Liver Cirrhosis: Complications, Scoring Systems & Step-by-Step Management

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--- # **LIVER CIRRHOSIS — COMPLETE MEDICAL REFERENCE** --- ## **1. Definition** Liver cirrhosis is **irreversible, progressive fibrosis** with distortion of hepatic architecture and formation of **regenerative nodules**, leading to **portal hypertension** and **hepatic insufficiency**. --- ## **2. Pathophysiology** * Chronic liver injury → activation of **hepatic stellate cells** → collagen deposition (Type I & III) → fibrosis. * Fibrosis + nodules → increased intrahepatic resistance → **portal hypertension**. * Reduced synthetic/metabolic function → **hypoalbuminemia, coagulopathy, hyperbilirubinemia**. * Portal hypertension → **varices, ascites, splenomegaly, HRS**. * Shunting → **encephalopathy**, **systemic vasodilation**, **RAAS activation**. --- ## **3. Causes / Etiology** ### **Most common** * Alcoholic liver disease * NAFLD / NASH * Chronic Hepatitis B * Chronic Hepatitis C ### **Others** * Autoimmune hepatitis * Primary Biliary Cholangitis (PBC) * Primary Sclerosing Cholangitis (PSC) * Hemochromatosis * Wilson disease * α1-antitrypsin deficiency * Drug induced (methotrexate, amiodarone) --- ## **4. Full Clinical Features** ### **Compensated** * Often asymptomatic * Fatigue, anorexia * Mild RUQ discomfort ### **Decompensated** * **Jaundice** * **Ascites** * **Variceal bleeding** * **Hepatic encephalopathy** * **Spontaneous bacterial peritonitis (SBP)** * **Hepatorenal syndrome (HRS)** * **Coagulopathy** * **Hepatocellular carcinoma (HCC)** ### **Stigmata** * Spider nevi * Palmar erythema * Gynecomastia * Testicular atrophy * Dupuytren contracture * Caput medusae * Parotid enlargement (alcoholic) --- ## **5. Diagnostic Evaluation** ### **Blood tests** * LFT: ↑bilirubin, ↑AST/ALT (mild), ↑ALP * ↓Albumin * ↑INR * ↑Platelet destruction → thrombocytopenia ### **Scoring labs** * **Child-Pugh**: bilirubin, albumin, INR, ascites, encephalopathy * **MELD-Na**: bilirubin, creatinine, INR, sodium ### **Imaging** * USG: shrunken liver, nodular surface, splenomegaly, ascites * Doppler: portal vein flow, portal hypertension * FibroScan: stiffness >14 kPa suggests cirrhosis * CT/MRI for HCC screening ### **Endoscopy** * Screen for varices ### **Ascitic fluid analysis** * Cell count, albumin (SAAG >1.1 = portal hypertension) --- ## **6. Differential Diagnoses** * Acute liver failure * Congestive hepatopathy * Budd-Chiari syndrome * Non-cirrhotic portal hypertension (schistosomiasis, nodular regenerative hyperplasia) * Severe NAFLD without cirrhosis --- # **7. Scoring Systems** ## **A. Child–Pugh Score** | Parameter | Points (1–3) | | -------------- | -------------------------------- | | Bilirubin | <2 / 2–3 / >3 | | Albumin | >3.5 / 2.8–3.5 / <2.8 | | INR | <1.7 / 1.7–2.3 / >2.3 | | Ascites | None / mild / moderate-severe | | Encephalopathy | None / Grade I–II / Grade III–IV | **Class A (5–6) – Mild**, **B (7–9)**, **C (10–15) – Severe** --- ## **B. MELD-Na Score** Used for transplant priority. MELD = 3.78 ln(bilirubin) + 11.2 ln(INR) + 9.57 ln(creatinine) + 6.43 Add Na adjustment. **MELD >15 → transplant referral** **MELD >20–25 → poor prognosis** --- # **8. Complications With Step-by-Step Management** --- # **A. Ascites** ### **Step-by-Step Management** 1. **Salt restriction <2 g/day** 2. **Diuretics** * **Spironolactone : Furosemide ratio 100 mg : 40 mg daily** 3. **Weight loss target: 0.5 kg/day (no edema), 1 kg/day (with edema)** 4. **Large-volume paracentesis if tense ascites** * Give **Albumin 8 g/L removed** 5. **Refractory ascites** → TIPS or transplant ### **Drugs** #### **Spironolactone** * **MoA:** Aldosterone antagonist * **Dose:** 100–400 mg/day * **PK:** Hepatic metabolism * **AE:** Hyperkalemia, gynecomastia * **Contra:** Renal failure K+ >5.5 * **Interactions:** ACEi/ARBs ↑K+ * **Monitoring:** K+, creatinine * **Counselling:** Avoid high-K foods #### **Furosemide** * **MoA:** Loop diuretic * **Dose:** 40–160 mg/day * **AE:** Hypokalemia, dehydration * **Contra:** Severe electrolyte imbalance * **Interactions:** Aminoglycosides → ototoxicity * **Monitoring:** Electrolytes, BP --- # **B. Spontaneous Bacterial Peritonitis (SBP)** ### **Diagnostic criteria:** PMN ≥250/mm³ ### **Treatment** 1. **Cefotaxime 2 g IV q8h OR Ceftriaxone 2 g/day for 5–7 days** 2. **Albumin** * Day 1: 1.5 g/kg * Day 3: 1 g/kg ### **Secondary Prophylaxis** * **Norfloxacin 400 mg/day** OR **Bactrim DS daily** --- # **C. Hepatic Encephalopathy** ### **Step-by-Step** 1. Identify precipitant (infection, GI bleed, constipation, electrolyte imbalance) 2. **Lactulose** 20–30 mL orally until 2–3 soft stools/day 3. **Rifaximin** 550 mg BID adjunct ### **Drugs** #### **Lactulose** * **MoA:** Acidifies colon, traps ammonia * **AE:** Diarrhea, bloating * **Monitoring:** Stool frequency * **Counselling:** Adjust dose to 2–3 stools/day #### **Rifaximin** * **MoA:** Nonabsorbable antibiotic reducing NH₃-producing bacteria * **AE:** Nausea, C. diff rare * **Interactions:** None major --- # **D. Variceal Bleeding** ### **Acute Management** 1. **Resuscitate, maintain Hb 7–8 g/dL** 2. **Octreotide infusion**: 50 µg bolus → 50 µg/hr for 3–5 days 3. **Prophylactic Antibiotics**: Ceftriaxone 1 g/day 4. **Endoscopic Band Ligation** (EBL) 5. **If failure:** Balloon tamponade → TIPS ### **Secondary prophylaxis** * **Propranolol 20–40 mg BID** + **repeat EBL** ### **Drugs** #### **Propranolol** * **MoA:** ↓ portal pressure by blocking β1/β2 * **AE:** Bradycardia, hypotension, asthma worsening * **Monitoring:** Resting HR target 55–60 #### **Octreotide** * **MoA:** Splanchnic vasoconstriction * **AE:** Hyperglycemia, gallstones --- # **E. Hepatorenal Syndrome (HRS)** ### **Definition:** Renal failure in cirrhosis without structural kidney disease. ### **Treatment** 1. **Albumin 1 g/kg on day 1, then 20–40 g/day** 2. **Vasoconstrictors:** * **Terlipressin 1 mg IV q6h**, titrate * Alternatives: **Midodrine + Octreotide** ### **Transplant is definitive treatment** --- # **F. Hepatocellular Carcinoma (HCC)** ### **Screening** * **Ultrasound + AFP every 6 months** ### **Diagnosis** * Triphasic CT or MRI showing arterial enhancement + washout ### **Management** * Early: Resection, ablation, transplant * Advanced: Sorafenib, Lenvatinib #### **Sorafenib (Drug details)** * **MoA:** Multi-kinase inhibitor (VEGFR, RAF) * **Dose:** 400 mg BID * **AE:** Hand-foot syndrome, diarrhea, HTN --- # **9. General Management of Cirrhosis (Step-by-Step)** ### **Step 1 — Treat underlying cause** * Alcohol abstinence * Antivirals: Tenofovir/Entecavir for HBV; DAAs for HCV * Weight loss for NAFLD * Immunosuppression for autoimmune hepatitis ### **Step 2 — Lifestyle** * Stop alcohol * Nutrition: 1.2–1.5 g/kg protein, small frequent meals, late evening snack * Vaccinations: HAV, HBV, Pneumococcal ### **Step 3 — Screen & prevent complications** * Variceal screening every 2–3 yrs (if no varices) * HCC screening every 6 months ### **Step 4 — Manage portal hypertension** * Nonselective beta blockers * EBL if large varices ### **Step 5 — Transplant evaluation** * **MELD ≥15**, recurrent complications, refractory ascites --- # **10. Patient Counselling Points** * Avoid NSAIDs (risk renal failure & bleeding) * Avoid high-salt diet * Maintain strict alcohol abstinence * Monitor weight daily (ascites control) * Recognize encephalopathy symptoms * Medication adherence (especially lactulose, beta-blockers) * Follow vaccination schedule * Never take herbal or unregulated medicines ---