Cirrhosis

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Practice Essentials

Cirrhosis is defined histologically as a diffuse hepatic process characterized by fibrosis and conversion of the normal liver architecture into structurally abnormal nodules. The progression of liver injury to cirrhosis may occur over weeks to years.

Signs and symptoms

Some patients with cirrhosis are completely asymptomatic and have a reasonably normal life expectancy. Other individuals have a multitude of the most severe symptoms of end-stage liver disease and a limited chance for survival. Common signs and symptoms may stem from decreased hepatic synthetic function (eg, coagulopathy), portal hypertension (eg, variceal bleeding), or decreased detoxification capabilities of the liver (eg, hepatic encephalopathy).

Portal hypertension

Portal hypertension can have prehepatic, intrahepatic, or posthepatic causes. Budd-Chiari syndrome, a posthepatic cause, is characterized by the following symptoms:

Ascites is suggested by the following findings on physical examination:

Hepatic encephalopathy

The symptoms of hepatic encephalopathy may range from mild to severe and may be observed in as many as 70% of patients with cirrhosis. Symptoms are graded on the following scale:

Findings on physical examination in hepatic encephalopathy include asterixis and fetor hepaticus.

Additional signs and symptoms

Many patients with cirrhosis experience fatigue, anorexia, weight loss, and muscle wasting. Cutaneous manifestations of cirrhosis include jaundice, spider angiomata, skin telangiectasias ("paper money skin"), palmar erythema, white nails, disappearance of lunulae, and finger clubbing, especially in the setting of hepatopulmonary syndrome.

Diagnosis

Hepatorenal syndrome

Hepatorenal syndrome is diagnosed when a creatinine clearance rate of less than 40 mL/min is present or when a serum creatinine level of greater than 1.5 mg/dL, a urine volume of less than 500 mL/day, and a urine sodium level of less than 10 mEq/L are present.[1] Urine osmolality is greater than plasma osmolality.

Portal hypertension

During angiography, a catheter is placed selectively via either the transjugular or transfemoral route into the hepatic vein to measure portal pressure.

Hepatic encephalopathy

An elevated arterial or free venous serum ammonia level is the classic laboratory abnormality reported in patients with hepatic encephalopathy.

Electroencephalography may be helpful in the initial workup of a patient with cirrhosis and altered mental status, when ruling out seizure activity may be necessary.

Computed tomography (CT) scanning and MRI studies of the brain may be important in ruling out intracranial lesions when the diagnosis of hepatic encephalopathy is in question.

Ascites

Paracentesis is essential in determining whether ascites is caused by portal hypertension or by another process.

Management

Specific medical therapies may be applied to many liver diseases in an effort to diminish symptoms and to prevent or forestall the development of cirrhosis. Examples of such treatments include the following:

Once cirrhosis develops, treatment is aimed at the management of complications as they arise. Examples include the following:

Liver transplantation

Patients should be referred for consideration for liver transplantation after the first signs of hepatic decompensation.

Overview

Cirrhosis represents the final common histologic pathway for a wide variety of chronic liver diseases. The term cirrhosis was first introduced by Laennec in 1826. It is derived from the Greek term scirrhus and refers to the orange or tawny surface of the liver seen at autopsy.

Cirrhosis is defined histologically as a diffuse hepatic process characterized by fibrosis and the conversion of normal liver architecture into structurally abnormal nodules. The progression of liver injury to cirrhosis may occur over weeks to years. Indeed, patients with hepatitis C may have chronic hepatitis for as long as 40 years before progressing to cirrhosis.

Many forms of liver injury are marked by fibrosis, which is defined as an excess deposition of the components of the extracellular matrix (ie, collagens, glycoproteins, proteoglycans) in the liver. This response to liver injury potentially is reversible. By contrast, in most patients, cirrhosis is not a reversible process.

In addition to fibrosis, the complications of cirrhosis include, but are not limited to, portal hypertension, ascites, hepatorenal syndrome, and hepatic encephalopathy.

Often a poor correlation exists between the histologic findings in cirrhosis and the clinical picture. Some patients with cirrhosis are completely asymptomatic and have a reasonably normal life expectancy. Other individuals have a multitude of the most severe symptoms of end-stage liver disease and have a limited chance for survival. Common signs and symptoms may stem from decreased hepatic synthetic function (eg, coagulopathy), decreased detoxification capabilities of the liver (eg, hepatic encephalopathy), or portal hypertension (eg, variceal bleeding).

In August 2012, the Centers for Disease Control and Prevention (CDC) expanded their existing, risk-based testing guidelines to recommend a 1-time blood test for hepatitis C virus (HCV) infection in baby boomers—the generation born between 1945 and 1965, who account for approximately three fourths of all chronic HCV infections in the United States—without prior ascertainment of HCV risk (see Recommendations for the Identification of Chronic Hepatitis C Virus Infection Among Persons Born During 1945–1965).[2]  One-time HCV testing in this population could identify nearly 808,600 additional people with chronic infection. All individuals identified with HCV should be screened and/or managed for alcohol abuse, followed by referral to preventative and/or treatment services, as appropriate.

For patient education information, see the Mental Health Center, as well as Alcoholism.

Etiology

Alcoholic liver disease once was considered to be the predominant source of cirrhosis in the United States, but hepatitis C has emerged as the nation's leading cause of chronic hepatitis and cirrhosis.

Many cases of cryptogenic cirrhosis appear to have resulted from nonalcoholic fatty liver disease (NAFLD). When cases of cryptogenic cirrhosis are reviewed, many patients have 1 or more of the classic risk factors for NAFLD: obesity, diabetes, and hypertriglyceridemia.[3] It is postulated that steatosis may regress in some patients as hepatic fibrosis progresses, making the histologic diagnosis of NAFLD difficult. Flavinoids have been reported to have positive effects on key pathophysiologic pathways in NAFLD (eg, lipid metabolism, insulin resistance, inflammation, oxidative stress) and may hold future potential for inclusion in NAFLD treatment.[4]

Up to one third of Americans have NAFLD. About 2-3% of Americans have nonalcoholic steatohepatitis (NASH), in which fat deposition in the hepatocyte is complicated by liver inflammation and fibrosis. It is estimated that 10% of patients with NASH will ultimately develop cirrhosis. NAFLD and NASH are anticipated to have a major impact on the United States' public health infrastructure.

The most common causes of cirrhosis in the United States include the following:

Miscellaneous causes of chronic liver disease and cirrhosis include the following:

Epidemiology

United States data

Chronic liver disease and cirrhosis result in about 35,000 deaths each year in the United States. Cirrhosis is the ninth leading cause of death in the United States and is responsible for 1.2% of all US deaths. Many patients die from the disease in their fifth or sixth decade of life.

Each year, 2000 additional deaths are attributed to fulminant hepatic failure (FHF). FHF may be caused viral hepatitis (eg, hepatitis A and B), drugs (eg, acetaminophen), toxins (eg, Amanita phalloides, the yellow death-cap mushroom), autoimmune hepatitis, Wilson disease, or a variety of less common etiologies. Cryptogenic causes are responsible for one third of fulminant cases. Patients with the syndrome of FHF have a 50-80% mortality rate unless they are salvaged by liver transplantation.

International data

Worldwide, cirrhosis is the 14th most common cause of death, but in Europe, it is the 4th most common cause of death.[5]

Hepatic Fibrosis

The development of hepatic fibrosis reflects an alteration in the normally balanced processes of extracellular matrix production and degradation.[6] The extracellular matrix, the normal scaffolding for hepatocytes, is composed of collagens (especially types I, III, and V), glycoproteins, and proteoglycans.

Stellate cells, located in the perisinusoidal space, are essential for the production of extracellular matrix. Stellate cells, which were once known as Ito cells, lipocytes, or perisinusoidal cells, may become activated into collagen-forming cells by a variety of paracrine factors. Such factors may be released by hepatocytes, Kupffer cells, and sinusoidal endothelium following liver injury. As an example, increased levels of the cytokine transforming growth factor beta1 (TGF-beta1) are observed in patients with chronic hepatitis C and those with cirrhosis. TGF-beta1, in turn, stimulates activated stellate cells to produce type I collagen.

In a study that evaluated serum cytokine levels between healthy patients, those with stable cirrhosis, and patients with decompensated cirrhosis with and without development of acute-on-chronic liver failure (ACLF), Dirchwolf et al found the presence of distinct cytokine phenotypes was associated with cirrhosis severity.[7] Relative to the healthy patients, those with cirrhosis had elevated levels of proinflammatory cytokines (interleukin [IL]-6, -7, -8, -10, and -12, and tumor necrosis factor-alpha [TNF-α]) and chemoattractant elements. Leukocyte count was positively correlated with disease severity across the scoring systems used, levels of IL-6 and IL-8 had positive correlation with Model for End-Stage Liver Disease (MELD) score, and IL-6 alone had a positive correlation with chronic liver failure-sequential organ failure assessment (Clif-SOFA) score at day 7 (but a negative correlation with IL-2 at admission).[7]

Increased collagen deposition in the space of Disse (the space between hepatocytes and sinusoids) and the diminution of the size of endothelial fenestrae lead to the capillarization of sinusoids. Activated stellate cells also have contractile properties. Capillarization and constriction of sinusoids by stellate cells contribute to the development of portal hypertension.

Future drug strategies to prevent fibrosis may focus on reducing hepatic inflammation, inhibiting stellate cell activation, inhibiting the fibrogenic activities of stellate cells, and stimulating matrix degradation.

Portal Hypertension

Causes

The normal liver has the ability to accommodate large changes in portal blood flow without appreciable alterations in portal pressure. Portal hypertension results from a combination of increased portal venous inflow and increased resistance to portal blood flow.

Patients with cirrhosis demonstrate increased splanchnic arterial flow and, accordingly, increased splanchnic venous inflow into the liver. Increased splanchnic arterial flow is explained partly by decreased peripheral vascular resistance and increased cardiac output in the patient with cirrhosis. Nitric oxide appears to be the major driving force for this phenomenon.[8]

Furthermore, evidence for splanchnic vasodilation exists. Putative splanchnic vasodilators include glucagon, vasoactive intestinal peptide, substance P, prostacyclin, bile acids, tumor necrosis factor-alpha (TNF-alpha), and nitric oxide.

Increased resistance across the sinusoidal vascular bed of the liver is caused by fixed factors and dynamic factors. Two thirds of intrahepatic vascular resistance can be explained by fixed changes in the hepatic architecture. Such changes include the formation of regenerating nodules and, after the production of collagen by activated stellate cells, deposition of the collagen within the space of Disse.

Dynamic factors account for one third of intrahepatic vascular resistance. Stellate cells serve as contractile cells for adjacent hepatic endothelial cells. The nitric oxide produced by the endothelial cells, in turn, controls the relative degree of vasodilation or vasoconstriction produced by the stellate cells. In cirrhosis, decreased local production of nitric oxide by endothelial cells permits stellate cell contraction, with resulting vasoconstriction of the hepatic sinusoid. (This contrasts with the peripheral circulation, where there are high circulating levels of nitric oxide in cirrhosis.) Increased local levels of vasoconstricting chemicals, such as endothelin, may also contribute to sinusoidal vasoconstriction.

The portal hypertension of cirrhosis is caused by the disruption of hepatic sinusoids. However, portal hypertension may be observed in a variety of noncirrhotic conditions.

Prehepatic causes

Prehepatic causes include splenic vein thrombosis and portal vein thrombosis. These conditions commonly are associated with hypercoagulable states and with malignancy (eg, pancreatic cancer). In a retrospective study (2002-2014) of 66 patients with cirrhosis and portal vein thrombosis, Chen et al reported that warfarin anticoagulation may potentially safely and effectively resolve cases of more advanced portal vein thrombosis.[9] However, they did not observe any benefit of anticoagulation on decompensation or mortality. Levels of albumin were significant predictors of decompensated disease at 1 year.[9]

Intrahepatic causes

Intrahepatic causes of portal hypertension are divided into presinusoidal, sinusoidal, and postsinusoidal conditions. The classic sinusoidal cause of portal hypertension is cirrhosis.

The classic form of presinusoidal portal hypertension is caused by the deposition of Schistosoma oocytes in presinusoidal portal venules, with the subsequent development of granulomata and portal fibrosis. Schistosomiasis is the most common noncirrhotic cause of variceal bleeding worldwide. Schistosoma mansoni infection is described in Puerto Rico, Central and South America, the Middle East, and Africa. S japonicum is described in the Far East. S hematobium, observed in the Middle East and Africa, can produce portal fibrosis but more commonly is associated with urinary tract deposition of eggs.

The classic postsinusoidal condition is an entity known as veno-occlusive disease. Obliteration of the terminal hepatic venules may result from ingestion of pyrrolizidine alkaloids in Comfrey tea or Jamaican bush tea or following the high-dose chemotherapy that precedes bone marrow transplantation.

Posthepatic causes

Posthepatic causes of portal hypertension may include chronic right-sided heart failure and tricuspid regurgitation and obstructing lesions of the hepatic veins and inferior vena cava. The latter conditions, and the symptoms they produce, are termed Budd-Chiari syndrome. Predisposing conditions include hypercoagulable states, tumor invasion into the hepatic vein or inferior vena cava, and membranous obstruction of the inferior vena cava. Inferior vena cava webs are observed most commonly in South and East Asia and are postulated to be due to nutritional factors.

Symptoms of Budd-Chiari syndrome are attributed to decreased outflow of blood from the liver, with resulting hepatic congestion and portal hypertension. These symptoms include hepatomegaly, abdominal pain, and ascites. Cirrhosis ensues only later in the course of disease. Differentiating Budd-Chiari syndrome from cirrhosis by history or physical examination may be difficult. Thus, Budd-Chiari syndrome must be included in the differential diagnosis of conditions that produce ascites and varices.

Hepatic vein patency is checked most readily by performing abdominal ultrasonography, with Doppler examination of the hepatic vessels. Abdominal computed tomography (CT) scanning with intravenous (IV) contrast, abdominal magnetic resonance imaging (MRI), and visceral angiography also may provide information regarding the patency of hepatic vessels.

Kondo et al have reported that portal hemodynamics on Doppler ultrasonography may provide noninvasive prognostic implications for decompensation and long-term outcomes in patients with cirrhosis.[10] In their retrospective study of 236 cirrhotic patients (compensated, n = 110; decompensated, n = 126) (mean followup, 33.2 mo), a significant predictor for the presence of decompensation was baseline higher model for end-stage liver disease (MELD) score; moreover, signficant prognostic factors for developing cirrhosis included higher alanine transaminase levels, lower albumin levels, and lower mean velocity in the portal trunk.[10] For compensated patients, significant predictors were hepatocellular carcinoma and lower albumin levels, whereas in decompensated patients, they were elevated bilirubin levels and overt ascites.[10]  

Measurement

AASLD recommendations

The 2016 American Association for the study of Liver Diseases (AASLD) provides the following guidance for noninvasive testing for the diagnosis of clinically significant portal hypertension (CSPH)[72] :

Widespread use of the transjugular intrahepatic portosystemic shunt (TIPS) procedure in the 1990s for the management of variceal bleeding led to a resurgence of clinicians' interest in measuring portal pressure. During angiography, a catheter may be placed selectively via either the transjugular or transfemoral route into the hepatic vein. In the healthy patient, free hepatic vein pressure (FHVP) is equal to inferior vena cava pressure. FHVP is used as an internal zero reference point.

Wedged hepatic venous pressure (WHVP) is measured by inflating a balloon at the catheter tip, thus occluding a hepatic vein branch. Measurement of the WHVP provides a close approximation of portal pressure. The WHVP actually is slightly lower than the portal pressure because of some dissipation of pressure in the sinusoidal bed. The WHVP and portal pressure are elevated in patients with sinusoidal portal hypertension, as is observed in cirrhosis.

Complications

The HVPG is defined as the difference in pressure between the portal vein and the inferior vena cava. Thus, the HVPG is equal to the WHVP value minus the FHVP value (ie, HVPG = WHVP - FHVP). The normal HVPG is 3-6 mm Hg.

Portal hypertension is defined as a sustained elevation of portal pressure above normal. An HVPG of 8 mm Hg is believed to be the threshold above which ascites potentially can develop. An HVPG of 12 mm Hg is the threshold for the potential formation of varices. High portal pressures may predispose patients to an increased risk of variceal hemorrhage.[11]

AASLD recommendations

The AASLD recommends the following for noninvasive testing for the diagnosis of gastroesophageal varices[72] :

Ascites

Ascites, which is an accumulation of excessive fluid within the peritoneal cavity, can be a complication of either hepatic or nonhepatic disease. The 4 most common causes of ascites in North America and Europe are cirrhosis, neoplasm, congestive heart failure, and tuberculous peritonitis.

In the past, ascites was classified as being a transudate or an exudate. In transudative ascites, fluid was said to cross the liver capsule because of an imbalance in Starling forces. In general, ascites protein would be less than 2.5 g/dL in this form of ascites. A classic cause of transudative ascites would be portal hypertension secondary to cirrhosis and congestive heart failure.

In exudative ascites, fluid was said to weep from an inflamed or tumor-laden peritoneum. In general, ascites protein in exudative ascites would be greater than 2.5 g/dL. Causes of the condition would include peritoneal carcinomatosis and tuberculous peritonitis.

Nonperitoneal causes

Attributing ascites to diseases of nonperitoneal or peritoneal origin is more useful. Thanks to the work of Bruce Runyon, the serum-ascites albumin gradient (SAAG) has come into common clinical use for differentiating these conditions. Nonperitoneal diseases produce ascites with a SAAG greater than 1.1 g/dL. (See Table 1, below.)[12]

Table 1. Nonperitoneal Causes of Ascites[13]



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Chylous ascites, caused by obstruction of the thoracic duct or cisterna chyli, most often is due to malignancy (eg, lymphoma) but occasionally is observed postoperatively and following radiation injury. Chylous ascites also may be observed in the setting of cirrhosis. The triglyceride concentration of the ascites is greater than 110 mg/dL and greater than that observed in plasma. Patients should be placed on a low-fat diet that is supplemented with medium-chain triglycerides. Treatment with diuretics and large-volume paracentesis may be required.

Peritoneal causes

Peritoneal diseases produce ascites with a SAAG of less than 1.1 g/dL. (See Table 2, below.)

Table 2. Peritoneal Causes of Ascites[13]



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The role of portal hypertension in the pathogenesis of cirrhotic ascites

The formation of ascites in cirrhosis depends on the presence of unfavorable Starling forces within the hepatic sinusoid and on some degree of renal dysfunction. Patients with cirrhosis are observed to have increased hepatic lymphatic flow.

Fluid and plasma proteins diffuse freely across the highly permeable sinusoidal endothelium into the space of Disse. Fluid in the space of Disse, in turn, enters the lymphatic channels that run within the portal and central venous areas of the liver.

Because the trans-sinusoidal oncotic gradient is approximately zero, the increased sinusoidal pressure that develops in portal hypertension increases the amount of fluid entering the space of Disse. When the increased hepatic lymph production observed in portal hypertension exceeds the ability of the cisterna chyli and thoracic duct to clear the lymph, fluid crosses into the liver interstitium. Fluid may then extravasate across the liver capsule into the peritoneal cavity.

The role of renal dysfunction in the pathogenesis of cirrhotic ascites

Patients with cirrhosis experience sodium retention, impaired free-water excretion, and intravascular volume overload. These abnormalities may occur even in the setting of a normal glomerular filtration rate. They are, to some extent, due to increased levels of renin and aldosterone.

The peripheral arterial vasodilation hypothesis states that splanchnic arterial vasodilation, driven by high nitric oxide levels, leads to intravascular underfilling. This causes stimulation of the renin-angiotensin system and the sympathetic nervous system and results in antidiuretic hormone release. These events are followed by an increase in sodium and water retention and in plasma volume, as well as by the overflow of fluid into the peritoneal cavity.

Clinical features of ascites

Ascites is suggested by the presence of the following findings upon physical examination:

A fluid wave may be elicited in patients with massive tense ascites. However, physical examination findings are much less sensitive than abdominal ultrasonography, which can detect as little as 30 mL of fluid. Furthermore, ultrasonography with Doppler can help to assess the patency of hepatic vessels.

Factors associated with worsening of ascites include excess fluid or salt intake, malignancy, venous occlusion (eg, Budd-Chiari syndrome), progressive liver disease, and spontaneous bacterial peritonitis (SBP).

Spontaneous bacterial peritonitis

SBP is observed in 15-26% of patients hospitalized with ascites. The syndrome arises most commonly in patients whose low-protein ascites (< 1 g/dL) contains low levels of complement, resulting in decreased opsonic activity. SBP appears to be caused by the translocation of gastrointestinal (GI) tract bacteria across the gut wall and also by the hematogenous spread of bacteria. The most common causative organisms are Escherichia coli, Streptococcus pneumoniae, Klebsiella species, and other gram-negative enteric organisms.[14]

Classic SBP is diagnosed by the presence of neutrocytosis, which is defined as greater than 250 polymorphonuclear cells (PMNs) per mm3 of ascites, in the setting of a positive ascites culture. Culture-negative neutrocytic ascites is observed more commonly. Both conditions represent serious infections that carry a 20-30% mortality rate.

The most commonly used regimen in the treatment of SBP is a 5-day course of cefotaxime at 1-2g intravenously every 8 hours.[15] Alternatives include oral ofloxacin and other IV antibiotics with activity against gram-negative enteric organisms. Many authorities advise repeat paracentesis in 48-72 hours to document a decrease in the ascites PMN count to less than 250 cells/mm3 to ensure efficacy of therapy.

Once SBP develops, patients have a 70% chance of redeveloping the condition within 1 year. Prophylactic antibiotic therapy can reduce the recurrence rate of SBP to 20%. Some of the regimens used in the prophylaxis of SBP include norfloxacin at 400 mg orally every day[16] and trimethoprim-sulfamethoxazole at 1 double-strength tablet 5 days per week.[17]

Therapy with norfloxacin at 400 mg orally twice per day for 7 days can reduce serious bacterial infection in patients with cirrhosis who have GI bleeding. One study noted that the 37% incidence of serious bacterial infection was reduced to 10% when treatment with norfloxacin was instituted.[18] Furthermore, it can be argued that all patients with low-protein ascites should undergo prophylactic therapy (eg, with norfloxacin 400 mg daily PO) at the time of hospital admission, given the high incidence of hospital-acquired SBP.[19]

Hernias

Umbilical and inguinal hernias are common in patients with moderate and massive ascites. The use of an elastic abdominal binder may protect the skin overlying a protruding umbilical hernia from maceration and may help to prevent rupture and subsequent infection. Timely, large-volume paracentesis also may help to prevent this disastrous complication.

Umbilical hernias should not undergo elective repair unless patients are significantly symptomatic or their hernias are irreducible. As with all other surgeries in patients with cirrhosis, herniorrhaphy carries multiple potential risks, such as intraoperative bleeding, postoperative infection, and liver failure, because of anesthesia-induced reductions in hepatic blood flow. However, these risks become acceptable in patients with severe symptoms from their hernia. Urgent surgery is necessary in the patient whose hernia has been complicated by bowel incarceration.

Other complications of massive ascites

Patients with massive ascites may experience abdominal discomfort, depressed appetite, and decreased oral intake. Diaphragmatic elevation may lead to symptoms of dyspnea. Pleural effusions may result from the passage of ascitic fluid across channels in the diaphragm.

Paracentesis in the diagnosis of ascites

Paracentesis is essential in determining whether ascites is caused by portal hypertension or by another process. Ascites studies also are used to rule out infection and malignancy. Paracentesis should be performed in all patients with either new onset of ascites or worsening ascites. Paracentesis also should be performed when SBP is suggested by the presence of abdominal pain, fever, leukocytosis, or worsening hepatic encephalopathy. Some argue that paracentesis should be performed in all patients with cirrhosis who have ascites at the time of hospitalization, given the significant possibility of asymptomatic SBP. (See Table 3, below.)

Table 3. Ascites Tests



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Ascitic fluid with more than 250 PMNs/mm3 defines neutrocytic ascites and SBP. Many cases of ascites fluid with more than 1000 PMNs/mm3 (and certainly >5000 PMNs/mm3) are associated with appendicitis or a perforated viscus with resulting bacterial peritonitis. Appropriate radiologic studies must be performed in such patients to rule out surgical causes of peritonitis.

Lymphocyte-predominant ascites raises concerns about the possibility of underlying malignancy or tuberculosis. Similarly, grossly bloody ascites may be observed in malignancy and tuberculosis. (Bloody ascites is seen infrequently in uncomplicated cirrhosis.) A common clinical dilemma is how to interpret the ascites PMN count in the setting of bloody ascites. This author recommends subtraction of 1 PMN for every 250 red blood cells (RBCs) in ascites to ascertain a corrected PMN count.

The yield of ascites culture studies may be increased by directly inoculating 10 mL of ascetic fluid into aerobic and anaerobic culture bottles at the patient's bedside.[20]

Medical treatment of ascites

Therapy for ascites should be tailored to the patient's needs. Some patients with mild ascites respond to sodium restriction or diuretics taken once or twice per week. Other patients require aggressive diuretic therapy, careful monitoring of electrolytes, and occasional hospitalization to facilitate even more intensive diuresis.

The development of massive ascites that is refractory to medical therapy has dire prognostic implications, with only 50% of patients surviving 6 months.[21]

Sodium restriction

Salt restriction is the first line of therapy. In general, patients begin with a diet containing less than 2000 mg of sodium daily. Some patients with refractory ascites require a diet containing less than 500 mg of sodium daily. However, ensuring that patients do not construct diets that might place them at risk for calorie and protein malnutrition is important. Indeed, the benefit of commercially available liquid nutritional supplements (which often contain moderate amounts of sodium) often exceeds the risk of slightly increasing the patient's salt intake.

Diuretics

Diuretics should be considered the second line of therapy. Spironolactone (Aldactone) blocks the aldosterone receptor at the distal tubule. It is dosed at 50-300 mg once daily. Although the drug has a relatively short half-life, its blockade of the aldosterone receptor lasts for at least 24 hours. Adverse effects of spironolactone include hyperkalemia, gynecomastia, and lactation. Other potassium-sparing diuretics, including amiloride and triamterene, may be used as alternative agents, especially in patients complaining of gynecomastia.

Furosemide (Lasix) may be used as a solo agent or in combination with spironolactone. The drug blocks sodium reuptake in the loop of Henle. It is dosed at 40-240 mg daily in 1-2 divided doses. Patients infrequently need potassium repletion when furosemide is dosed in combination with spironolactone. An Italian study by Angeli et al found sequential dosing with a potassium-sparing diuretic plus furosemide to be superior for patients with moderate ascites without renal failure when compared with potassium-sparing diuretic monotherapy.[22]

Aggressive diuretic therapy in hospitalized patients with massive ascites can safely induce a weight loss of 0.5-1kg daily, provided that patients undergo careful monitoring of renal function. Diuretic therapy should be held in the event of electrolyte disturbances, azotemia, or induction of hepatic encephalopathy.

Albumin

Thus far, evidence-based medicine has not firmly supported the use of albumin as an aid to diuresis in a patient with cirrhosis who is hospitalized. The author's anecdotal experience suggests that albumin may increase the efficacy and safety of diuretics. The author's practice in hospitalized patients who are hypoalbuminemic is to administer IV furosemide following IV infusion of albumin at 25g twice daily, in addition to providing ongoing therapy with spironolactone. One article supported the use of chronic albumin infusions to achieve diuresis in patients with diuretic-resistant ascites.[23]

Albumin infusion may protect against the development of renal insufficiency in patients with SBP. Patients receiving cefotaxime and albumin at 1 g/kg daily experienced a lower risk of renal failure and a lower in-hospital mortality rate than patients treated with cefotaxime and conventional fluid management.[24]

V2 receptor antagonists

Vasopressin V2 receptor antagonists are a class of agents with the potential to increase free-water excretion, improve diuresis, and decrease the need for paracentesis. However, no such agent has received US Food and Drug Administration (FDA) approval for this indication.

Tolvaptan (Samsca, Otsuka Pharmaceutical Co; Tokyo, Japan) is an oral V2 receptor antagonist; it received FDA approval in 2009 only for the management of hyponatremia. A black box warning cautions against treatment initiation in outpatients. Furthermore, it may be associated with an increased incidence of GI bleeding in patients with cirrhosis. The author advises against its use for ascites management at this time.

Large-volume paracentesis

Aggressive diuretic therapy is ineffective in controlling ascites in approximately 5-10% of patients. Such patients with massive ascites may need to undergo large-volume paracentesis to obtain relief from symptoms of abdominal discomfort, anorexia, or dyspnea. The procedure also may help to reduce the risk of umbilical hernia rupture.

Large-volume paracentesis was first used in ancient times. It fell out of favor from the 1950s through the 1980s with the advent of diuretic therapy and following a handful of case reports describing paracentesis-induced azotemia. In 1987, Gines and colleagues demonstrated that large-volume paracentesis could be performed with minimal or no impact on renal function.[25] This and other studies showed that 5-15 L of ascites could be removed safely at one time.

Large-volume paracentesis is thought to be safe in patients with peripheral edema and in patients not currently treated with diuretics. Debate exists whether colloid infusions (eg, with 5-10g of albumin per 1L of ascites removed) are necessary to prevent intravascular volume depletion in patients who are receiving ongoing diuretic therapy or in patients with mild or moderate, underlying renal insufficiency.

Peritoneovenous shunts

LeVeen shunts and Denver shunts are devices that permit the return of ascites fluid and proteins to the intravascular space. Plastic tubing inserted subcutaneously under local anesthesia connects the peritoneal cavity to the internal jugular vein or subclavian vein via a pumping chamber. These devices are successful at relieving ascites and reversing protein loss in some patients. However, shunts may clot and require replacement in 30% of patients.

Serious complications are observed in at least 10% of the recipients of these devices, including peritoneal infection, sepsis, disseminated intravascular coagulation, congestive heart failure, and death. The author considers peritoneovenous shunts to be a last resort for patients with refractory ascites who are not candidates for TIPS or liver transplantation. The safety of repeat large-volume paracentesis procedures may actually outweigh the safety of peritoneovenous shunt placement.

Portosystemic shunts and transjugular intrahepatic portosystemic shunts

The prime indication for portocaval shunt surgery is the management of refractory variceal bleeding. Since 1945, however, the medical field has recognized that portocaval shunts, by decompressing the hepatic sinusoid, may improve ascites. The performance of a side-to-side portocaval shunt for ascites management must be weighed against the approximate 5% mortality rate associated with this surgery and the chance (as high as 30%) of inducing hepatic encephalopathy.

A TIPS is an effective tool in managing massive ascites in some patients. Ideally, TIPS placement produces a decrease in sinusoidal pressure and in plasma renin and aldosterone levels, with subsequent improved urinary sodium excretion. In one study, 74% of patients with refractory ascites achieved complete remission of ascites within 3 months of TIPS placement.[26] Typically, about one half of appropriately selected patients undergoing TIPS achieve significant relief of ascites.

Multiple studies have demonstrated that TIPS is superior to large-volume paracentesis when it comes to the control of ascites.[27] One meta-analysis of individual patient data demonstrated an improvement in transplant-free life expectancy in patients whose massive ascites was treated with a TIPS, as opposed to large-volume paracentesis.[28] However, the creation of a TIPS has the potential to worsen preexisting hepatic encephalopathy and exacerbate liver dysfunction in patients with severe, underlying liver failure.[29]

Both a pre-TIPS bilirubin level of greater than 3 mg/dL and a pre-TIPS Model for End-Stage Liver Disease (MELD) score of greater than 18 (see the MELD Score calculator) are associated with an increased mortality rate when a TIPS is created for the management of ascites.[30, 31] In the author's opinion, TIPS use should be reserved for patients with Child Class B cirrhosis or patients with Child Class C cirrhosis without severe coagulopathy or encephalopathy.

In the 1990s, shunt stenosis was observed in one half of cases within 1 year of TIPS placement, necessitating angiographic revision. Although the advent of coated stents appears to have reduced the incidence of shunt stenosis, patients must still be willing to return to the hospital for Doppler and angiographic follow-up of TIPS patency.

Liver transplantation

Patients with massive ascites have 1-year survival rate of less than 50%. Liver transplantation should be considered as a potential means of salvaging the patient prior to the onset of intractable liver failure or hepatorenal syndrome.

Hepatorenal Syndrome

This syndrome represents a continuum of renal dysfunction that may be observed in patients with a combination of cirrhosis and ascites. Hepatorenal syndrome is caused by the vasoconstriction of large and small renal arteries and the impaired renal perfusion that results.[32]

The syndrome may represent an imbalance between renal vasoconstrictors and vasodilators. Plasma levels of a number of vasoconstricting substances—including angiotensin, antidiuretic hormone, and norepinephrine—are elevated in patients with cirrhosis. Renal perfusion appears to be protected by vasodilators, including prostaglandins E2 and I2 and atrial natriuretic factor.

Nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit prostaglandin synthesis. They may potentiate renal vasoconstriction, with a resulting drop in glomerular filtration. Thus, the use of NSAIDs is contraindicated in patients with decompensated cirrhosis.

Most patients with hepatorenal syndrome are noted to have minimal histologic changes in the kidneys. Kidney function usually recovers when patients with cirrhosis and hepatorenal syndrome undergo liver transplantation. In fact, a kidney donated by a patient dying from hepatorenal syndrome functions normally when transplanted into a renal transplant recipient.

Types of hepatorenal syndrome

Hepatorenal syndrome progression may be slow (type II) or rapid (type I).[33] Type I disease frequently is accompanied by rapidly progressive liver failure. Hemodialysis offers temporary support for such patients. These individuals are salvaged only by performance of liver transplantation. Exceptions to this rule are the patients with fulminant hepatic failure (FHF) or severe alcoholic hepatitis who spontaneously recover liver and kidney function. In type II hepatorenal syndrome, patients may have stable or slowly progressive renal insufficiency. Many such patients develop ascites that is resistant to management with diuretics.

Diagnosis

Hepatorenal syndrome is diagnosed when a creatinine clearance rate of less than 40 mL/min is present or when a serum creatinine level of greater than 1.5 mg/dL, a urine volume of less than 500 mL/day, and a urine sodium level of less than 10 mEq/L are present.[1] Urine osmolality is greater than plasma osmolality.

In hepatorenal syndrome, renal dysfunction cannot be explained by preexisting kidney disease, prerenal azotemia, the use of diuretics, or exposure to nephrotoxins. Clinically, the diagnosis may be reached if the central venous pressure is determined to be normal or if no improvement in renal function occurs following the infusion of at least 1.5 L of a plasma expander.

Treatment

Nephrotoxic medications, including aminoglycoside antibiotics, should be avoided in patients with cirrhosis. Patients with early hepatorenal syndrome may be salvaged by aggressive expansion of intravascular volume with albumin and fresh frozen plasma and by avoidance of diuretics. The use of renal-dose dopamine is not effective.

A number of investigators have employed systemic vasoconstrictors in an attempt to reverse the effects of nitric oxide on peripheral arterial vasodilation. In Europe, administration of IV terlipressin (an analog of vasopressin not available in the United States) improved renal dysfunction in patients with hepatorenal syndrome.[34, 35]

A combination of midodrine (an oral alpha agonist), subcutaneous octreotide, and albumin infusion has also been demonstrated to improve renal function in small cohorts of patients with hepatorenal syndrome.[36]

Hepatic Encephalopathy

Hepatic encephalopathy, a syndrome observed in some patients with cirrhosis, is marked by personality changes, intellectual impairment, and a depressed level of consciousness. The diversion of portal blood into the systemic circulation appears to be a prerequisite for the syndrome. Indeed, hepatic encephalopathy may develop in patients without cirrhosis who undergo portocaval shunt surgery.

Pathogenesis

A number of theories have been postulated to explain the pathogenesis of hepatic encephalopathy in patients with cirrhosis. Patients may have altered brain energy metabolism and increased permeability of the blood-brain barrier. The latter may facilitate the passage of neurotoxins into the brain. Putative neurotoxins include short-chain fatty acids, mercaptans, false neurotransmitters (eg, tyramine, octopamine, beta phenylethanolamines), ammonia, and gamma-aminobutyric acid (GABA).

Ammonia hypothesis

Ammonia is produced in the GI tract by bacterial degradation of amines, amino acids, purines, and urea. Normally, ammonia is detoxified in the liver by conversion to urea and glutamine. In liver disease or portosystemic shunting, portal blood ammonia is not converted efficiently to urea. Increased levels of ammonia may enter the systemic circulation because of portosystemic shunting.

Ammonia has multiple neurotoxic effects, including alteration of the transit of amino acids, water, and electrolytes across the neuronal membrane. Ammonia also can inhibit the generation of excitatory and inhibitory postsynaptic potentials. Therapeutic strategies to reduce serum ammonia levels tend to improve hepatic encephalopathy. However, approximately 10% of patients with significant encephalopathy have normal serum ammonia levels. Furthermore, many patients with cirrhosis have elevated ammonia levels without evidence of encephalopathy.

Gamma-aminobutyric acid hypothesis

GABA is a neuroinhibitory substance produced in the GI tract. It was postulated that GABA crosses the extrapermeable blood-brain barriers of patients with cirrhosis and then interacts with supersensitive postsynaptic GABA receptors.[37] This would lead to the generation of inhibitory postsynaptic potentials. Clinically, this interaction was believed to produce the symptoms of hepatic encephalopathy. Subsequent work has suggested that brain GABA levels are not increased in patients with cirrhosis.

However, brain levels of neurosteroids are increased in patients with cirrhosis.[38] They are capable of binding to their receptor within the neuronal GABA receptor complex and can increase inhibitory neurotransmission. Some investigators currently contend that neurosteroids may play a key role in hepatic encephalopathy.[39]

Clinical features

The symptoms of hepatic encephalopathy may range from mild to severe and may be observed in as many as 70% of patients with cirrhosis. Symptoms are graded on the following scale:

Patients with mild and moderate hepatic encephalopathy demonstrate decreased short-term memory and concentration on mental status testing. Findings on physical examination include asterixis and fetor hepaticus.

Laboratory abnormalities

An elevated arterial or free venous serum ammonia level is the classic laboratory abnormality reported in patients with hepatic encephalopathy. This finding may aid in the assignment of a correct diagnosis to a patient with cirrhosis who presents with altered mental status.

However, serial ammonia measurements are inferior to clinical assessment in gauging improvement or deterioration in patients under therapy for hepatic encephalopathy. No utility exists for checking the ammonia level in a patient with cirrhosis who does not have hepatic encephalopathy.

Some patients with hepatic encephalopathy have the classic, but nonspecific, electroencephalogram (EEG) changes of high-amplitude low-frequency waves and triphasic waves. Electroencephalography may be helpful in the initial workup of a patient with cirrhosis and altered mental status, when ruling out seizure activity may be necessary.

CT scan and MRI studies of the brain may be important in ruling out intracranial lesions when the diagnosis of hepatic encephalopathy is in question.

Common precipitants

Some patients with a history of hepatic encephalopathy have normal mental status when under medical therapy. Others have chronic memory impairment in spite of medical management. Both groups of patients are subject to episodes of worsened encephalopathy. Common precipitants of hyperammonemia and worsening mental status are as follows:

Dietary protein overload is an infrequent cause of worsening encephalopathy. Medications, notably opiates, benzodiazepines, antidepressants, and antipsychotic agents, also may worsen encephalopathic symptoms.

Differential diagnosis

Conditions to consider in the differential diagnosis of encephalopathy include the following:

Management

Nonhepatic causes of altered mental function must be excluded in patients with cirrhosis who have worsening mental function. A check of the blood ammonia level may be helpful in such patients. Medications that depress central nervous system (CNS) function, especially benzodiazepines, should be avoided. Precipitants of hepatic encephalopathy should be corrected (eg, hypovolemia, metabolic disturbances, GI bleeding, infection, constipation).

Lactulose

Lactulose is helpful in patients with an acute onset of severe encephalopathy symptoms and in patients with milder, chronic symptoms. This nonabsorbable disaccharide stimulates the passage of ammonia from tissues into the gut lumen and inhibits intestinal ammonia production. Initial lactulose dosing is 30 mL orally once or twice daily. Dosing is increased until the patient has 2-4 loose stools per day. Dosing should be reduced if the patient complains of diarrhea, abdominal cramping, or bloating.

Higher doses of lactulose may be administered via either a nasogastric or rectal tube to hospitalized patients with severe encephalopathy. Other cathartics, including colonic lavage solutions that contain polyethylene glycol (PEG) (eg, Go-Lytely), also may be effective in patients with severe encephalopathy.

In a study, Sharma et al concluded that the use of lactulose effectively prevents hepatic encephalopathy recurrence in cirrhosis. Patients with cirrhosis recovering from hepatic encephalopathy were randomized to receive lactulose (n = 61) or placebo (n = 64). Over a median follow-up of 14 months, 12 patients (19.6%) in the lactulose group developed hepatic encephalopathy, compared with 30 patients (46.8%) in the placebo group.[40]

Antibiotics

Neomycin and other antibiotics (eg, metronidazole, oral vancomycin, paromomycin, oral quinolones) serve as second-line agents. They work by decreasing the colonic concentration of ammoniagenic bacteria. Neomycin dosing is 250-1000 mg orally 2-4 times daily. Treatment with neomycin may be complicated by ototoxicity and nephrotoxicity.

Rifaximin (Xifaxan) is a nonabsorbable antibiotic that received FDA approval in 2004 for the treatment of travelers' diarrhea and was given approval in 2010 for the reduction of recurrent hepatic encephalopathy. This drug was also approved in May 2015 for the treatment of diarrhea-predominant irritable bowel syndrome (IBS-D). Data from Europe suggest that rifaximin can decrease colonic levels of ammoniagenic bacteria, with resulting improvement in the symptoms of hepatic encephalopathy.

A double-blind, placebo-controlled trial, indicated that rifaximin can prevent the occurrence hepatic encephalopathy. In the study, 299 patients whose recurrent hepatic encephalopathy was in remission received either rifaximin 550 mg or placebo twice daily. Each group also received lactulose. Breakthrough episodes of hepatic encephalopathy occurred in 22% of patients treated with rifaximin and in 46% of patients who were given placebo, while hepatic encephalopathy – related hospitalization occurred in 14% of rifaximin patients and in 23% of placebo patients.[41] Rifaximin also appeared to be more effective than lactulose in trials that compared the 2 drugs head-to-head.[42]

Other drugs

Other chemicals capable of decreasing blood ammonia levels are L-ornithine L-aspartate (available in Europe) and sodium benzoate.[43]

Protein restriction

Low-protein diets were recommended routinely in the past for patients with cirrhosis. High levels of aromatic amino acids contained in animal proteins were believed to lead to increased blood levels of the false neurotransmitters tyramine and octopamine, with resultant worsening of encephalopathic symptoms. In this author's experience, the vast majority of patients can tolerate a protein-rich diet (>1.2 g/kg daily) that includes well-cooked chicken, fish, vegetable protein, and, if needed, protein supplements.

Protein restriction is rarely necessary in patients with symptoms of chronic encephalopathy. Many patients with cirrhosis have protein-calorie malnutrition at baseline; the routine restriction of dietary protein intake increases their risk for worsening malnutrition.

In the author's opinion, protein restriction is infrequently valuable in patients with an acute flare-up of symptoms of hepatic encephalopathy. One study randomized hospitalized patients with hepatic encephalopathy to receive either a normal-protein diet or a low-protein diet, in addition to standard treatment measures, and found no difference between the 2 groups in outcomes for hepatic encephalopathy.[44]

Other Manifestations of Cirrhosis

All chronic liver diseases that progress to cirrhosis have in common the histologic features of hepatic fibrosis and nodular regeneration. However, the patients' signs and symptoms may vary, depending on the underlying etiology of the disease.

As an example, patients with end-stage liver disease caused by hepatitis C may develop profound muscle wasting, marked ascites, and severe hepatic encephalopathy, with only mild jaundice. In contrast, patients with end-stage primary biliary cirrhosis may be deeply icteric, with no evidence of muscle wasting. These patients may complain of extreme fatigue and pruritus and have no complications of portal hypertension. In both cases, medical management is focused on the relief of symptoms. Liver transplantation should be considered as a potential therapeutic option, given the inexorable course of most cases of end-stage liver disease.

Many patients with cirrhosis experience fatigue, anorexia, weight loss, and muscle wasting. Cutaneous manifestations of cirrhosis include jaundice, spider angiomata, skin telangiectasias (termed "paper money skin" by Dame Sheila Sherlock), palmar erythema, white nails, disappearance of lunulae, and finger clubbing, especially in the setting of hepatopulmonary syndrome.

Patients with cirrhosis may experience increased conversion of androgenic steroids into estrogens in skin, adipose tissue, muscle, and bone. Males may develop gynecomastia and impotence. Loss of axillary and pubic hair is noted in men and women. Hyperestrogenemia also may explain spider angiomata and palmar erythema.

Hematologic manifestations

Anemia may result from folate deficiency, hemolysis, or hypersplenism.[45] Thrombocytopenia usually is secondary to hypersplenism and decreased levels of thrombopoietin. Coagulopathy results from decreased hepatic production of coagulation factors. If cholestasis is present, decreased micelle entry into the small intestine leads to decreased vitamin K absorption, with resulting reduction in hepatic production of factors II, VII, IX, and X. Patients with cirrhosis also may experience fibrinolysis and disseminated intravascular coagulation.

The oral thrombopoietin receptor agonist (TPO-RA) avatrombopag (Doptelet) was approved by the FDA in May 2018 for adults with thrombocytopenia secondary to chronic liver disease who are scheduled to undergo a procedure.[73]

Approval was based on the ADAPT-1 and ADAPT-2 clinical trials (N=435). The trials investigated the use of avatrombopag at two doses, 40 and 60 mg. The doses were selected on the basis of baseline platelet count and were administered orally over 5 consecutive days. Patients underwent their procedure 5 to 8 days after receiving the last dose. At both doses tested, a higher proportion of patients who received avatrombopag demonstrated an increase in platelet count compared with patients who received placebo. The primary endpoint was the proportion of patients not requiring platelet transfusions or rescue procedures for bleeding up to 7 days following the procedure. Patients who received avatrombopag met the primary endpoint 65.6%-68.6% relative to 22.9%-33.3% who received placebo. Patients who received avatrombopag 40 mg met the primary endpoint 87.9%-88.1% compared with 38.2%-33.3% who received placebo.[74]

A second TPO-RA, lusutrombopag (Mulpleta) was approved in July 2018 for treatment of thrombocytopenia in adults with chronic liver disease who are scheduled to undergo a procedure.[75]  Approval was based on an international, randomized trial (N=215). The study met its primary efficacy endpoint: 64.8% of patients in the lusutrombopag group required no platelet transfusion and no rescue therapy for bleeding, compared with 29% in placebo group (P< 0.0001).[76]

Pulmonary and cardiac manifestations

Patients with cirrhosis may have impaired pulmonary function. Pleural effusions and the diaphragmatic elevation caused by massive ascites may alter ventilation-perfusion relations. Interstitial edema or dilated precapillary pulmonary vessels may reduce pulmonary diffusing capacity.

Patients also may have hepatopulmonary syndrome (HPS). In this condition, pulmonary arteriovenous anastomoses result in arteriovenous shunting. HPS is a potentially progressive and life-threatening complication of cirrhosis. Classic HPS is marked by the symptom of platypnea and the finding of orthodeoxia, but the syndrome must be considered in any patient with cirrhosis who has evidence of oxygen desaturation.

HPS is detected most readily by echocardiographic visualization of late-appearing bubbles in the left atrium following the injection of agitated saline. Patients can receive a diagnosis of HPS when their PaO2 is less than 70 mm Hg. Some cases of HPS may be corrected by liver transplantation. In fact, a patient's course to liver transplantation may be expedited when his or her PaO2 is less than 60 mm Hg.

Portopulmonary hypertension (PPHTN) is observed in up to 6% of patients with cirrhosis. Its etiology is unknown. PPHTN is defined as the presence of a mean pulmonary artery pressure of greater than 25 mm Hg in the setting of a normal pulmonary capillary wedge pressure.

Routine Doppler echocardiography is performed as part of the regular workup in many liver transplant programs to rule out the interval development of PPHTN in patients on the transplant waiting list. Indeed, the presence of a mean pulmonary pressure of greater than 35 mm Hg significantly increases the risks of liver transplant surgery. Patients who develop severe PPHTN may require aggressive medical therapy in an effort to stabilize pulmonary artery pressures and to decrease their chance of perioperative mortality.

Hepatocellular carcinoma and cholangiocarcinoma

Hepatocellular carcinoma (HCC) ultimately arises in 10-25% of patients with cirrhosis in the United States. It typically occurs in about of 3% of patients per year, when the etiology of cirrhosis is hepatitis B, hepatitis C, or alcohol. It develops more commonly in patients with underlying hereditary hemochromatosis or alpha-1 antitrypsin deficiency. HCC is observed less commonly in primary biliary cirrhosis and is a rare complication of Wilson disease.

Hepatobiliary scintigraphy may improve radioembolization treatment planning in HCC patients when clinical and laboratory findings may not be sufficient.[46] This imaging modality may aid in estimating liver function reserve and its segmental distribution, particularly in those with underlying cirrhosis.

Cholangiocarcinoma occurs in approximately 10% of patients with primary sclerosing cholangitis. Early diagnosis of HCC is critical because it is potentially curable through either liver resection or liver transplant.

Other diseases

Other conditions that appear with increased incidence in patients with cirrhosis include peptic ulcer disease, diabetes, and gallstones.

Assessment of the Severity of Cirrhosis

For many years, the most common prognostic tool used in patients with cirrhosis was the Child-Turcotte-Pugh (CTP) system. Child and Turcotte first introduced their scoring system in 1964 as a means of predicting the operative mortality associated with portocaval shunt surgery. Pugh's revised system in 1973 substituted albumin for the less specific variable of nutritional status.[47] Subsequent revisions have used the International Normalized Ratio (INR) in addition to prothrombin time.

Epidemiologic work shows that the CTP score may predict life expectancy in patients with advanced cirrhosis. A CTP score of 10 or greater is associated with a 50% chance of death within 1 year. (See Table 4, below.)

Table 4. Child-Turcotte-Pugh Scoring System for Cirrhosis



View Table

See Table

Since 2002, liver transplant programs in the United States have used the Model for End-Stage Liver Disease (MELD) scoring system to assess the relative severity of patients' liver disease. Patients may receive a MELD score of 6-40 points (see the MELD Score calculator). The 3-month mortality statistics are associated with the following MELD scores[48] :

Pharmacologic Treatment

Specific medical therapies may be applied to many liver diseases in an effort to diminish symptoms and to prevent or forestall the development of cirrhosis. Examples include prednisone and azathioprine for autoimmune hepatitis, interferon and other antiviral agents for hepatitis B and C,[49] phlebotomy for hemochromatosis, ursodeoxycholic acid for primary biliary cirrhosis, and trientine and zinc for Wilson disease.

These therapies become progressively less effective if chronic liver disease evolves into cirrhosis. Once cirrhosis develops, treatment is aimed at the management of complications as they arise. Certainly variceal bleeding, ascites, and hepatic encephalopathy are among the most serious complications experienced by patients with cirrhosis. However, attention also must be paid to patients' chronic constitutional complaints.

According to an analysis of data from the TURQUOISE-II study, presented in October 2014 at the Annual Scientific Meeting of the American College of Gastroenterology (ACG), treatment with the combination of the protease inhibitor ABT-450 boosted with ritonavir, the NS5A inhibitor ombitasvir, and the non-nucleoside polymerase inhibitor dasabuvir plus ribavirin (3D + RBV) improved measures of liver function at 12 weeks in hepatitis C patients with cirrhosis.[50]

Highly significant improvements from baseline were seen at 12 weeks for the liver enzymes alanine aminotransferase, aspartate aminotransferase, and gamma-glutamyl transferase.[50]  Among patients with elevated transaminase levels at baseline, levels normalized after 12 weeks in 70-90% of cases. Highly significant improvements were also observed in conjugated bilirubin and albumin levels and in prothrombin time at 12 weeks.

Zinc deficiency

Zinc deficiency commonly is observed in patients with cirrhosis. Treatment with zinc sulfate at 220 mg orally twice daily may improve dysgeusia and can stimulate appetite. Furthermore, zinc is effective in the treatment of muscle cramps and is adjunctive therapy for hepatic encephalopathy.

Pruritus

Pruritus is a common complaint in cholestatic liver diseases (eg, primary biliary cirrhosis) and in noncholestatic chronic liver diseases (eg, hepatitis C). Although increased serum bile acid levels once were thought to be the cause of pruritus, endogenous opioids are more likely to be the culprit pruritogen. Mild itching complaints may respond to treatment with antihistamines and topical ammonium lactate.

Cholestyramine is the mainstay of therapy for the pruritus of liver disease. To avoid compromising GI absorption, care should be taken to avoid coadministration of this organic anion binder with any other medication.

Other medications that may provide relief against pruritus in addition to antihistamines (eg, diphenhydramine, hydroxyzine) and ammonium lactate 12% skin cream (Lac-Hydrin), include ursodeoxycholic acid, doxepin, and rifampin. Naltrexone may be effective but is often poorly tolerated. Gabapentin is an unreliable therapy. Patients with severe pruritus may require institution of ultraviolet light therapy or plasmapheresis.

Hypogonadism

Some male patients suffer from hypogonadism. Patients with severe symptoms may undergo therapy with topical testosterone preparations, although their safety and efficacy is not well studied. Similarly, the utility and safety of growth hormone therapy remains unclear.

Osteoporosis

Patients with cirrhosis may develop osteoporosis. Supplementation with calcium and vitamin D is important in patients at high risk for osteoporosis, especially patients with chronic cholestasis or primary biliary cirrhosis and patients receiving corticosteroids for autoimmune hepatitis. The discovery on bone densitometry studies of decreased bone mineralization may prompt the institution of therapy with an aminobisphosphonate (eg, alendronate sodium).

Vaccination

Patients with chronic liver disease should receive vaccination to protect them against hepatitis A. Other protective measures include vaccination against influenza and pneumococci.

Drug hepatotoxicity in the patient with cirrhosis

The institution of any new medical therapy warrants the performance of more frequent liver chemistries; patients with liver disease can ill afford to have drug-induced liver disease superimposed on their condition. Medications associated with drug-induced liver disease include the following:

Statins

Hepatic 3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitors are frequently associated with mild elevations of alanine aminotransferase (ALT) levels. However, severe hepatotoxicity is reported infrequently.[51] The literature suggests that statins can be used safely in most patients with chronic liver disease.[52] Certainly, liver chemistries should be followed frequently after the initiation of therapy.

In a retrospective cohort study (1988-2011) evaluating mortality in cirrhotic patients on statins (n = 81) compared to those not on statins (n = 162), Kumar and colleagues did not find an association between increased mortality and statin use, but they did note statin use may delay decompensation.[53]

In a study of the effects of statins in 58 patients with primary biliary cirrhosis, Rajab and Kaplan concluded that statin use is safe in patients with this condition.[54] Individuals in the study were on statins for a median period of 41 months, with ALT levels measured every 3 months. The authors found that these levels did not increase, being slightly elevated when statin treatment began and normal by the last follow-up analysis. Patients did not complain of muscle pain or weakness, and serum cholesterol levels fell by 30%.

Analgesics

The use of analgesics in patients with cirrhosis can be problematic. Although high-dose acetaminophen is a well-known hepatotoxin, most hepatologists permit the use of acetaminophen in patients with cirrhosis at doses of up to 2000 mg daily.

NSAID use may predispose patients with cirrhosis to develop GI bleeding. Patients with decompensated cirrhosis are at risk for NSAID-induced renal insufficiency, presumably because of prostaglandin inhibition and worsening of renal blood flow. Opiate analgesics are not contraindicated but must be used with caution in patients with preexisting hepatic encephalopathy on account of the drugs' potential to worsen underlying mental function.

Other drugs

Aminoglycoside antibiotics are considered obligate nephrotoxins in patients with cirrhosis and should be avoided. Low-dose estrogens and progesterone appear to be safe in the setting of liver disease.

A review by Lewis and Stine provided recommendations on the safe use of medications in patients with cirrhosis, including the following[55, 56] :

Nutrition and Exercise

Many patients complain of anorexia, which may be compounded by the direct compression of ascites on the GI tract. Care should be taken to ensure that patients receive adequate calories and protein in their diets. Patients frequently benefit from the addition of commonly available liquid and powdered nutritional supplements to the diet. Only rarely are patients not able to tolerate proteins in the form of chicken, fish, vegetables, and nutritional supplements. Institution of a low-protein diet out of concern that hepatic encephalopathy may develop places the patient at risk for profound muscle wasting.

The 2010 practice guidelines for alcoholic liver disease published by the American Association for the Study of Liver Diseases and the American College of Gastroenterology recommend aggressive treatment of protein calorie malnutrition in patients with alcoholic cirrhosis. Multiple feedings per day, including breakfast and a snack at night, are specified.[57]

Regular exercise, including walking and even swimming, should be encouraged in patients with cirrhosis, to prevent these patients from slipping into a vicious cycle of inactivity and muscle wasting. Debilitated patients frequently benefit from a formal exercise program supervised by a physical therapist.

Surgical Risks

Surgery and general anesthesia carry increased risks in the patient with cirrhosis. Anesthesia reduces cardiac output, induces splanchnic vasodilation, and causes a 30-50% reduction in hepatic blood flow. This places the cirrhotic liver at additional risk for decompensation.

Surgery is said to be safe in the setting of mild chronic hepatitis. Its risk in patients with severe chronic hepatitis is unknown. Patients with well-compensated cirrhosis have increased, but acceptable, morbidity and mortality risks. Care should be taken to avoid postoperative infection, fluid overload, unnecessary sedatives and analgesics, and potentially hepatotoxic and nephrotoxic drugs (eg, aminoglycoside antibiotics).

In the prelaparoscopic era, a study of nonshunt abdominal surgeries demonstrated a 10% mortality rate for patients with Child Class A cirrhosis, as opposed to a 30% mortality rate for patients with Child Class B cirrhosis and a 75% mortality rate for patients with Child Class C cirrhosis.[58] Although cholecystectomy was among the riskier surgeries noted, several reports have described the successful performance of laparoscopic cholecystectomy in patients with Child Class A or B cirrhosis.[59]

Studies have used the MELD score as a tool in predicting postoperative outcomes in abdominal surgery (see the MELD Score calculator). In one study, a preoperative MELD score of greater than 14 was a better predictor of postoperative death than Child Class C status.[60]

In a study of patients with cirrhosis who underwent major digestive, orthopedic, or cardiovascular surgery, the preoperative MELD scores and their associated 30-day postoperative mortality rates were as follows[61] :

The benefits and the risks of surgery should be carefully weighed before advising the patient with cirrhosis to undergo surgery.

Liver Transplantation

Liver transplantation has emerged as an important strategy in the management of patients with decompensated cirrhosis. Patients should be referred for consideration of liver transplantation after the first signs of hepatic decompensation.

Advances in surgical technique, organ preservation, and immunosuppression have resulted in dramatic improvements in postoperative survival. In the early 1980s, the percentage of patients surviving 1 year and 5 years after liver transplant were only 70% and 15%, respectively. Now, patients can anticipate a 1-year survival rate of 85-90% and a 5-year survival rate of higher than 70%. Quality of life after liver transplant is good or excellent in most cases.

Contraindications to transplant

Contraindications for liver transplantation include severe cardiovascular or pulmonary disease, active drug or alcohol abuse, malignancy outside the liver, sepsis, or psychosocial problems that might jeopardize patients' abilities to follow their medical regimens after transplant.

According to the 2010 guidelines for alcoholic liver disease from the American Association for the Study of Liver Diseases, patients whose end-stage liver disease is alcohol related should be considered as candidates for transplantation after a medical and psychosocial evaluation that includes formal assessment of the probability of long-term abstinence.[57]

In a retrospective nationwide Danish study (1990-2013) that evaluated the cumulative incidence of heavy drinking in 156 recipients of liver transplants for alcoholic liver disease, Askgaard et al found that predictors of posttransplantation heavy drinking included younger age, being retired, and not having a lifetime diagnosis of alcohol dependence.[62]

The presence of the human immunodeficiency virus (HIV) in the bloodstream also is a contraindication to transplant. However, successful liver transplantations are now being performed in patients with no detectable HIV viral load due to antiretroviral therapy.[63] Additional clinical studies are required before liver transplantation can be offered routinely to such patients.

Organ allocation

Approximately 6500 liver transplants are performed in the United States each year. An increasing number of lives are being saved every year by transplant. However, the number of diagnosed cases of cirrhosis is rising, fueled in part by the hepatitis C epidemic and by the growing number of cases of nonalcoholic fatty liver disease (NAFLD). This has resulted in a dramatic increase in the number of patients listed as candidates for liver transplantation.

Approximately 12-15% of patients listed as candidates die while waiting because of the relatively static number of organ donations. Strategies to improve the current donor organ shortage include programs to increase public awareness of the importance of organ donation, increased use of living donor liver transplantation for pediatric and adult recipients, organ donation after cardiac death, and the use of extended criteria donors (ECDs).

An ECD "deviates in some aspect from the ideal donor." One example of an ECD organ is the hepatitis C-infected liver with minimal fibrosis that is transplanted into a hepatitis C-infected recipient. Such transplants have been performed successfully for a number of years. Other examples of ECDs include donors older than 70 years and donors with relatively minimal fatty livers.

The need for a more efficient and equitable system of organ allocation resulted in dramatic changes in United States organ allocation policy in 2002.[64] Previously, patients who were accepted as liver transplant candidates with 7-9 CTP points (Child Class B) received low priority on the transplant waiting list maintained by the United Network for Organ Sharing (UNOS). Patients with 10 or more CTP points (Child Class C) received a higher priority. Emergent liver transplantation at UNOS status 1 was reserved primarily for noncirrhotic patients suffering from fulminant hepatic failure.

Since 2002, livers from deceased donors (ie, cadaveric organs) have been allocated to cirrhotic patients using the MELD scoring system and the Pediatric End-Stage Liver Disease (PELD) scoring system[48] (see the MELD Score calculator and the PELD Score calculator).

In the MELD scoring system for adults, a patient receives a score based on the following formula:

MELD score = 0.957 x Loge (creatinine mg/dL) + 0.378 x Loge (bilirubin mg/dL) + 1.120 x Loge (INR) + 0.643

As an example, a cirrhotic patient with a creatinine level of 1.9 mg/dL, a bilirubin level of 4.2 mg/dL, and an INR of 1.2 would receive the following score:

MELD score = (0.957 x Loge 1.9) + (0.378 x Loge 4.2) + (1.120 x Loge 1.2) + 0.643 = 2.039

That value is then multiplied by 10 to give the patient a risk score of 20. Patients' MELD scores are recalculated every time they undergo laboratory testing. Patients can be assigned a maximum MELD score of 40 points.

The PELD system uses a somewhat different formula: PELD score = 0.480 x Loge (total bilirubin mg/dL) + 1.857 x Loge (INR) - 0.687 x Loge (albumin g/dL) + 0.436 if the patient is younger than 1 year + 0.667 if the patient has growth failure (< 2 standard deviations). This value is multiplied by 10 to give a final risk score.

Within any region of the country, a donor organ in a particular ABO blood group is allocated to the cirrhotic patient within the same blood group who has the highest MELD or PELD score. Special rules have been developed to address potentially life-threatening liver disease complications, such as hepatocellular carcinoma and hepatopulmonary syndrome. Patients with these conditions, as well as other exceptional cases, can receive a higher MELD or PELD score than that calculated from creatinine, bilirubin, and INR alone.

The timing of the transplant surgery for patients on the transplant waiting list is a key issue. Typically, it is believed that the risks of the transplant may exceed the benefits when the MELD score is less than 15. However, when the MELD score is greater than 15, the benefits of the transplant typically exceed the risks.[65] Needless to say, there can be many exceptions to this so-called rule.

Living donor liver transplantation

The advent of living donor liver transplantation (LDLT) has introduced a new variable into any discussion of the timing of transplantation. LDLT has the potential to make liver transplantation an elective procedure not only for the cirrhotic patient with significant complications but also for the cirrhotic patient with a poor quality of life.

LDLT became a reality for pediatric recipients in 1988 and for adult recipients a decade later. The procedure arose from advances in surgical technique and a worsening shortage of deceased donor organs. In LDLT, up to 60% of a healthy volunteer donor's liver can be surgically resected and transplanted into the abdomen of a recipient. Graft survival in LDLT recipients is on par with that seen in the recipients of deceased donor organs.

However, LDLT has its limitations. The most obvious problem is the low, but real, risk of serious operative complications for the healthy volunteer liver donor. It is estimated that about 0.4% of the more than 3000 healthy liver donors worldwide over the last decade have died as a consequence of their surgery. Thus, transplant programs must maximize donor safety. They must also ensure that the benefits of LDLT to the potential recipient offset the risks to the donor.

Furthermore, not every potential recipient is sufficiently stable to undergo safe and effective LDLT. Indeed, the recipient's risk of posttransplant mortality increases when his or her MELD score is greater than 25. In the author's opinion, LDLT should not be performed in such recipients.

Liver donation after cardiac death

The shortage of donor organs has spurred interest in the use of liver allografts from non–heart beating donors (NHBDs). Typically, an NHBD is an individual who has sustained irreversible neurologic damage but whose clinical condition does not meet formal brain death criteria. Knowing this, a prospective donor's family will give consent for withdrawal of care and for organ donation. The donor is then brought to the operating room, with the anticipation that withdrawal of ventilator support will result in the cessation of the patient's cardiopulmonary function. Once death is declared, organ procurement surgery can proceed.

In contrast to the organ procured from a heart-beating donor (HBD), the allograft obtained from an NHBD may be subject to considerable warm ischemia time before it is perfused with the cold preservative solution.

A review comparing the results of liver transplantation using allografts from 144 NHBDs and 26,856 HBDs over an 8-year period found better outcomes in HBD transplant recipients.[66] One- and 3-year graft survival rates were 70% and 63%, respectively, with organs from NHBDs, as opposed to 80% and 72%, respectively, with organs from HBDs. Higher rates of primary nonfunction and retransplantation were seen in the recipients of allografts from NHBDs.

Other authors have described a higher incidence of hepatic artery stenosis, hepatic abscesses, and bilomas in the recipients of allografts from NHBDs.[67] It is possible that improved results will be seen by limiting donor age, by minimizing donor warm ischemia time, and by not attempting to transplant livers from NHBDs into recipients who are severely ill.

The future of liver transplantation

Exciting new technical advances also may help to improve patients' chances of survival. In the future, expanded use of hepatocyte transplantation may occur. In this therapy, a splenic artery catheter is used to deliver billions of cryopreserved hepatocytes into the spleen of a patient who has end-stage liver disease. The patient then undergoes routine immunosuppression. This strategy has been employed successfully in a small number of patients with cirrhosis and fulminant hepatic failure (FHF) who were not candidates for liver transplant surgery.

Bioartificial livers may see increased application in the care of patients with FHF and, perhaps, cirrhosis. The 2 most studied devices are composed of semipermeable capillary hollow fiber membranes enclosed in a plastic shell. Either human C3A hepatoma cells or pig hepatocytes are attached to the exterior surface of the membranes as blood from the patient is pumped through the device. Intracranial pressure and hepatic encephalopathy improved in some patients with FHF who were assisted with these devices. However, currently available bioartificial livers have not yet fulfilled the goals of biotransforming and removing toxins while supplying the patient with clotting factors and growth factors.

Xenotransplantation may come into use during the next decade. To date, all attempts at xenotransplantation in humans have suffered from severe, early humoral or late cellular rejection and have resulted in patient death. Advances in genetic engineering may lead to the development of swine as an organ donor because its livers are more likely to undergo graft acceptance when transplanted into humans. Once this obstacle is overcome, a determination can be made as to whether a swine liver is an effective substitute for a human liver.

Most importantly, the medical world awaits the development of medical therapies that forestall the development of hepatic fibrosis long before patients develop cirrhosis and its complications.

Patient Monitoring

Patients with cirrhosis should undergo routine follow-up monitoring of their complete blood count, renal and liver chemistries, and prothrombin time. The author's policy is to monitor stable patients 3-4 times per year.

Surveillance of esophageal varices

The author performs routine diagnostic endoscopy to determine whether the patient has asymptomatic esophageal varices. Follow-up endoscopy is performed in 2 years if varices are not present. If varices are present, treatment is initiated with a nonselective beta blocker (eg, propranolol, nadolol), aiming for a 25% reduction in heart rate. Such therapy offers effective primary prophylaxis against new onset of variceal bleeding.[68] Patients with large esophageal varices should undergo prophylactic endoscopic variceal ligation.

Surveillance for hepatocellular carcinoma

The incidence of hepatocellular carcinoma (HCC) has risen in the United States. The practice guidelines of the American Association for the Study of Liver Diseases recommend that patients with cirrhosis undergo surveillance for HCC with ultrasonography every 6 months.[69] The discovery of a liver nodule should prompt the performance of a 4-phase CT scan or an MRI scan (ie, unenhanced, arterial, venous, and delayed phases). Lesions that enhance in the arterial phase and exhibit "washout" in the delayed phases are highly suggestive of HCC.

Many authors contend that the combination of arterial enhancement and washout on CT scanning or MRI offers greater diagnostic power for HCC than does guided liver biopsy.[70, 71] Indeed, guided liver biopsies have a 20-30% false negative rate in making the diagnosis of HCC. Current guidelines support the use of CT scanning and MRI in confirming the presence of HCC. Biopsy is not required in order to define a lesion as HCC.[69] However, CT scanning or ultrasonographically guided liver biopsy may be useful when a nodule’s enhancement characteristics are not typical for HCC.

Patients with a diagnosis of HCC and no evidence of extrahepatic disease, as determined by chest and abdominal CT scans and by bone scan, should be offered curative therapy. Commonly, this therapy entails liver resection surgery for patients with Child Class A cirrhosis and an accelerated course to liver transplantation for patients with Child Class B or C cirrhosis.

Patients who are awaiting liver transplantation are often offered minimally invasive therapies in an effort to keep tumors from spreading. These therapies include percutaneous injection therapy with ethanol, radiofrequency and microwave thermal ablation, chemoembolization, intensity-modulated radiation therapy, and radioembolization.

AASLD Treatment Recommendations

The 2016 American Association for the Study of Liver Diseases (AASLD) practice guidelines include, but are not limited to, the information outlined below.[72]

Cirrhosis

For individuals with compensated cirrhosis and mild portal hypertension, the AASLD provides the following guidance[72] :

For individuals with compensated cirrhosis and CSPH but without gastroesophageal varices, the AASLD recommends the following[72] :

In patients with compensated cirrhosis and gastroesophageal varices, AASLD recommendations include the following[72] :

Variceal bleeding

For patients who present with acute esophageal VH, the AASLD guidelines indicate the following[72] :

For individuals who have recovered from an episode of acute esophageal VH, the AASLD recommends the following[72] :

EASL Recommendations

In 2018, the European Association for the Study of the Liver (EASL) released updated guidelines for the management of decompensated cirrhosis[77]  and hepatocellular carcinoma (HCC),[78]  as outlined below.

Cirrhosis

In patients with decompensated cirrhosis, the etiologic factor, should be removed, particularly alcohol consumption and hepatitis B or C virus infection, as this strategy is associated with decreased risk of decompensation and increased survival.

Strategies based on targeting abnormalities in the gut-liver axis by antibiotic administration (ie, rifaximin), improving the disturbed systemic circulatory function (ie, long-term albumin administration), decreasing the inflammatory state (ie, statins), and reducing portal hypertension (ie, beta blockers) have shown potential benefit to decrease cirrhosis progression in patients with decompensated cirrhosis.

A diagnostic paracentesis is recommended in all patients with new-onset grade 2 or 3 ascites, or in those hospitalized for worsening of ascites or any complication of cirrhosis.

Neutrophil count and culture of ascitic fluid culture (bedside inoculation blood culture bottles with 10 mL fluid each) should be performed to exclude bacterial peritonitis. A neutrophil count above 250 cells/µL is required to diagnose spontaneous bacterial peritonitis (SBP).

Ascitic total protein concentration should be performed to identify patients at higher risk of developing SBP.

The serum ascites albumin gradient (SAAG) should be calculated when the cause of ascites is not immediately evident, and/or when conditions other than cirrhosis are suspected.

Cytology should be performed to differentiate malignancy-related from non-malignant ascites.

Since the development of grade 2 or 3 ascites in patients with cirrhosis is associated with reduced survival, liver transplantation (LT) should be considered as a potential treatment option.

A moderate restriction of sodium intake (80–120 mmol/day, corresponding to 4.6–6.9 g of salt) is recommended in patients with moderate, uncomplicated ascites. This is generally equivalent to a no-added-salt diet with avoidance of pre-prepared meals. Adequate nutritional education of patients on how to manage dietary sodium is also recommended.

Diets with a very low sodium content (< 40 mmol/day) should be avoided, as they favor diuretic-induced complications and can endanger a patient’s nutritional status.

Patients with the first episode of grade 2 (moderate) ascites should receive an anti-mineralocorticoid drug alone, starting at 100 mg/day with stepwise increases every 72 hr (in 100 mg steps) to a maximum of 400 mg/day if there is no response to lower doses.

In patients who do not respond to anti-mineralocorticoids, as defined by a body weight reduction of less than 2 kg/wk, or in patients who develop hyperkalemia, furosemide should be added at an increasing stepwise dose from 40 mg/day to a maximum of 160 mg/day (in 40 mg steps).

Patients with long-standing or recurrent ascites should be treated with a combination of an anti-mineralocorticoid drug and furosemide, the dose of which should be increased sequentially according to the response.

Torasemide can be given in patients exhibiting a weak response to furosemide.

During diuretic therapy, a maximum weight loss of 0.5 kg/day in patients without edema and 1 kg/day in patients with edema is recommended.

Once ascites has largely resolved, the dose of diuretics should be reduced to the lowest effective dose.

In patients presenting with gastrointestinal (GI) hemorrhage, renal impairment, hepatic encephalopathy, hyponatremia, or alterations in serum potassium concentration, these abnormalities should be corrected before starting diuretic therapy. In these patients, cautious initiation of diuretic therapy and frequent clinical and biochemical assessments should be performed. Diuretic therapy is generally not recommended in patients with persistent overt hepatic encephalopathy.

Diuretics should be discontinued if severe hyponatremia (serum sodium concentration < 125 mmol/L), acute kidney injury (AKI), worsening hepatic encephalopathy, or incapacitating muscle cramps develop.

Furosemide should be stopped if severe hypokalemia occurs (< 3 mmol/L). Anti-mineralocorticoids should be stopped if severe hyperkalemia occurs (>6 mmol/L).

Albumin infusion or baclofen administration (10 mg/day, with a weekly increase of 10 mg/day up to 30 mg/day) is recommended in patients with muscle cramps.

Large volume paracentesis (LVP) is the first-line therapy in patients with large ascites (grade 3 ascites), which should be completely removed in a single session. LVP should be followed with plasma volume expansion to prevent post-paracentesis circulatory dysfunction (PPCD).

In patients undergoing LVP greater than 5 L of ascites, plasma volume expansion should be performed by infusing albumin (8 g/L of ascites removed), as it is more effective than other plasma expanders, which are not recommended for this setting

In patients undergoing LVP less than 5 L of ascites, the risk of developing PPCD is low. However, it is generally agreed that these patients should still be treated with albumin because of concerns about use of alternative plasma expanders.

Non-steroidal anti-inflammatory drugs should not be used in patients with ascites because of the high risk of developing further sodium retention, hyponatremia, and AKI.

Repeated LVP plus albumin (8 g/L of ascites removed) is recommended as first-line treatment for refractory ascites.

Diuretics should be discontinued in patients with refractory ascites who do not excrete >30 mmol/day of sodium under diuretic treatment.

Antibiotic prophylaxis is recommended in cirrhotic patients with acute GI bleeding because it reduces the incidence of infections and improves control of bleeding and survival. Treatment should be initiated on presentation of bleeding and continued for up to 7 days. Ceftriaxone (1 g/24 hr) is the first choice in patients with decompensated cirrhosis, those already on quinolone prophylaxis, and in hospital settings with high prevalence of quinolone-resistant bacterial infections. Oral quinolones (norfloxacin 400 mg bid) should be used in the remaining patients.

Hepatocellular carcinoma

Vaccination against hepatitis B reduces the risk of HCC and is recommended for all newborns and high-risk groups.

In patients with chronic hepatitis, antiviral therapies leading to maintained hepatitis B virus (HBV) suppression in chronic hepatitis B and sustained viral response in hepatitis C are recommended, since they have been shown to prevent progression to cirrhosis and HCC development.

Once cirrhosis is established, antiviral therapy is beneficial in preventing cirrhosis progression and decompensation. Furthermore, successful antiviral therapy reduces but does not eliminate the risk of HCC development. Antiviral therapies should follow the EASL guidelines for management of chronic hepatitis B and C infection.

Coffee consumption has been shown to decrease the risk of HCC in patients with chronic liver disease. In these patients, coffee consumption should be encouraged.

Diagnosis of HCC in cirrhotic patients should be based on non-invasive criteria and/or pathology.

In noncirrhotic patients, diagnosis of HCC should be confirmed by pathology.

Noninvasive criteria can only be applied to cirrhotic patients for nodule(s) ≥1 cm, in light of the high pre-test probability and are based on imaging techniques obtained by multiphasic computed tomography (CT), dynamic contrast-enhanced magnetic resonance imaging (MRI), or contrast-enhanced ultrasound (CEUS). Diagnosis is based on the identification of the typical hallmarks of HCC, which differ according to imaging techniques or contrast agents (arterial phase hyperenhancement (APHE) with washout in the portal venous or delayed phases on CT and MRI using extracellular contrast agents or gadobenate dimeglumine, APHE with washout in the portal venous phase on MRI using gadoxetic acid, APHE with late-onset (>60 s) washout of mild intensity on CEUS).

Because of their higher sensitivity and the analysis of the whole liver, CT scanning or MRI should be used first.

Fluorodeoxyglucose (FDG)-positron emission tomography (PET) scan is not recommended for early diagnosis of HCC because of the high rate of false-negative cases.

In patients at high risk of developing HCC, nodule(s) less than 1 cm in diameter detected by ultrasound should be followed at ≤4-month intervals in the first year. If there is no increase in the size or number of nodules, surveillance could be returned to the usual 6-month interval thereafter.

In cirrhotic patients, diagnosis of HCC for nodules of ≥1 cm in diameter can be achieved with non-invasive criteria and/or biopsy-proven pathologic confirmation.

Repeated bioptic sampling is recommended in cases of inconclusive histologic or discordant findings, or in cases of growth or change in enhancement pattern identified during follow-up, but with imaging still not diagnostic for HCC.

Staging systems for clinical decision making in HCC should include tumor burden, liver function, and performance status.

Multiphasic contrast-enhanced CT scanning or MRI is recommended for assessment of response after resection, loco-regional, or systemic therapies.

Perioperative mortality of liver resection (LR) in cirrhotic patients should be less than 3%.

LR is recommended for single HCC of any size and in particular for tumors >2 cm, when hepatic function is preserved, and when sufficient remnant liver volume is maintained.

Tumor vascular invasion and extrahepatic metastases are an absolute contraindication for liver transplantation in HCC.

Thermal ablation with radiofrequency is the standard of care for patients with BCLC (Barcelona Clinic Liver Cancer) 0 and A tumors not suitable for surgery. Thermal ablation in single tumors 2 to 3 cm in size is an alternative to surgical resection based on technical factors (location of the tumor) and hepatic and extrahepatic patient conditions.

In patients with very early stage HCC (BCLC-0), radiofrequency ablation in favorable locations can be adopted as first-line therapy even in surgical patients.

Ethanol injection is an option in some cases where thermal ablation is not technically feasible, especially in tumors < 2 cm. 

Sorafenib is the standard first-line systemic therapy for HCC. It is indicated for patients with well-preserved liver function (Child-Pugh A) and with advanced tumors (BCLC–C) or earlier stage tumors progressing upon or unsuitable for loco-regional therapies.

Lenvatinib has been shown to be non-inferior to sorafenib and is also recommended in first-line therapy for HCC given its approval. It is indicated for patients with well-preserved liver function (Child-Pugh A class), with good performance status, and with advanced tumors – BCLC-C without main portal vein invasion or tumors progressing upon or unsuitable for loco-regional therapies.

Regorafenib is recommended as second-line treatment for patients tolerating and progressing on sorafenib and with well-preserved liver function (Child-Pugh A class) and good performance status. Recently, cabozantinib has shown survival benefits versus placebo in this setting.

What is the correlation between cirrhosis and chronic liver disease?How is cirrhosis defined histologically?What is the liver fibrosis?What are the complications of cirrhosis?How might the clinical presentation of cirrhosis vary among patients?What are the CDC risk-based testing guidelines for hepatitis C virus (HCV) infection?What are characteristics of Budd-Chiari syndrome in patients with cirrhosis?What is cirrhosis?What is the range of clinical presentations of cirrhosis?Which findings are suggest of ascites in cirrhosis?How are symptoms of hepatic encephalopathy graded in patients with cirrhosis?What are the physical findings of hepatic encephalopathy in cirrhosis?What are cutaneous signs and symptoms of cirrhosis?How is hepatorenal syndrome diagnosed in cirrhosis?How is portal hypertension diagnosed in cirrhosis?How is hepatic encephalopathy diagnosed in cases of cirrhosis?What is the role of electroencephalography in the evaluation of cirrhosis?What is the role of imaging in the evaluation of cirrhosis?What is the role of paracentesis in the evaluation of cirrhosis?Which treatments may diminish symptoms or prevent cirrhosis?What are possible complications of cirrhosis?When is liver transplantation indicated in the treatment of cirrhosis?What is the leading cause of cirrhosis in the US?What are the causes of cryptogenic cirrhosis?What is the prevalence of cirrhosis in nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH)?What are the most common causes of cirrhosis in the US?What are the less common causes of chronic liver disease and cirrhosis?What are the mortality rates for cirrhosis in the US?What is the global mortality rate for cirrhosis?What is the pathogenesis of hepatic fibrosis?What is the role of stellate cells in the pathogenesis of cirrhosis?What is the role of serum cytokines in the pathogenesis of cirrhosis?What is the role of collagen in the pathogenesis of cirrhosis?What are future drug strategies to prevent hepatic fibrosis and cirrhosis?What causes portal hypertension in cirrhosis?How is portal hypertension manifested in cirrhosis?What causes increased resistance of portal blood flow in cirrhosis?What are the dynamic factors that account cause portal hypertension in cirrhosis?What causes the portal hypertension of cirrhosis?What are the prehepatic causes of portal hypertension of cirrhosis?What are the intrahepatic causes of portal hypertension of cirrhosis?What causes presinusoidal portal hypertension in cirrhosis?What causes postsinusoidal portal hypertension in cirrhosis?What are the posthepatic causes of portal hypertension in cirrhosis?What are the signs and symptoms of Budd-Chiari syndrome?What is the role of abdominal ultrasonography in the evaluation of cirrhosis?What is the significance of portal hemodynamics on Doppler ultrasonography in the evaluation of cirrhosis?What are the AASLD recommendations for noninvasive testing in the diagnosis of clinically significant portal hypertension (CSPH)?What is the role of a transjugular intrahepatic portosystemic shunt (TIPS) in the evaluation of cirrhosis?How is wedged hepatic venous pressure (WHVP) measured in cirrhosis?How is the hepatic venous pressure gradient (HVPG) determined in cirrhosis?How is portal hypertension in cirrhosis defined?What are the AASLD recommendations for noninvasive testing in the diagnosis of gastroesophageal varices?What causes ascites?What is transudative ascites in cirrhosis?What are exudative ascites?What are nonperitoneal causes of ascites?What are chylous ascites?What are peritoneal causes of ascites?How do ascites form in cirrhosis?How does ascites lead to cirrhosis?What is the pathophysiology of ascites in cirrhosis?What is the peripheral arterial vasodilation hypothesis of ascites in cirrhosis?Which physical findings suggests ascites?What is the role of ultrasonography in the evaluation of ascites and cirrhosis?Which factors are associated with the worsening of ascites?What is spontaneous bacterial peritonitis (SBP) in cirrhosis?How is spontaneous bacterial peritonitis (SBP) diagnosed?What are the treatment options for spontaneous bacterial peritonitis (SBP)?What is the frequency of recurrence of spontaneous bacterial peritonitis (SBP) in cirrhosis?What is the role of norfloxacin for in the treatment of cirrhosis?How is rupture of umbilical hernia prevented in cirrhosis?When is surgery indicated for the treatment of umbilical hernias in cirrhosis?What are possible complications of massive ascites in cirrhosis?What is the role of paracentesis in the evaluation of ascites in cirrhosis?What is the role of ascitic fluid measurement in the evaluation of cirrhosis?What does a finding of lymphocyte-predominant ascites suggest in the evaluation of cirrhosis?How can the yield of ascites culture studies be increased in the evaluation of cirrhosis?What are the goals of treatment for ascites in cirrhosis?What are the prognosis of massive ascites in cirrhosis?What is the first line of therapy for ascites?What is the second line of therapy for ascites?What is the role of furosemide in the treatment of ascites and cirrhosis?What is the role of diuretic therapy in the inpatient treatment of ascites and cirrhosis?What is the role of albumin in the treatment of cirrhosis?What are the benefits of albumin infusion in the treatment of cirrhosis?What is the role of V2 receptor antagonists in the treatment of cirrhosis?What is the effectiveness of aggressive diuretic therapy in the treatment of cirrhosis?What is the role of large-volume paracentesis in the treatment of cirrhosis?What is the role of peritoneovenous shunts in the treatment of cirrhosis?What are possible complications of peritoneovenous shunts in the treatment of cirrhosis?When is a portacaval shunt indicated in the treatment of cirrhosis?What is the role of transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of cirrhosis?What are the limitations to the use of transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of cirrhosis?When is liver transplantation considered for the treatment of cirrhosis?What is hepatorenal syndrome in cirrhosis?When are NSAIDs contraindicated in the treatment of cirrhosis?What are the histologic changes of hepatorenal syndrome in patients with cirrhosis?How is hepatorenal syndrome categorized in cirrhosis?How is hepatorenal syndrome diagnosed in cirrhosis?What are the treatment options for hepatorenal syndrome in patients with cirrhosis?What are the signs and symptoms of encephalopathy in patients with cirrhosis?What is the pathogenesis of encephalopathy in cirrhosis?What is the ammonia hypothesis of encephalopathy pathogenesis in cirrhosis?What is the gamma-aminobutyric acid hypothesis of encephalopathy pathogenesis in cirrhosis?What is the grading system for encephalopathy in cirrhosis?What are the clinical findings suggestive of mild and moderate encephalopathy in cirrhosis?What are lab abnormalities characteristic of encephalopathy in cirrhosis?What are common precipitants of hyperammonemia and worsening mental status in hepatic encephalopathy?Which factors may worsen encephalopathy symptoms in cirrhosis?Which conditions should be included in the differential diagnoses of hepatic encephalopathy?What is the initial treatment of encephalopathy in patients with cirrhosis?What is the role of lactulose in the treatment of cirrhosis?What are the treatment options for severe encephalopathy in cirrhosis?What is the effectiveness of lactulose in the treatment of cirrhosis?What is the role of antibiotics in the treatment of encephalopathy in cirrhosis?Which drugs may be used to decrease blood ammonia in cirrhosis?What is the role of low-protein diets in the treatment of cirrhosis?When is protein restriction indicated in the treatment of cirrhosis?Which histologic features are characteristic of cirrhosis progression?What are the signs and symptoms of cirrhosis?How do reproductive hormones affect the clinical presentation of cirrhosis?What are the hematologic manifestations of cirrhosis?What is the role of oral thrombopoietin receptor agonists (TPO-RA) in the treatment of thrombocytopenia among patients with chronic liver disease?What are the pulmonary manifestations of cirrhosis?What is hepatopulmonary syndrome (HPS) in patients with cirrhosis?How is hepatopulmonary syndrome (HPS) diagnosed in cirrhosis?How is portopulmonary hypertension (PPHTN) diagnosed in cirrhosis?What are the increased risks of portopulmonary hypertension (PPHTN) in cirrhosis?What is the frequency of hepatocellular carcinoma (HCC) in cirrhosis?What is the frequency of cholangiocarcinoma in cirrhosis?Which conditions are common comorbidities of cirrhosis?What is Child-Turcotte-Pugh (CTP) system and how is it used to predict life expectancy in patients with cirrhosis?What is the Model for End-Stage Liver Disease (MELD) score and how is it used in patients with cirrhosis?What is the focus of medical treatment to prevent cirrhosis?What is the role of pharmacologic therapies in the treatment of cirrhosis?What is the role of combination therapy for the treatment of cirrhosis?What are the treatment options for zinc deficiency in cirrhosis?What are the treatment options for mild pruritus in cirrhosis?What is the role of cholestyramine in the treatment of cirrhosis?Which medications are used for the treatment of pruritus in cirrhosis?What are the treatment options for hypogonadism in cirrhosis?What are the treatment options for osteoporosis in cirrhosis?Which vaccinations should patients with cirrhosis receive?Which medications should be used with caution in patients with cirrhosis?What is the role of statins in the treatment of cirrhosis?What is the role of analgesics in the treatment of cirrhosis?What is the role of aminoglycoside antibiotics in the treatment of cirrhosis?What are the recommendations for safe use of medications in patients with cirrhosis?What dietary modifications are needed in the treatment of cirrhosis?What activity modifications are needed in the treatment of cirrhosis?What are the risks of surgery and general anesthesia in patients with cirrhosis?When is surgery considered safe in patients with cirrhosis?What are the mortality rates for abdominal surgeries in patients with cirrhosis?What is the efficacy of the Model for End-Stage Liver Disease (MELD) score for predicting postoperative outcomes in cirrhosis?What 30-day postoperative mortality rates are associated with Model for End-Stage Liver Disease (MELD) scores in patients with cirrhosis?What is an extended criteria donor (ECD) for liver transplantation in cirrhosis?What is the role of liver transplantation in cirrhosis?Which factors have contributed to improved postoperative survival following liver transplantation for cirrhosis?What are the contraindications for liver transplantation in cirrhosis?When are patients with alcoholic cirrhosis considered for liver transplantation?When are patients with HIV infection and cirrhosis considered for liver transplantation?What is being done to decrease the donor shortage for liver transplantation in the treatment of cirrhosis?What criteria are used in the organ allocation system for liver transplantation in patients with cirrhosis?How is the Model for End-Stage Liver Disease (MELD) scoring system used to determine organ allocation in cirrhosis?What is the organ allocation formula used by Pediatric End-Stage Liver Disease (PELD)?How do hepatocellular carcinoma and hepatopulmonary syndrome affect organ allocation in patients with cirrhosis?How are the risks and benefits of liver transplantation weighed in cirrhosis?What is the role of living donor liver transplantation (LDLT) in the treatment of cirrhosis?What are the limitations to living donor liver transplantation (LDLT) in the treatment of cirrhosis?What are the risks of living donor liver transplantation (LDLT) for the treatment of cirrhosis?What are non–heart beating donors (NHBDs) and what are the risks in liver transplantation for cirrhosis?How do the outcomes of liver transplantation using allografts from non–heart beating donors (NBHDs) compare with those from heart-beating donors (HBDs) for patients with cirrhosis?What is the future of liver transplantation in the treatment of cirrhosis?What is the role of bioartificial livers in the treatment of cirrhosis?What is the role of xenotransplantation in the treatment of cirrhosis?What would be the ideal future treatment approach to cirrhosis?What is included in routine follow-up monitoring for cirrhosis?How is surveillance of esophageal varices performed in patients with cirrhosis?What are the American Association for the Study of Liver Diseases guidelines for the monitoring of hepatocellular carcinoma (HCC) in patients with cirrhosis?How should hepatocellular carcinoma (HCC) be monitored in patients with cirrhosis?Which therapies are performed for patients with hepatocellular carcinoma (HCC) and cirrhosis awaiting liver transplantation?What are the AASLD treatment guidelines for cirrhosis?What are the AASLD treatment guidelines for variceal bleeding?What are the EASL treatment guidelines for cirrhosis?What are the EASL treatment guidelines for hepatocellular carcinoma?

Author

David C Wolf, MD, FACP, FACG, AGAF, FAASLD, Medical Director of Liver Transplantation, Westchester Medical Center; Professor of Clinical Medicine, Division of Gastroenterology and Hepatobiliary Diseases, Department of Medicine, New York Medical College

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Salix; Gilead; Abbvie; Intercept; Merck.

Chief Editor

BS Anand, MD, Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

Disclosure: Nothing to disclose.

Acknowledgements

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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Causes of Nonperitoneal Ascites Examples
Intrahepatic portal hypertensionCirrhosis



Fulminant hepatic failure



Veno-occlusive disease



Extrahepatic portal hypertensionHepatic vein obstruction (ie, Budd-Chiari syndrome)



Congestive heart failure



HypoalbuminemiaNephrotic syndrome



Protein-losing enteropathy, Malnutrition



Miscellaneous disordersMyxedema



Ovarian tumors



Pancreatic ascites



Biliary ascites



ChylousSecondary to malignancy



Secondary to trauma



Secondary to portal hypertension



Causes of Peritoneal Ascites Examples
Malignant ascitesPrimary peritoneal mesothelioma



Secondary peritoneal carcinomatosis



Granulomatous peritonitisTuberculous peritonitis



Fungal and parasitic infections (eg, Candida,



Histoplasma, Cryptococcus, Schistosoma mansoni, Strongyloides, Entamoeba histolytica)



Sarcoidosis



Foreign bodies (ie, talc, cotton, wood fibers, starch, and barium)



VasculitisSystemic lupus erythematosus



Henoch-Schönlein purpura



Miscellaneous disordersEosinophilic gastroenteritis



Whipple disease



Endometriosis



Routine Optional Special
Cell countGlucose (minimal use)Cytology
AlbuminLactate dehydrogenaseTuberculosis smear and culture
CultureGram stainTriglycerides (to rule out chylous ascites)
Total protein Bilirubin (to rule out biliary leak when clinically suspected)
  Amylase (to rule out pancreatic duct leak when clinically suspected)
Clinical Variable 1 Point 2 Points 3 Points
EncephalopathyNoneGrade 1-2Grade 3-4
AscitesAbsentSlightModerate or large
Bilirubin (mg/dL)< 22-3>3
Bilirubin in PBC* or PSC** (mg/dL)< 44-1010
Albumin (g/dL)>3.52.8-3.5< 2.8
Prothrombin time(seconds prolonged or INR)< 4 s or INR < 1.74-6 s or INR 1.7-2.3>6 s or INR >2.3
*PBC = Primary biliary cirrhosis



**PSC = Primary sclerosing cholangitis



Child Class A = 5-6 points, Child Class B = 7-9 points, Child Class C = 10-15 points