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:

  • Differentiate between compensated and decompensated cirrhosis
  • Recognize the significance of MELD-Na score
  • Evaluate a patient presenting with acute decompensation of cirrhosis
  • Evaluate and manage of common complications of cirrhosis including hepatic encephalopathy, ascites, variceal bleeding, hepatorenal syndrome and spontaneous bacterial peritonitis

Teaching Instructions: This talk is designed as a chalk talk. Click on each figure to find the teaching script for each step of the chalk talk. The latter half of the talk includes an interactive table. Click on each line of the table for additional learning/teaching information.


Part 1: Overview of Cirrhosis

Part 2: Decompensated Cirrhosis 

Complications of Cirrhosis: Interactive Board


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.
  8. Salpeter, SR, et al. Systematic review of noncancer presentations with a median survival of 6 months or less. American Journal of Medicine. 2012, 125(5):512.e1-6.