Cirrhosis

Cirrhosis Overview – Lee Richardson

Background

  • For any patient admitted with cirrhosis, know the etiology of their cirrhosis, whether they are compensated or decompensated, and their admission MELD score.
  • Etiology:
    • Most common causes = Alcohol-associated liver disease, non-alcoholic steatohepatitis (NASH) and HCV (becoming less common with DAA success)
    • Less common causes: HBV, metabolic (hemochromatosis, Wilson’s disease), A1AT deficiency, autoimmune hepatitis, PSC, PBC, veno-occlusive disease, R sided heart disease (congestive hepatopathy), and medication-induced
  • Decompensated Cirrhosis:  Cirrhosis + Ascites, Hepatic Encephalopathy or Gastroesophageal Variceal Hemorrhage (the presence of varices without prior hemorrhage is not decompensation)
    • Average life expectancy of a patient with compensated cirrhosis = 10-13 years
    • Average life expectancy of a patient with decompensated cirrhosis = 2 years

 

 

Evaluation

  • Goal is to establish the diagnosis of cirrhosis, determine the cause of cirrhosis and determine candidacy and necessary evaluation for transplantation.
  • History:
    • Known history of prior liver disease (if so, from what, and when did they learn about it?). Presence/absence of: fatigue, easy bruising, lower extremity edema, weight loss, pruritus, yellowing of the skin or eyes, increasing abdominal girth, prior episodes of disorientation to place, person, or time, sleep disturbances.
    • Extensive social hx including alcohol (start year, quitting year, avg amt/day, prior treatment, DUI) and drug use hx (type and route plus the above elements in EtOH hx), family history of liver disease
  • Physical exam: Splenomegaly, caput medusae, ascites, asterixis/HE, conjunctival icterus, spider angiomata, gynecomastia, palmar erythema, jaundice, testicular atrophy, easy bruising/bleeding, edema/anasarca
  • Labs:
    • Initial Workup: CMP, CBC, U/A, HCV antibody, HBV panel, iron panel (ferritin, transferrin saturation), AFP, Peth
    • Unless requested by the hepatology team, the following tests can be deferred to the OP setting: AMA (PBC), ASMA (AIH), ANA w/ reflex, IgG, A1AT phenotype, ceruloplasmin (wilson’s), generally defer anti-LKM, anti-SLA (type 2 AIH, requires attending approval) to Hep recs
  • Imaging:
    • Abdominal u/s with duplex unless done in past 6 months, or indication for repeating (e.g., concern for PVT w/ new EVH)
    • consider triple phase CTAP (contrasted study that looks at arterial and venous phases) vs MRI abdomen w/contrast if required by hep team (transplant eval)
    • HCC surveillance is further discussed below
  • Liver biopsy: Gold standard for diagnosis not always needed if clinical picture, labs, and imaging consistent with cirrhosis (See Radiology Section for who to consult for biopsy)

 

Management

  • Malnutrition occurs in 20-60% of patients with cirrhosis
    • Nutrition consult if ascites present (unless recently done)
    • High protein (1.2-1.5g/kg) diet
    • 2g Na restriction, reinforce regularly
    • Consider MVI, folate, thiamine, particularly to pts w/ EtOH Use Disorder
    • Fluid restriction only needed for hyponatremia (as noted below)
  • Ensure pts are up to date on required vaccines; these can be administered while inpatient before discharge. Indicated vaccines include HBV/HAV, PPSV23, Prevnar, Flu, COVID 19
  • Consider addiction psych (medical therapy) and SW c/s (behavioral therapy with IOP, AA) for EtOH use disorder

 

Additional Information

Lab abnormalities in cirrhosis:

  • Calculate daily MELD-Na scores in pts being considered for Liver transplant
  • Coagulopathies: thrombocytopenia (from both hypersplenism and increased PLT sequestration and ↓ thrombopoietin production in liver), ↓ coagulation factor production
  • Hyponatremia: Usually hypervolemic hyponatremia in cirrhotic patients; benefit from fluid restriction if hyponatremic
  • Hypoalbuminemia: Albumin transfusion is indicated in certain scenarios (detailed below) for volume expansion, anti-inflammatory and anti-oxidant properties
    • Order 25% albumin and NOT 5% (5% albumin is only used to maintain effective circulating volume following major hepatic resection or hepatic transplant)
  • Indications for albumin administration:
    • SBP (see SBP section)
    • LVP (see Ascites section)
    • Diagnosis/Treatment  of HRS (see HRS section)
    • Hyponatremia (<125 and not responsive to fluid restriction)