Liver cirrhosis

• After a diagnosis of cirrhosis, offer the patient an upper GI endoscopy to detect oesophageal varices

  Repeat every 3 years for surveillance
• Patients with cirrhosis should have a MELD score calculated every 6 months
• Offer ultrasound and measurement of serum alpha-fetoprotein every 6 months as surveillance for hepatocellular carcinoma for patients with cirrhosis
• Transient elastography is used to diagnose cirrhosis - retest every 2 years

  Liver biopsy can be performed to confirm the diagnosis
• Spironolactone is the first line treatment for ascites from liver cirrhosis. Furosemide can be added.
• Characteristics of decompensated cirrhosis:

  • Coagulopathy - reduced clotting factor synthesis (measure PT)
  • Jaundice - impaired breakdown of bilirubin
  • Encephalopathy - reduced detoxification
  • Ascites - poor albumin synthesis and increased portal pressure
  • GI bleeding - increased portal pressure causing varices
• The Child-Pugh score is used to grade the severity of cirrhosis:

  • Encephalopathy
  • Ascites
  • Bilirubin
  • Albumin
  • INR
• Stages of hepatic encephalopathy:

  0 - Minimal HE. Slight changes in memory and concentration

  I - Mild HE. Mood changes and sleep problems

  II - Moderate HE. Inappropriate behaviours, slurred speech

  III - Severe HE. Disorientation, extreme sleepiness or anxiety

  IV - coma
• Hepatic encephalopathy treatment:

  • First line = lactulose (reduced ammonia absorption) aim for 2-3 bowel movements a day
  • Second line = Long term antibiotic (rifaximin) to reduce the proportion of ammonia- producing colonic bacteria
• Ascites:

  • Aldosterone antagonists: Treatment involves the use of aldosterone antagonists (e.g. spironolactone) that can be combined with loop diuretics (i.e. furosemide).
  • Paracentesis: Patients with tense (grade III) ascites require large volume paracentesis that involves percutaneous drainage of ascites with human albumin solution cover to prevent post-drainage circulatory dysfunction.
• Ascites develops due to a combination of portal hypertension and loss of oncotic pressure (hypoalbuminaemia). Due to widespread vasodilatation and underperfusion of the kidneys, the renin-angiotension-aldosterone systems (RAAS) is active leading to excess water and sodium reabsorption that exacerbates ascites.
• Primary prophylaxis of varices in cirrhosis involves the use of non-selective beta-blockers (propranolol, carvediol) to reduce portal pressure

  They should also be on beta blockers post bleed and be offered a banding surveillance programme
• Surveillance endoscopy to detect varices in patients with decompensated cirrhosis is recommended every 1-3 years or when further decompensation occurs
• Spontaneous bacterial peritonitis:

  • Antibiotics: Follow local guidance, should not be delayed, ascitic tap should be obtained prior.
  • Human albumin solution: Helps to prevent the development of acute kidney injury and hepatorenal syndrome.
  • Prophylaxis: Patients at risk of, or following confirmed, SBP should be managed with long-term prophylactic antibiotics (e.g. rifaximin).
• Albumin prevents rapid re-accumulation of ascetic fluid while simultaneously decreasing the risk of post-paracentesis related circulatory dysfunction - AKI and hepatorenal syndrome
• Current liver transplant criteria for selection if based on the United Kingdom model for end-stage liver disease (UKELD) score - Based on serum creatinine, sodium, bilirubin and INR. Minimum score for listing is 49
• A MELD score is a number that ranges from 6 to 40, based on lab tests. It ranks your degree of sickness, which shows how much you need a liver transplant. The higher the number, the more urgent your case is.

  • Creatinine
  • Bilirubin
  • INR
  • Serum sodium
• NICE recommend using the MELD (Model for End-Stage Liver Disease) score every 6 months in patients with compensated cirrhosis. The formula considers the bilirubin, creatinine, INR and sodium and whether they require dialysis, giving an estimated 3-month mortality as a percentage.
• Monitoring for complications involves:

  • MELD score every 6 months
  • Ultrasound and alpha-fetoprotein every 6 months for hepatocellular carcinoma
  • Endoscopy every 3 years for oesophageal varices