Update in the Treatment of the Complications of Cirrhosis

Abstract

Cirrhosis consists of 2 main stages: compensated and decompensated, the latter defined by the development/presence of ascites, variceal hemorrhage, and hepatic encephalopathy. The survival rate is entirely different, depending on the stage. Treatment with nonselective β-blockers prevents decompensation in patients with clinically significant portal hypertension, changing the previous paradigm based on the presence of varices. In patients with acute variceal hemorrhage at high risk of failure with standard treatment (defined as those with a Child-Pugh score of 10-13 or those with a Child-Pugh score of 8-9 with active bleeding at endoscopy), a pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) improves the mortality rate and has become the standard of care in many centers. In patients with bleeding from gastrofundal varices, retrograde transvenous obliteration (in those with a gastrorenal shunt) and/or variceal cyanoacrylate injection have emerged as alternatives to TIPS. In patients with ascites, emerging evidence suggests that TIPS might be used earlier, before strict criteria for refractory ascites are met. Long-term albumin use is under assessment for improving the prognosis of patients with uncomplicated ascites and confirmatory studies are ongoing. Hepatorenal syndrome is the least common cause of acute kidney injury in cirrhosis, and first-line treatment is the combination of terlipressin and albumin. Hepatic encephalopathy has a profound impact on the quality of life of patients with cirrhosis. Lactulose and rifaximin are first- and second-line treatments for hepatic encephalopathy, respectively. Newer therapies such as L-ornithine L-aspartate and albumin require further assessment.

Keywords: ascites; cirrhosis; hepatic encephalopathy; portal hypertension; variceal hemorrhage.

Figure 1.

The presence of clinically-significant portal hypertension (CSPH, determined noninvasively) establishes the indication for carvedilol with the goal of preventing cirrhosis decompensation. cACLD= compensated advanced chronic liver disease (noninvasive surrogate of compensated cirrhosis); LS = liver stiffness; PLT= platelet count; EVL= endoscopic variceal ligation. *Patients with LS <20 kPa and PLT >150,000/mm3 can circumvent endoscopy because the risk of having high-risk varices is minimal

Figure 2.

RTO procedure (performed with balloon-occlusion or BRTO). A gastro-renal shunt (GRS), which usually connects the splenic vein (SV) and the left renal vein (LRV) creating the gastrofundal varices (GV) nidus in the fundus of the stomach, is a requisite for performing the procedure. The efferent of the GRS is catheterized and occluded with a balloon. Subsequent retrograde injection of a sclerosant obliterates the gastric varices.

Figure 3.

Management algorithm in a patient with cirrhosis and ascites presenting with AKI.