Chapter 54: Portal Hypertension and Cirrhosis

KEY CONCEPTS

• Cirrhosis is a severe, chronic, potentially irreversible disease associated with significant morbidity and mortality. The progression of cirrhosis secondary to alcohol intake, both in those with alcoholic cirrhosis and cirrhosis due to other causes, can be interrupted by abstinence from alcohol. It is therefore imperative for the clinician to educate and support abstinence from alcohol as part of the overall treatment strategy of the underlying liver disease.

• Patients with cirrhosis should receive endoscopic screening for varices, and certain patients with varices should receive primary prophylaxis with nonselective β-adrenergic blockade therapy to prevent variceal hemorrhage.

• When nonselective β-adrenergic blocker therapy is used to prevent re-bleeding, therapy can be titrated to achieve a goal heart rate of 55 to 60 beats/min or the maximal tolerated dose.

• Octreotide is the preferred vasoactive agent for the medical management of variceal bleeding. Endoscopic band ligation is the primary therapeutic tool for the management of acute variceal bleeding.

• The combination of spironolactone and furosemide is the recommended initial diuretic therapy for patients with ascites.

• All patients who have survived an episode of spontaneous bacterial peritonitis (SBP) should receive long-term antibiotic prophylaxis.

• The mainstay of treatment of hepatic encephalopathy (HE) involves therapy to lower blood ammonia concentrations and includes diet modifications, lactulose, and rifaximin alone or in combination with lactulose.

Patient Care Process for Cirrhosis

Collect

• Patient medical history

  • Recent history of anorexia or weight loss

  • Risk factors for hepatitis B and C

  • Personal and family history of autoimmune or hepatitic diseases

• Social history (specifically ethanol use—quantity and duration)

• Current medications including nonprescription medications

• Objective data

  • Blood pressure (BP), heart rate (HR), respiratory rate (RR), height, weight, O₂-saturation

  • Labs including albumin, bilirubin, complete blood count (CBC) with platelets, prothrombin time (PT), international normalized ratio (INR), alkaline phosphatase, aspartate transaminase (AST), alanine transaminase (ALT), gamma-glutamyl transpeptidase (GGT)

Assess

• Presence of jaundice, pruritis, palmar erythema, spider angiomata and hyperpigmentation

• Presence of medications that can cause cirrhosis (see Table 54-1)

• Presence of complications of cirrhosis (ascites, portal hypertension, esophageal varices, hepatic encephalopathy, coagulation disorders)

• Child-Pugh score (see Table 54-2) for need for medication dosage adjustments

• Patient's willingness to stop drinking alcohol

Plan^*

• Identify and treat possible causes of cirrhosis (ie, hepatitis C)

• Remove offending medications that may cause or exacerbate cirrhosis or complications of cirrhosis

• Create a plan to treat acute complications of cirrhosis, if present

  • Ascites: sodium restriction and furosemide + spironolactone (see Table 54-4)

  • Portal Hypertension

    • Primary prevention of esophageal varices: beta-blocker (nadolol, propranolol, or carvedilol) and/or EVL for prevention

    • Treatment of acute variceal bleeding: octreotide + EVL, SBP prophylaxis (eg, ceftriaxone, ciprofloxacin or trimethoprim/sulfamethoxazole DS) × 7 days (see Fig. 54-4 and Table 54-3)

    • Secondary prevention: nadolol or propranolol + EVL

  • Spontaneous bacterial peritonitis

    • Treatment: empiric antibiotic therapy with appropriate antibiotic (ie, cefotaxime) based on ascitic fluid PMN count and/or symptoms (see Table 54-4)

    • Secondary prevention: sulfamethoxazole/trimethoprim DS ...