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