Inpatient Management of Cirrhosis

Adapted from a powerpoint presentation by Yilin Zhang, MD; Neha Deshpande, MD and Eric Lamotte, MD.
Edits, updates and graphics by Yilin Zhang, MD.


OBJECTIVES:

  • Compensated vs. decompensated cirrhosis
  • Significance of MELD-Na score
  • Evaluation of acute decompensation
  • Management of common complications of cirrhosis

Part 1: Overview of Cirrhosis

Part 2: Complications of Cirrhosis 

Acute decompensation occurs when the there is an ↑ in MELD score or developement of one of the complications of cirrhosis. Click on each tab for additional details on each complication. 


TAKE HOME POINTS:

  • MELD-Na score predicts 3 month mortality and is used for liver transplant allocation.
  • Acute decompensation of cirrhosis occurs when patients have an increase in their MELD-Na score or develop new complications of cirrhosis.
  • The precipitants of many of the complications of cirrhosis overlap and include infection/ SBP, GI bleeding or portal vein thrombosis and initial work-up should include diagnostic paracentesis, evaluation for clinical signs of bleeding and potentially a RUQ US with duplex.
  • Essentially everyone admitted to the hospital with cirrhosis and ascites should receive a diagnostic paracentesis.

REFERENCES:

  1. Ge, PS & Runyon, BA. Treatment of Patients with Cirrhosis. NEJM. 2016;375:767-77
  2. Liou, IW. Management of end-stage liver disease. Med Clin North Am. 2014 Jan;98(1):119-52.
  3. Sharma, BG, et al. A Randomnized, Double-Blind, Controlled Trial Comparing Rifaximin Plus Lactulose with Lactulose Alone in Treatment of Overt Hepatic Encephalopathy. The American Journal of Gastroenterology. 2013; 108: 1458-1463.
  4. Rahimi, RS, et al. Lactulose vs polyethylene glycol 3350 –electrolyte solution for treatment of overt hepatic encephalopathy:  the HELP randomized clinical trial. JAMA Internal Medicine. 2014; 174(11): 1727-33.
  5. Rahimi, RS & Rockey, DC. Novel Ammonia-Lowering Agents for Hepatic Encephalopathy. Clin Liver Dis. 2015; 19(3): 539-49.
  6. Sachar, H, Vaidya, K & Laine, L. Intermittent vs Continuous Proton Pump Inhibitor Therapy for High-Risk Bleeding Ulcers. JAMA Internal Mediicne. 2014; 174(11): 1755-1762.
  7. Villaneuva, C, et al. Transfusion Strategies for Acute Upper Gastrointestinal Bleeding. NEJM. 2013; 368: 11-2