12 mmHg), resulting in complications such as refractory ascites, EV bleeding, SBP, HE, HRS, HPS, etc.

• To assess severity in practice, the Child-Pugh score is used – A (5-6), B (7-9), C (10-15).

Approach to cirrhotic complications management frequently encountered in practice:

1. EV bleeding is discussed in the GI bleeding section.

2. Ascites: High SAAG (>=1.1 g/dL), low protein (< 2.5 g/dL)

• Sodium restriction – Na < 2 g/day (+/- fluid restriction 1-1.5 L/d in large-volume ascites + Serum Na < 120-125 mmol/L)

• Diuretic therapy - Spironolactone 100 mg + Furosemide 40 mg PO OD can increase dose q 3-5 d (max dose: spironolactone 400 mg, furosemide 160 mg). Caution!! BW should not decrease > 0.5 kg/d >> precipitated causes – HE, renal failure

• Large-volume paracentesis (LVP) – considered in large/tense ascites or refractory ascites (diuretic-resistant/refractory ascites)

• If LVP > 5 L: give 25% albumin IV 6-8 g per removed L

• For AKI/CKD, give albumin regardless of the amount removed

• Avoid – NSAIDs, Beta-blockers (in ascites w/ BP drops), ACEIs, ARBs

1. Spontaneous bacterial peritonitis (SBP)

• Diagnostic criteria: from ascitic fluid; culture positive for 1 type of bacterium, PMN >= 250 cells/cumm (Neutrophils >= 50% of WBC)

• Most common pathogens: E.coli, K.pneumoniae, Streptococcal pneumococci

• Empirical ATB: cefotaxime IV 2 g q 8 h x 5 days before adjusting based on sensitivity, Avoid Aminoglycosides >> renal toxicity

• Albumin IV 1.5 g/kg in 6 h, then 1 g/kg on day 3 +ATB >> reduces mortality, especially in patients with TB > 4 mg/dL, BUN > 30 mg/dL, Cr > 1 mg/dL

• No need to repeat ascitic fluid tapping if improvement within 48 h

1. Hepatic encephalopathy
   

• Precipitating causes – “BIGSCALP, HABAZOD” (B = blood transfusion, I = infection, G = GI bleeding, S = sedatives, C = constipation, A = alkalosis, L = low K, P = high protein diet, H = hyper/hypo Na, A = azothemia, B = beta blocker, A = acidosis, Z = Zn deficiency, O = oral methionamine, D = decompensated cirrhosis)

• Supportive care

• Identify and treat precipitating causes

• Lactulose 30-45 ml q 1-2 h until bowel movement before stepping down to lactulose 90-150 ml/d; hold if diarrhea >= 3-4 times (to prevent recurrence of HE)

• If not responding to lactulose within 48 h, consider ATB >> Metronidazole 250 mg BD or Neomycin 2-4 g OD (max dose 6 g/d), watch for renal toxicity, do not exceed 1 week

• Protein restriction should only be done during acute HE episodes!! Provide at least 1500 kcal/d (from Fat+Carb); after HE improvement >> Maintain protein intake 1.2 - 1.5 g/kg/d, calories 35-40 kcal/kg/d
  

The Child-Pugh score

The Child-Pugh score is a clinical grading system used to assess the prognosis of chronic liver disease, particularly cirrhosis. It is utilized to determine the severity of cirrhosis and helps guide treatment decisions and predict outcomes. The score is based on five clinical measures: bilirubin, albumin, prothrombin time/international normalized ratio (INR), ascites, and hepatic encephalopathy. Each parameter is scored from 1 to 3, with 1 indicating less severe disease and 3 indicating more severe disease.

Here's a breakdown of the scoring system:

1. Bilirubin (mg/dL)

• 1 point: <2.0

• 2 points: 2.0-3.0

• 3 points: >3.0

1. Albumin (g/dL)

• 1 point: >3.5

• 2 points: 2.8-3.5

• 3 points: <2.8

1. Prothrombin Time (INR) or prolongation of prothrombin time (seconds over control)

• 1 point: INR <1.7 or PT <4 seconds over control

• 2 points: INR 1.7-2.3 or PT 4-6 seconds over control

• 3 points: INR >2.3 or PT >6 seconds over control

1. Ascites

• 1 point: None

• 2 points: Moderate

• 3 points: Severe

1. Hepatic Encephalopathy

• 1 point: None

• 2 points: Grade 1-2 (mild confusion, mood or behavior changes)

• 3 points: Grade 3-4 (severe confusion, coma)

The total score can range from 5 to 15, with the total score placing the patient into one of three classes:

• Class A: 5-6 points (compensated disease)

• Class B: 7-9 points (significant functional compromise)

• Class C: 10-15 points (decompensated disease)

The Child-Pugh score is significant because:

• It helps estimate the prognosis of patients with cirrhosis.

• It aids in making decisions about the management of cirrhotic patients, including the timing of liver transplantation.

• It is used in clinical research to stratify patients and to assess the impact of therapeutic interventions on patient outcomes.

Patients in Class A have the best prognosis, with a relatively well-preserved liver function, while those in Class C have severe liver dysfunction, indicative of a poor prognosis without liver transplantation. The score, while useful, has its limitations and should be considered alongside other clinical findings and diagnostic tests.