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

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Dx cirrhosis: What to teach your patient

Patients with cirrhosis should be educated about complications of their condition, including ascites, esophageal varices, hepatic encephalopathy, hepatorenal syndrome, spontaneous bacterial peritonitis, and hepatocellular carcinoma (HCC).⁵ It’s important to explain that they will need to be evaluated every 6 months with serology and ultrasound to assess disease changes.⁶ Annual screening for HCC should be done with ultrasound or computed tomography scanning with or without alpha-fetoprotein.⁶

Ensure that your patient knows that he needs to receive the recommended immunizations. The Centers for Disease Control and Prevention recommends that patients with cirrhosis should receive annual influenza, pneumococcal 23, and hepatitis A and B series vaccinations.⁷

Advise patients with cirrhosis to be cautious when taking any medications. Patients with cirrhosis should avoid nonsteroidal anti-inflammatory drugs because these medications encourage sodium retention, which can exacerbate ascites.⁶ Acetaminophen use is discouraged, but should not be harmful unless the patient takes >2 g/d.⁸

Emphasize the importance of eating a healthy diet. Malnutrition is common in patients with cirrhosis³ and correlates with more severe disease and poorer outcomes, including mortality.⁹ Nutritional recommendations for patients with alcohol-related liver disease include thiamine 50 mg orally or intramuscularly, and riboflavin and pyridoxine in the recommended daily doses.¹⁰ Advise patients to take other vitamins, as needed, to treat any deficiencies.⁹

CASE › After evaluating Mr. M, you prescribe spironolactone 100 mg/d and furosemide 40 mg twice a day to address ascites, and propranolol—which you titrate to 80 mg twice a day—to prevent variceal hemorrhage. Mr. M is maintained on these medications and returns with his daughter, as he has been doing every 2 to 3 months. He is excited that he breathes easily as long as he avoids salt and takes his medications. He continues to see his hepatologist regularly, and his last paracentesis was 4 months ago. He has not used any alcohol since he was taught about the relationship between alcohol and his breathing.

CORRESPONDENCE
Suzanne Minor, MD, FAAF P, Assistant Professor of Family Medicine, Department of Humanities, Health, & Society, Florida International University, Herbert Wertheim College of Medicine, 11200 SW 8th Street, AHC II, 554A, Miami, FL 33199; seminor@fiu.edu