PRACTICE RECOMMENDATIONS
› Prescribe low-dose diuretics and recommend sodium restriction for patients with cirrhosis who have grade 2 (moderate) ascites. C
› Initiate treatment with beta-blockers to prevent variceal bleeding in all patients with medium or large varices, as well as in those with small varices who also have red wale signs and/or Child-Pugh Class B or C cirrhosis. A
› Consider evaluation for liver transplantation for a patient with cirrhosis who has experienced a major complication (eg, ascites, hepatic encephalopathy, or variceal hemorrhage) or one who has a model for end-stage liver disease (MELD) score ≥15. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE › Joe M, age 59, seeks care at the local emergency department (ED) for shortness of breath. He also complains that his abdomen has been getting “bigger and bigger.” The ED physician recognizes that he is suffering from cirrhosis with secondary ascites and admits him. A paracentesis is performed and 7 L of fluid are removed. The patient is started on furosemide 40 mg/d and the health care team educates him about the relationship between his alcohol consumption and his enlarging abdomen. At discharge, he is told to follow up with his primary care physician.
Two weeks later, the patient arrives at your clinic for followup. What is the next step in managing this patient?
Cirrhosis—the end stage of chronic liver disease characterized by inflammation and fibrosis—is a relatively common and often fatal diagnosis. In the United States, an estimated 633,000 adults have cirrhosis,1 and each year approximately 32,000 people die from the condition.2 The most common causes of cirrhosis are heavy alcohol use, chronic hepatitis B or C infection, nonalcoholic fatty liver disease, and nonalcoholic steatohepatitis.3 Cirrhosis typically involves degeneration and necrosis of hepatocytes, which are replaced by fibrotic tissues and regenerative nodules, leading to loss of liver function.4
Patients with cirrhosis can be treated as outpatients—that is, until they decompensate. Obviously, treatment specific to the underlying causes of cirrhosis, such as interferon for a patient with hepatitis and abstinence for a patient with alcohol-related liver disease, should be the first concern. However, this article focuses on the family physician’s role in identifying and treating several of the most common complications of cirrhosis, including ascites, variceal bleeding, hepatic encephalopathy, and hepatorenal syndrome. We will also cover which patients should be referred for evaluation for liver transplantation. (For a guide to providing patient education for individuals with cirrhosis, see “Dx cirrhosis: What to teach your patient”.3,5-10)
Sodium restriction, diuretics are first steps for ascites
The goals of ascites treatment are to prevent or relieve dyspnea and abdominal pain and to prevent life-threatening complications, such as spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome.11 Patient education is key regarding weight gain; that’s why it’s important to instruct patients to contact you if they gain more than 2 lbs/d for 3 consecutive days or more than 10 lbs.12
Approximately 10% of patients with ascites respond well to sodium restriction alone (1500-2000 mg/d).11 In addition to sodium restriction, patients with grade 2 ascites (moderate ascites with proportionate abdominal distension) should receive a low-dose diuretic, such as spironolactone (initial dose, 50-100 mg/d; increase up to 200-300 mg/d)13 or amiloride (5-10 mg/d).5
Painful gynecomastia and hyperkalemia are the most common adverse effects of spironolactone.13 Amiloride has fewer adverse effects than spironolactone, but is less effective.11 Low-dose furosemide (20-40 mg/d) may be added, although weight loss should be monitored to watch for excessive diuresis, which can lead to renal failure, hyponatremia, or encephalopathy.5,13 Also monitor electrolytes to watch for hypokalemia or hyponatremia.13
Recommended weight loss to prevent renal failure is 300 to 500 g/d (.66-1.1 lbs/d) for patients without peripheral edema, and 800 to 1000 g/d (1.7-2.2 lbs/d) for patients with peripheral edema.5,13
Patients with grade 3 (tense) or refractory ascites should have large-volume paracentesis (LVP) plus an albumin infusion.5 LVP (removal of >5 L of fluid) is more effective, faster, and has less risk of adverse effects than increasing the dosage of the patient’s diuretic.5,13 LVP can be done in an outpatient setting and is considered safe—even for patients with a prolonged prothrombin time.13,14 Rare complications of LVP include significant bleeding at the puncture site, infection, and intestinal perforation.5
Diuretics should be prescribed after LVP to prevent ascites recurrence.5 Plasma expanders can prevent hepatorenal syndrome, ascites recurrence, and dilutional hyponatremia.5,11 Albumin is the most efficacious of these agents;5,14 it is administered intravenously at a dose of 8 to 10 g/L of fluid removed.13,15