OIA2004 LIVER CIRRHOSIS MANAGEMENT

Definition of Cirrhosis

Chronic liver damage marked by fibrosis and regenerative nodules → impairs blood flow and function.

Key Causes of Cirrhosis

Alcoholism, chronic hepatitis B/C, NAFLD, autoimmune diseases, drug-induced (e.g., isoniazid), metabolic and vascular disorders.

Stages of Chronic Liver Disease

Progresses from compensated to decompensated cirrhosis, leading to complications like ascites, varices, and encephalopathy.

Gold Standard Diagnosis

Percutaneous liver biopsy, supported by labs: ↓ albumin, ↑ PT/INR, AST, ALT, ALP, GGT.

Ascites Definition

Accumulation of fluid in the peritoneal cavity—most common complication.

Pathogenesis of Ascites

Portal hypertension → splanchnic vasodilation → ↓ MAP → RAAS activation → Na⁺/water retention → ascites.

Portal Hypertension

Defined as HVPG > 5 mmHg; key cause of varices and ascites.

Esophageal Varices

Result of collateral vessel formation due to portal hypertension.

Hepatic Encephalopathy (HE)

CNS dysfunction from ammonia and nitrogenous toxins buildup → confusion, coma.

Coagulation Defects

↓ clotting factors + ↓ platelets = risk of bleeding or thrombosis.

Child-Pugh Score

Assesses cirrhosis severity based on bilirubin, albumin, INR, ascites, encephalopathy.

Drug Dosing in Liver Disease

Child-Pugh score guides dose adjustments in liver impairment.

Prevent Disease Progression

Address cause (e.g., alcohol abstinence), prevent/treat complications.

Acute Bleeding Management

Use octreotide + endoscopic variceal ligation (EVL); stabilize hemodynamics.

Portal Hypertension Prophylaxis

Non-selective β-blockers (propranolol, nadolol) or EVL.

Sodium Restriction

Limit to <2 g/day for effective control.

Diuretic Therapy

First-line: Spironolactone + Furosemide (100:40 mg ratio).

Monitor for Diuretic Side Effects

Risk of electrolyte imbalance, renal impairment.

SBP Common Pathogens

E. coli, Klebsiella, Streptococcus pneumoniae.

SBP First-line Treatment

Cefotaxime IV (3rd gen cephalosporin).

SBP Secondary Prophylaxis

Long-term with ciprofloxacin or TMP-SMX.

Primary Prophylaxis

Propranolol or EVL to prevent first bleed.

Acute Bleed Treatment

Octreotide + EVL, plus SBP prophylaxis.

Secondary Prophylaxis

β-blocker + EVL to prevent rebleeding.

First-line Treatment for HE

Lactulose: traps ammonia → acidic stool.

Add-on Antibiotic

Rifaximin: ↓ ammonia-producing bacteria.

Flumazenil in HE

Used short-term if benzodiazepine toxicity suspected.

Common Offenders

Isoniazid, methyldopa, nitrofurantoin.

Avoid NSAIDs in Cirrhosis

e.g., Naproxen can worsen bleeding/ascites.

Protein Restriction in HE

Moderate in severe HE; avoid complete restriction.

Albumin Use

In large-volume paracentesis, SBP to improve oncotic pressure.

SBP Empiric Therapy

Best option: IV cefotaxime, not vancomycin or TMP-SMX.

Medication to Discontinue in Ascites

NSAIDs (e.g., naproxen)—worsen renal perfusion.

Prevent SBP Recurrence

Ciprofloxacin or TMP-SMX long-term.

Prevent Variceal Bleed

Non-selective β-blockers like nadolol or propranolol.

Hepatorenal Syndrome (HRS)

Renal failure without intrinsic kidney disease, linked to portal HTN and vasodilation.

Pulmonary Issues

Cirrhosis may cause hepatopulmonary syndrome (dyspnea, hypoxemia).

Endocrine Dysfunction

Common in men: gynecomastia, decreased libido.

Alcohol Abstinence

Critical in alcoholic cirrhosis; improves survival.

Regular Monitoring

For HCC screening (US + AFP), renal function, electrolytes, mental status.