Page 6 - 06- Cirrhosis of the Liver

gastropathy
Ascites/edema: low-sodium (<2 g/day) diet and spironolactone 100 to 400 mg/day with or
without furosemide 40 to 160 mg/day PO; torsemide may substitute for furosemide. If serum
sodium <120 mmol/L, then 1.0 to 1.5 L/day water restriction. If new onset, rule out
spontaneous bacterial peritonitis (SBP). If history of SBP, consider SBP prophylaxis (TMP-
SMX DS daily, norfloxacin 400 mg PO daily).
Encephalopathy: lactulose 15 to 45 mL BID; titrate to induce 2 to 3 loose bowel movements
daily. Combination therapy with rifaximin (550 mg PO BID) is recommended regimen to
prevent recurrent hepatic encephalopathy (4)[B].
Pruritus: ursodiol, cholestyramine, or antihistamines (e.g., hydroxyzine)
Renal insufficiency: Stop NSAIDs, diuretics, and nephrotoxic drugs; normalize electrolytes;
and hospitalize for plasma expansion or dialysis.
Prophylactic antibiotics for invasive procedures, GI bleeding, or history of SBP
Proton pump inhibitor for esophageal varices requiring banding or portal hypertensive
gastropathy
ISSUES FOR REFERRAL
Evaluate for liver transplant at onset of complications (ascites, variceal bleeding,
encephalopathy), jaundice, or liver lesion suggestive of HCC and/or when evidence of hepatic
dysfunction develops (Child-Turcotte-Pugh >7 and Model for End-Stage Liver Disease [MELD]
>10).

SURGERY/OTHER PROCEDURES
Varices: endoscopic ligation, 4 to 6 treatments (if acute bleed, use pre-
esophagogastroduodenoscopy [EGD] octreotide as vasoconstrictor); transjugular intrahepatic
shunt (TIPS) second-line or salvage therapy for acute bleed
Ascites: if tense, therapeutic paracentesis every 2 weeks PRN; caution if pedal edema absent
Fulminant hepatic failure: liver transplantation
HCC: curable if small with radiofrequency ablation or resection and transplant

COMPLEMENTARY & ALTERNATIVE MEDICINE
Zinc sulfate 220 mg BID may improve dysgeusia and appetite; adjunct for hepatic
encephalopathy
Milk thistle may lower transaminases and improve symptoms.
Danshen and huangqi injections may promote improvement; further studies needed

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS
Major GI bleeding, altered mental status, sepsis/infection, rapidly progressing hepatic
decompensation, renal failure

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS
Regular physical conditioning may help with fatigue.

Patient Monitoring
Once stable, monitor liver enzymes, platelets, and PT q6–12mo.