Cirrhosis Overview

Hepatology Editor: Emily Chan, MD & Emily Poellinger, MD
Reviewed by: Claudio Tombazzi, MD
Section Editor: Sobia Siddiqui

One-liner Example: 65yo M with cirrhosis due to HCV decompensated by ascites and HE (MELD 3.0: 25) who is listed for transplant and followed by Dr. Izzy 

Etiology: MASLD/MASH, ALD (Alcohol-associated Liver Disease), HCV, HBV, Wilson’s, hemochromatosis, A1AT deficiency, autoimmune hepatitis, PSC, PBC, congestive hepatopathy (heart failure/pulm hypertension), Budd-Chiari, toxin, medication-induced 

Major decompensations: ascites and/or hepatic hydrothorax, hepatic encephalopathy (HE), variceal hemorrhage (VH), spontaneous bacterial peritonitis (SBP), Hepatorenal syndrome (HRS).

  • AASLD specifically defines transition from compensated to decompensated cirrhosis by three clinically overt complications of portal hypertension: ascites, HE, or variceal hemorrhage 
    • *Always calculate daily MELD 3.0 scores (predicts 90-day mortality based on sex, albumin, total bilirubin, Cr, INR, Na)

History

  • Symptoms: confusion, sleep disturbances, abdominal swelling, lower extremity edema, scleral icterus/jaundice, pruritus, easy bruising/bleeding (skin, mouth, GI tract), dyspnea 
  • Social history: EtOH and drug use hx including current use, date of last drink, drinks/day, duration, prior rehab, DUIs, drinking despite known liver disease; these factors all impact transplant candidacy 
  • Ascites: diuretic dosing and adherence, Na restriction, frequency/volume of prior paracenteses, last para date, prior SBP, on SBP prophylaxis, prior TIPS. 
  • HE: lactulose/rifaximin adherence, # BMs/day, triggers (infection, GI bleed, constipation, sedatives, hypokalemia, dehydration/recent increase in diuretics) 
  • GI Bleed/varices: history of bleeding varices or just presence of varices, hematemesis, coffee ground emesis, melena, hematochezia (duration, volume, # of bleeding episodes), last EGD (varices, banding) and colonoscopy, compliance with non-selective BBs

Physical Exam

  • Neuro: mental status, asterixis, clonus.
  • Volume: ascites, anasarca, LE edema, pleural effusion.
  • Liver disease stigmata: muscle wasting, gynecomastia, testicular atrophy, palmar erythema, spider angiomas, caput medusae, Terry’s nails
  • Jaundice, scleral icterus, bruising/petechiae, splenomegaly.

Initial Workup

  • CMP, CBC, INR/PTT, UA, HCV Ab/viral load, HBsAg, antiHBc, antiHBs, iron studies, PEth 
  • Unless requested by hepatology, defer to outpatient: AFP, ANA, IgG, A1AT, ceruloplasmin, AMA (PBC), ASMA (AIH), anti-SLA (AIH), anti-LKM (AIH)

Imaging

  • Abdominal US with duplex unless done in past 6 months or indication for repeating sooner (concern for new portal vein thrombosis) note: portal vein thrombus on US should always be verified with contrasted cross sectional imaging (CT or MRI) 
  • For transplant eval, triple-phase HCC protocol CT or MRI abdomen with contrast 

Biopsy: gold standard for cirrhosis diagnosis but usually not needed if history, labs, and imaging are classic. Consider only if diagnosis or etiology is uncertain and will change management.

Common lab abnormalities

  • Hyponatremia: most commonly hypervolemic (dilutional). Advanced cirrhosis → portal hypertension →splanchnic arterial vasodilation → reduced effective arterial blood volume → activation of RAAS + ADH → Na retention and water reabsorption → dilutional hyponatremia. Hypovolemic hyponatremia can occur due to excessive diuretic use.
    • Workup when unclear: Serum osm, Urine osm, UNa (r/o SIADH, beer potomania, etc.) 
  • Coagulopathy (↑ INR): due to decreased hepatic synthesis of clotting factors. High INR ≠ automatically “needs FFP.”
  • Thrombocytopenia: due to splenic sequestration+ low TPO production. 
  • Hypoalbuminemia: ↓ production

Management

Indications for 25% albumin transfusion: 

  • SBP (1.5g/kg on day 1, 1g/kg on day 3), 
  • LVP –defined as 5L or more removed(6-8g/L of ascites) 
  • HRS (albumin challenge: 1g/kg/day with max 100 g/day x 2 days) 
  • HypoNa <120 and refractory to fluid restriction 

Hyponatremia: 

  • Do not correct Na faster than 6-8 mEq/L in 24 hours. 
  • Discontinue anti-hypertensives (including beta blockers) in patients with ascites and hyponatremia. 
  • Fluid restrict 2L at Na <130mmol/L, Hold diuretics if Na <125 mmol/L, albumin per above in those with <120mmol/L
  • Fluid restriction (1-1.5L, less than daily UOP) recommended only in patients with Na <120-125 mmol/L. 
  • Replete K to 4.0 mmol/L. 
  • 25% albumin infusion (1 g/kg split into BID dosing) has been shown to increase serum Na. 
  • Vaptans are generally not used given harm in recent RCTs. 
  • Salt tabs should NOT be used due to worsening hypervolemia. 
  • Consult Nephrology if not improved after 48 hours 

Nutrition:

  • High protein diet (do not restrict even with HE), 2g Na restriction if ascites 
  • Consider MVI, folate, thiamine (particularly in pts with Alcohol use disorder) 
  • Mediterranean diet for MASH 

Surveillance: 

  • Vaccines: HAV/HBV, PCV20/PCV21, Flu, COVID-19, Shingrix and RSV vaccines 
  • HCC screening: Ultrasound + AFP every 6 months. Use AFP cutoff ≥20 ng/mL to prompt diagnostic imaging 
  • Variceal screening/portal HTN: see variceal section; ensure appropriate NSBB/EVL. 
  • Monitor for other decompensations and treat accordingly, monitor MELD and consider transplant evaluation when ≥15 
  • Consider consulting Addiction Psych and Social Work for pts with Alcohol use disorder - can assist with arranging Intensive Outpatient Program (IOP), Recovery programs (AA, Celebrate recovery, etc.) 
  • Refer to hepatology outpatient

Medication Tips

  • Pain: Tylenol max 2g/day, No NSAIDs (risk of bleeding, AKI), limit sedating medications especially with HE. Avoid opiates when at all possible. If opioids required: Low-dose hydromorphone (1 mg PO) or oxycodone (2.5 mg PO) with extended dosing intervals. Prophylactic lactulose to prevent constipation/HE. 
  • Pruritus: Sarna lotion, can spot dose antihistamines. Can discuss with pharmacist/attending about starting sertraline, cholestyramine (interacts with many medications), or rifampin. 
  • Anxiety/insomnia: Hydroxyzine, avoid benzodiazepines. If needed for alcohol withdrawal, use lorazepam (Ativan) instead of chlordiazepoxide (Librium) or diazepam (Valium) due to its shorter half life, no active metabolites (low threshold for discussion with addiction psychiatry).
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