Cirrhosis complications: Keeping them under control

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Applied Evidence

Cirrhosis complications: Keeping them under control

J Fam Pract. 2015 June;64(6):338-342

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References

1. Scaglion S, Kliethermes S, Cao G, et al. The epidemiology of cirrhosis in the United States: A population-based study. J Clin Gastroenterol. 2014. October 8. [Epub ahead of print.]

2. Murphy SL, Xu JQ, Kochanek KD. Deaths: Final data for 2010. National Vital Statistics Reports. National Center for Health Statistics Web site. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_04.pdf. Accessed April 30, 2015.

3. National Institute of Diabetes and Digestive and Kidney Diseases. Cirrhosis. National Institute of Diabetes and Digestive and Kidney Diseases Web site. Available at: http://www.niddk.nih.gov/health-information/health-topics/liver-disease/cirrhosis/Pages/facts.aspx. Accessed April 30, 2015.

4. Zhou WC, Zhang QB, Qiao L. Pathogenesis of liver cirrhosis. World J Gastroenterol. 2014;20:7312-7324.

5. Ginès P, Cárdenas A, Arroyo V, et al. Management of cirrhosis and ascites. N Eng J Med. 2004;350:1646-1654.

6. Grattagliano I, Ubaldi E, Bonfrate L, et al. Management of liver cirrhosis between primary care and specialists. World J Gastroenterol. 2011;17:2273-2282.

7. Centers for Disease Control and Prevention. 2015 recommended immunizations for adults: By age. Centers for Disease Control and Prevention Web site. Available from: http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-schedule-easy-read.pdf. Accessed April 28, 2015.

8. Bacon BR. Cirrhosis and its complications. In: Fauci AS, Braunwald E, Kasper DL, et al, eds. Harrison’s Principles of Internal Medicine. 18th ed. New York, NY: McGraw-Hill; 2012. Available from: http://accessmedicine.mhmedical.com/content.aspx?bookid=1130&sectionid=79748841. Accessed April 28, 2015.

9. O’Shea RS, Dasarathy S, McCullough AJ. Alcoholic liver disease. Am J Gastroenterol. 2010;105:14-32.

10. National Institute on Alcohol Abuse and Alcoholism. Alcohol Alert. Alcoholic liver disease. U.S. Department of Health & Human Services. 2005. National Institute on Alcohol Abuse and Alcoholism Web site. Available at: http://pubs.niaaa.nih.gov/publications/aa64/aa64.htm. Accessed April 18, 2015.

11. Kashani A, Landaverde C, Medici V, et al. Fluid retention in cirrhosis: pathophysiology and management. QJM. 2008;101:71-85.

12. Chalasani NP, Vuppalanchi RK. Ascites: A common problem in people with cirrhosis. July 2013. American College of Gastroenterology Web site. Available at: http://patients.gi.org/topics/ascites/. Accessed April 28, 2015.

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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

Take steps to prevent variceal bleeding

Soon after a patient is diagnosed with cirrhosis, he or she should undergo esophagogastroduodenoscopy to screen for the presence and size of varices.¹⁶ Although they can’t prevent esophagogastric varices, nonselective beta-blockers (NSBBs) are the gold standard for preventing first variceal hemorrhage in patients with small varices with red wale signs on the varices and/or Child-Pugh Class B or C cirrhosis (TABLE¹⁷), and in all patients with medium or large varices.¹⁸ Propranolol is usually started at 20 mg BID, or nadolol is started at 20 to 40 mg/d.¹⁶ The NSBB dose is adjusted to the maximum tolerated dose, which occurs when the patient's heart rate is reduced to 55 to 60 beats/min.

NSBBs are associated with poor survival in patients with refractory ascites and thus are contraindicated in these patients.¹⁹ NSBBs also should not be taken by patients with SBP because use of these medications is associated with worse outcomes compared to those not receiving NSBBs.²⁰

Endoscopic variceal ligation is an alternative to NSBBs for the primary prophylaxis of variceal hemorrhage in patients with medium to large varices.¹⁸ In particular, ligation should be considered for patients with high-risk varices in whom beta-blockers are contraindicated or must be discontinued because of adverse effects.²¹

Avoid nitrates in patients with varices because these agents do not prevent first variceal hemorrhage and have been associated with higher mortality rates in patients older than 50.¹⁶ There is no significant additional benefit or mortality reduction associated with adding a nitrate to an NSBB.²² Transjugular intrahepatic portosystemic shunt (TIPS) or surgically created shunts are reserved for patients for whom medical therapy fails.¹⁸

Mental status changes suggest hepatic encephalopathy

Hepatic encephalopathy is a reversible impairment of neuropsychiatric function that is associated with impaired hepatic function. Because a patient with encephalopathy presents with an altered mental status, he or she may need to be admitted to the hospital for evaluation, diagnosis, and treatment.

The goals of hepatic encephalopathy treatment are to identify and correct precipitating causes and lower serum ammonia concentrations to improve mental status.¹⁵Nutritional support should be provided without protein restriction unless the patient is severely proteinintolerant.²³ The recommended initial therapy is lactulose 30 to 45 mL 2 to 4 times per day, to decrease absorption of ammonia in the gut. The dose should be titrated until patients have 2 to 3 soft stools daily.²⁴

For patients who can’t tolerate lactulose or whose mental status doesn’t improve within 48 hours, rifaximin 400 mg orally 3 times daily or 550 mg 2 times daily is recommended.²⁵ Neomycin 500 mg orally 3 times a day or 1 g twice daily is a second-line agent reserved for patients who are unable to take rifaximin; however, its efficacy is not well established, and neomycin has been associated with ototoxicity and nephrotoxicity.²⁴