Chapter 55: Portal Hypertension and Cirrhosis

Update Summary

May 15, 2023

The following sections were updated:

• Key Concepts: one key concept replaced with a new item

• Spontaneous Bacterial Peritonitis: new changes regarding antimicrobial therapy

• Self-Assessment Questions: edits made to questions 2, 6, and 8 and their corresponding answers

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, except those screened and considered to be at low risk, should receive endoscopic evaluation looking for the presence of varices. Patients with medium to large varices, or small varices with risk factors, should receive primary prophylaxis with nonselective β-adrenergic blockade therapy to prevent variceal hemorrhage.

• When nonselective β-adrenergic blocker therapy with propranolol or nadolol is used to prevent rebleeding, therapy should be titrated to achieve a goal heart rate of 55 to 60 beats/min, but systolic blood pressure must also be maintained above 90 mm Hg.

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

• Aldosterone antagonists and loop diuretics are recommended for the management of ascites in patients with cirrrhosis.

• 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.

BEYOND THE BOOK

Watch the short Medscape video “Cirrhosis Overview Clinical Presentation” (https://www.youtube.com/watch?v=XJQn8MXnTWg). This video reviews the basic pathophysiology of cirrhosis and connects it to the most common complications of decompensated cirrhosis. Create a summary table of treatment options for each complication associated with decompensated cirrhosis: portal hypertension (primary prophylaxis against bleeding, acute bleeding, and secondary prophylaxis against bleeding), ascites, spontaneous bacterial peritonitis (SBP) (acute treatment and secondary prophylaxis), and hepatic encephalopathy. Use the below table as a guide.