Overview of Complications in Cirrhosis

Abstract

Background: Cirrhosis is the outcome of chronic liver disease of any etiology due to progressive liver injury and fibrosis. Consequently, cirrhosis leads to portal hypertension and liver dysfunction, progressing to complications like ascites, variceal bleeding, hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, cirrhotic cardiomyopathy, sarcopenia, hepatocellular carcinoma, and coagulation disorders. End-stage liver disease leads to an impaired quality of life, loss of social and economic productivity, and reduced survival.

Methods: This narrative review explains the pathophysiology of complications of cirrhosis, the diagnostic approach and innovative management, with focus on data from India. A comprehensive literature search of the published data was performed in regard with the spectrum, diagnosis, and management of cirrhosis and its complications.

Results: There is a change in the epidemiology of metabolic syndrome, lifestyle diseases, alcohol consumption and the spectrum of etiological diagnosis in patients with cirrhosis. With the advent of universal vaccination and efficacious long-term viral suppression agents for chronic hepatitis B, availability of direct-acting antiviral agents for chronic hepatitis C, and a booming liver transplantation programme across the country, the management of complications is essential. There are several updates in the standard of care in the management of complications of cirrhosis, such as hepatorenal syndrome, hepatocellular carcinoma, and hepatic encephalopathy, and new therapies that address supportive and palliative care in advanced cirrhosis.

Conclusion: Prevention, early diagnosis, appropriate management of complications, timely transplantation are cornerstones in the management protocol of cirrhosis and portal hypertension. India needs improved access to care, outreach of public health programmes for viral hepatitis care, health infrastructure, and disease registries for improved healthcare outcomes. Low-cost initiatives like immunization, alcohol cessation, awareness about liver diseases, viral hepatitis elimination, and patient focused decision-making algorithms are essential to manage liver disease in India.

Keywords: AIH, autoimmune hepatitis; ALP, alkaline phosphatase; AVB, acute variceal bleeding; BMI, body mass index; CLD, chronic liver disease; CSPH, clinically significant portal hypertension; CTP, Child Turcotte Pugh Score; DAAs, direct-acting antiviral agents; GGT, gamma glutamyl transpeptidase; HBV, hepatitis B virus; HCC, hepatocellular carcinoma; HCV, hepatitis C virus; HE, hepatic encephalopathy; HR, hazard ratio; HRQoL, health-related quality of life; HVPG, hepatic vein pressure gradient; MELD, Model for End Stage Liver disease; MetS, metabolic syndrome; NAFLD, non-alcoholic fatty liver disease; NASH, non-alcoholic steatohepatitis; NSBB, Non-selective beta blockers; NVHCP, National Viral Hepatitis Control programme; SAAG, Serum-ascites albumin gradient; SBP, spontaneous bacterial peritonitis; WHO, World Health Organization; cirrhosis, ascites; hepatic encephalopathy; hepatocellular carcinoma; portal hypertension.

Figure 1

Diagnostic approach to ascites in patients with cirrhosis. CT, computed tomography; eGFR, estimated glomerular filtration rate; IHC, immunohistochemistry; LDH, lactate dehydrogenase; PET, positron emission tomography; RBC, red blood cells; SAAG, serum albumin ascitic gradient; TP, total protein; WBC, white blood cells.

Figure 2

Management of acute variceal bleeding in cirrhosis. BRTO, balloon occluded retrograde transvenous obliteration; EUS, endoscopic ultrasound; EVL, endoscopic variceal ligation; GI, gastrointestinal; GOV, gastroesophageal varices; LR, leinorenal shunt; PARTO, plug-assisted retrograde transvenous obliteration; TIPS, transjugular intrahepatic portosystemic shunt.

Figure 3

Update in the management of hepatocellular carcinoma.

Figure 4

Decline in Clinical Status guidelines. Adapted from Centers for Medicare & Medicaid Services. Local Coverage Determination (LCD) for Hospice Determining Terminal Status (L33393) Available from https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33393. Last accessed 23 November 2021.

Figure 5

Decline in Clinical Status guidelines. Adapted from Centers for Medicare & Medicaid Services. Local Coverage Determination (LCD) for Hospice Determining Terminal Status (L33393) Available from https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33393. Last accessed 23 November 2021.

Figure 6

Diagnostic criteria for end-of-life care with life expectancy ≤6 months in patients with cirrhosis.