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==Overview==
==Overview==
The change that [[cirrhosis]] causes to the [[liver]] is irreversible, therefore treatment is mostly centered on ameliorating the complications of [[cirrhosis]] such as [[ascites]], [[hepatic encephalopathy]], [[spontaneous bacterial peritonitis]], [[esophageal varices]] and [[hepatorenal syndrome]]. Chronic constitutional [[Symptom|symptoms]] such as [[pruritus|pruritus,]] [[hypogonadism]], [[osteoporosis]] and [[anorexia]] must be treated in [[Patient|patients]]. Maintenance of adequate [[nutrition]] (especially [[protein]] intake) is extremely important in [[cirrhosis]] patients. The underlying cause of [[cirrhosis]] needs to be managed and the treatment varies depending upon the cause of [[cirrhosis]].
The change that [[cirrhosis]] causes to the [[liver]] is irreversible, therefore treatment is mostly centered on ameliorating the complications of [[cirrhosis]] such as [[ascites]], [[hepatic encephalopathy]], [[spontaneous bacterial peritonitis]], [[esophageal varices]], and [[hepatorenal syndrome]]. Chronic constitutional [[Symptom|symptoms]] such as [[pruritus|pruritus,]] [[hypogonadism]], [[osteoporosis]], and [[anorexia]] must be treated in [[Patient|patients]]. Maintenance of adequate [[nutrition]] (especially [[protein]] intake) is extremely important in [[cirrhosis]] patients. The underlying cause of [[cirrhosis]] needs to be managed and the treatment varies depending upon the cause of [[cirrhosis]].


==Medical Therapy==
==Medical Therapy==
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===Pain management in cirrhosis===
===Pain management in cirrhosis===
* [[Cirrhosis|Cirrhotic]] patients can develop pain from [[ascites]] ([[back pain|back]] and [[abdominal pain]]) and pain from [[gynecomastia]] ([[mastalgia]]).
* [[Cirrhosis|Cirrhotic]] patients can develop pain secondary to [[ascites]] ([[back pain|back]] and [[abdominal pain]]) and [[gynecomastia]] ([[mastalgia]]).
* [[Pain]] management in [[cirrhosis]] needs special consideration as many [[analgesic]] and [[Non-steroidal anti-inflammatory drug|anti-inflammatory drugs]] are metabolized by the [[liver]] and dosage regulations are required to prevent further [[liver]] damage and drug toxicity.  
* [[Pain]] management in [[cirrhosis]] needs special consideration as many [[analgesic]] and [[Non-steroidal anti-inflammatory drug|anti-inflammatory drugs]] are metabolized by the [[liver]] and dosage regulations are required to prevent further [[liver]] damage and drug toxicity.  
* Drug dosages should be titrated as per the level of [[Liver|hepatic]] functioning in the [[patient]].
* Drug dosages should be titrated as per the level of [[Liver|hepatic]] functioning in the [[patient]].

Revision as of 19:56, 5 January 2018

Cirrhosis Microchapters

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Epidemiology and Demographics

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2] Sudarshana Datta, MD [3]

Overview

The change that cirrhosis causes to the liver is irreversible, therefore treatment is mostly centered on ameliorating the complications of cirrhosis such as ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, esophageal varices, and hepatorenal syndrome. Chronic constitutional symptoms such as pruritus, hypogonadism, osteoporosis, and anorexia must be treated in patients. Maintenance of adequate nutrition (especially protein intake) is extremely important in cirrhosis patients. The underlying cause of cirrhosis needs to be managed and the treatment varies depending upon the cause of cirrhosis.

Medical Therapy

Pruritus

Hypogonadism

Osteoporosis

Pain management in cirrhosis

Nutrition and exercise

The following points need to be kept in mind regarding nutrition in cirrhosis patients:[6][7][8][9]

Protein

Zinc

Vaccination

Treatment of Underlying Causes

Alcoholic Liver Disease

Alcoholic Liver Disease Medical Therapy
  • Mild to moderate alcoholic hepatitis:
    • Abstinence from alcohol
    • Preferred regimen (1): Aggressive enteral nutrition therapy
  • Severe Alcoholic hepatitis:
    • Preferred regimen (1): Four week course of prednisolone (40 mg/day for 28 days), typically followed by discontinuation or a 2-week taper (if no contraindications for steroid use).
    • Preferred regimen (2):Pentoxifylline therapy (400 mg orally 3 times daily for 4 weeks) is an alternative in severe disease, especially if there are contraindications to steroid therapy

Hepatitis C

Hepatitis C Medical Therapy[13][14][15][16][17][18]

Genotypes HCV 1 and 4

  • Preferred regimen (1): Peginterferon plus ribavirin for 48 weeks. The dose for peginterferon alfa-2a is 180 µg subcutaneously per week together with ribavirin using doses of 1,000 mg for those <75 kg in weight and 1,200 mg for those >75 kg; the dose for peginterferon alfa-2b is 1.5 µg/kg subcutaneously per week together with ribavirin using doses of 800 mg for those weighing <65 kg; 1,000 mg for those weighing >65 kg to 85 kg, 1,200 mg for >85 kg to 105 kg, and 1,400 mg for >105 kg.[19]

Genotypes HCV 2 and 3

Hepatitis B

Hepatitis B Medical Therapy[21][22][23][24][25][26][27][28][29][30][25]
a. ALT greater than 2 times normal or moderate/severe hepatitis on biopsy, and HBV DNA >20,000 IU/mL - treatment may be initiated with any of the 7 approved antiviral medications, but pegIFN-α, tenofovir or entecavir are preferred.
b. ALT persistently normal or minimally elevated (<2 times normal) - should not be initiated on treatment.
c. Children with elevated ALT greater than 2 times normal - treatment may be initiated with IFN-α or lamivudine if ALT levels remain elevated at this level for longer than 6 months.

Autoimmune Hepatitis

Autoimmune Hepatitis Medical Therapy

Primary Biliary Cirrhosis

Primary Biliary Cirrhosis Medical Therapy

Primary Sclerosing Cholangitis

Primary Sclerosing Cholangitis Medical Therapy

Wilson's Disease

Wilson's Disease Medical Therapy

Treatment of Complications

Ascites

Ascites Treatment[35][36][37][38][39][40][41][42][43]
  • Abstinence from alcohol.
  • Salt restriction to less than 2000 mg per day.
  • Fluid restriction unless the serum sodium is less than 120 - 125 mmol/L.
  • Diuretics are the first line drugs for the treatment of ascites.
  • Therapeutic paracentesis in tense ascites. Serial therapeutic paracentesis is a treatment option for refractory ascites.
  • Intravenous albumin infusion may also be considered in refractory cases. [44]
  • TIPS may be used in refractory cases of ascites.[45]

Esophageal Variceal Bleeding

Esophageal Varices Treatment[46][47]

{{#ev:youtube|9Vrmq8XKuXo|500}}

Hepatic Encephalopathy

The treatment of hepatic encephalopathy in cirrhosis is as follows: [82]

Hepatic Encephalopathy Treatment

Prevention of hepatic encephalopathy:

Hepatorenal Syndrome

Hepatorenal Syndrome Treatment[92][72][93][94]

Other treatment modalities:

Spontaneous Bacterial Peritonitis

Spontaneous Bacterial Peritonitis Medical Therapy[96][97][98][99][100][101]

Contraindicated medications

Cirrhosis is considered an absolute contraindication to the use of the following medications:

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