Page 7 - 06- Cirrhosis of the Liver

Patients >55 years with chronic HBV or HCV, elevated INR, or low platelets are at highest
risk for HCC; serial α-fetoprotein and liver ultrasound screening q6–12mo in patients with
cirrhosis
MRI with contrast best follow-up test for HCC if α-fetoprotein elevated and/or liver mass
found on ultrasound
Endoscopy at diagnosis and every 3 years (compensated) and every 1 year (decompensated) to
screen for varices
DIET
Protein (1.0 to 1.5 g/kg body weight), high fiber, daily multivitamin (without iron), sodium
restriction (<2 g/day), combined with fluid restriction, essential if ascites/edema

PATIENT EDUCATION
Educate about when to seek emergency care (e.g., hematemesis, altered mental status).
Drug, alcohol, and smoking cessation (no cannabis)
Update required immunizations; HCV transmission precautions

PROGNOSIS
5 to 20 years of asymptomatic disease from time of initial diagnosis
Model for end-state liver diseases (MELD) score and Child-Turcotte-Pugh (CTP) score
historically used to provide prognostic information. These scores lack contribution of
nutritional assessment. Sarcopenia (muscle wasting) suggested as an important predictor of
mortality in patients with cirrhosis
After onset of complications, death typically within 5 years without transplant
– 5% per year develop HCC.
– 50% of cirrhotics develop ascites over 10 years; 50% 5-year survival after ascites develop.
– Acute variceal bleeding is the most common fatal complication; 30% mortality
– Median survival after complications (ascites, variceal bleeding, encephalopathy) is 1.5
years.
– With transplant, 85% survive 1 year; after transplant, ~5% annual mortality
<25% of eligible patients receive a transplant because of donor organ shortage.

COMPLICATIONS
Ascites, edema, infections, hepatic encephalopathy, GI bleeding, esophageal varices,
gastropathy, colopathy, hepatorenal syndrome, hepatopulmonary syndrome, HCC, fulminant
hepatic failure, complications after transplant (e.g., surgical, rejection, infections)

REFERENCES

1. Singh S, Venkatesh SK, Wang Z, et al. Diagnostic performance of magnetic resonance
elastography in staging liver fibrosis: a systematic review and meta-analysis of individual
participant data. Clin Gastroenterol Hepatol. 2015;13(3):440–451.e6.
2. Hart CL, Morrison DS, Batty GD, et al. Effect of body mass index and alcohol consumption
on liver disease: analysis of data from two prospective cohort studies. BMJ. 2010;340:c1240.
3. Batirel A, Guclu E, Arslan F, et al. Comparable efficacy of tenofovir versus entecavir and
predictors of response in treatment-naïve patients with chronic hepatitis B: a multicenter real-
life study. Int J Infect Dis. 2014;28:153–159.
4. Sharma BC, Sharma P, Lunia MK, et al. A randomized, double-blind, controlled trial