The Southern Medical Journal (SMJ) is the official, peer-reviewed journal of the Southern Medical Association. It has a multidisciplinary and inter-professional focus that covers a broad range of topics relevant to physicians and other healthcare specialists.

SMJ // Article

Editorial

Outpatient Management of Cirrhosis

Authors: Adeel B. Shibli, MD, Allan Tachauer, MD, Smruti R. Mohanty, MD, MS

Abstract

Cirrhosis is an advanced stage of liver disease caused by a variety of insults to hepatic parenchyma including infections, autoimmune processes, genetic disorders and toxins. It is characterized by extensive fibrosis with nodule formation and interruption of normal hepatic blood flow. The major complications of cirrhosis are ascites, gastroesophageal varices-related bleeding, hepatic encephalopathy, hepatorenal syndrome and hepatocellular carcinoma (HCC). Therefore, ultimate treatment of decompensated cirrhosis is liver transplantation. Hence, cirrhotics with the above complications should be referred to a hepatologist at a liver transplant center for transplant evaluation and possible listing for liver transplant. Some of the complications such as variceal bleeding and refractory ascites require hospitalization and inpatient treatment, but many of the complications can be managed on an outpatient basis. Proper outpatient care decreases the number of hospitalizations leading to decreased morbidity and mortality until the patient receives liver transplant. Cirrhotics without any complications are usually managed by screening for HCC and periodic measurement of liver tests, including coagulation profiles, until the development of complications. Abstinence from alcohol is imperative even if the cirrhosis is not a result of alcohol. Other hepatotoxins and nonsteroidal anti-inflammatory drugs should also be avoided. Acetaminophen up to 2 g/d may safely be used in most cirrhotics for pain control.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Runyon BA, Van Epps DE. Diuresis of cirrhotic ascites increases its opsonic activity and may help prevent spontaneous bacterial peritonitis. Hepatology 1986;6:396–399.
 
2. Dolz C, Raurich JM, Ibanez J, et al. Ascites increases the resting energy expenditure in liver cirrhosis. Gastroenterology 1991;100:738–744.
 
3. Sandhu BS, Gupta R, Sharma J, et al. Norfloxacin and cisapride combination decreases the incidence of spontaneous bacterial peritonitis in cirrhotic ascites. J Gastroenterol Hepatol 2005;20:599–605.
 
4. Sort P, Navasa M, Arroyo V, et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med 1999;341:403–409.
 
5. Smith JL, Graham DY. Variceal hemorrhage: a critical evaluation of survival analysis.Gastroenterology 1982;82:968–973.
 
6. de Dombal FT, Clarke JR, Clamp SE, et al. Prognostic factors in upper G.I. bleeding. Endoscopy.1986;18 (Suppl 2):6–10.
 
7. Bolondi L, Gatta A, Groszmann RJ, et al. Session IV. Baveno II consensus statements: Imaging techniques and hemodynamic measurements in portal hypertension. In de Franchis, R (ed): Portal Hypertension II: Proceedings of the Second Baveno International Workshop on Definitions, Methodology and Therapeutic Strategies. Oxford, Blackwell Science, 1996, p 67.
 
8. Schepke M, Kleber G, Nurnberg D, et al. Ligation versus propranolol for the primary prophylaxis of variceal bleeding in cirrhosis. Hepatology 2004;40:65–72.
 
9. Jutabha R, Jensen DM, Martin P, et al. Randomized study comparing banding and propranolol to prevent initial variceal hemorrhage in cirrhotics with high-risk esophageal varices. Gastroenterology2005;128:870–881.
 
10. Butterworth RF, Giguere JF, Michaud J, et al. Ammonia: key factor in the pathogenesis of hepatic encephalopathy. Neurochem Pathol 1987;6:1–12.
 
11. Fischer JE, Baldessarini RJ. False neurotransmitters and hepatic failure. Lancet 1971;2:75–80.
 
12. Marchesini G, Fabbri A, Bianchi G, et al. Zinc supplementation and amino acid-nitrogen metabolism in patients with advanced cirrhosis. Hepatology 1996;23:1084–1092.
 
13. Gitlin N. Hepatic encephalopathy. In Zakim, D, Boyer TD (eds): Hepatology: A Textbook of Liver Disease, 3rd ed, vol 1. Philadelphia, W.B. Saunders, 1996, pp 605–617.
 
14. Mullen KD, Szauter KM, Kaminsky-Russ K. “Endogenous” benzodiazepine activity in body fluids of patients with hepatic encephalopathy. Lancet 1990;336:81–83.
 
15. Hu HL, Chen RD. Changes in free radicals, trace elements, and neurophysiological function in rats with liver damage induced by D-galactosamine. Biol Trace Elem Res 1992;34:19–25.
 
16. Krieger D, Krieger S, Jansen O, et al. Manganese and chronic hepatic encephalopathy. Lancet1995;346:270–274.
 
17. Williams R, James OF, Warnes TW, et al. Evaluation of the efficacy and safety of rifaximin in the treatment of hepatic encephalopathy: a double-blind, randomized, dose-finding multi-centre study. Eur J Gastroenterol Hepatol 2000;12:203–208.
 
18. Arroyo V, Ginès P, Gerbes AL, et al. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. International Ascites Club. Hepatology 1996;23:164–176.
 
19. Duvoux C, Zanditenas D, Hezode C, et al. Effects of noradrenalin and albumin in patients with type I hepatorenal syndrome: a pilot study. Hepatology 2002;36:374–380.
 
20. Angeli P, Volpin R, Gerunda G, et al. Reversal of type 1 hepatorenal syndrome with the administration of midodrine and octreotide.  | Hepatology 1999;29:1690–1697.
 
21. Uriz J, Ginès P, Cardenas A, et al. Terlipressin plus albumin infusion: an effective and safe therapy of hepatorenal syndrome. J Hepatol 2000;33:43–48.
 
22. Moreau R, Durand F, Poynard T, et al. Terlipressin in patients with cirrhosis and type 1 hepatorenal syndrome: a retrospective multicenter study. Gastroenterology 2002;122:923–930.
 
23. Mulkay JP, Louis H, Donckier V, et al. Long-term terlipressin administration improves renal function in cirrhotic patients with type 1 hepatorenal syndrome: a pilot study. Acta Gastroenterol Belg2001;64:15–19.
 
24. Ortega R, Ginès P, Uriz J, et al. Terlipressin therapy with and without albumin for patients with hepatorenal syndrome: results of a prospective, nonrandomized study. Hepatology 2002;36:941–948.
 
25. Rodriguez-Roisin R, Krowka MJ, Herve P, et al. Pulmonary-Hepatic vascular Disorders (PHD). Eur Respir J 2004;24:861–880.
 
26. Schenk P, Madl C, Rezaie-Majd S, et al. Methylene blue improves the hepatopulmonary syndrome.Ann Intern Med 2000;133:701–706.
 
27. Wu JT. Serum alpha-fetoprotein and its lectin reactivity in liver diseases: a review. Ann Clin Lab Sci1990;20:98–105.