Day 2 - Decompensated Cirrhosis — The Intern at Work

Etiology of Cirrhosis:

Most common in North America include: Alcoholic, Fatty liver, Viral (Hepatitis B or C)
Autoimmune causes (PBC, PSC), drug-induced, infiltrative causes less common.

Decompensated Cirrhosis:

is defined as manifestations of complications of liver disease including: esophageal varices, hepatic encephalopathy, coagulopathy, hepatorenal syndrome, ascites, HCC
Patients presenting with decompensated cirrhosis should be worked up for etiology of decompensated cirrhosis

Causes of Decompensated Cirrhosis:

Infection (including SBP), Upper GI bleed, non-adherence to medications, alcohol/drug use, portal vein thrombosis, HCC

*If patient has ascites, therapeutic tap should be completed to rule out SBP.

Treatment:

Ascites
- Medical Management: Spironolactone: Furosemide 5/2 ratio of prescribing
- Tap for SBP
  - PMN Cell count > 250 cell/uL is positive for SBP
  - Most SBP is culture negative
  - Abx:
    - Ceftriaxone 1g IV daily, Levofloxacin 400mg PO daily, Ciprofloxacin 500mg PO BID - minimum 5 days
Hepatic Encephalopathy
- Lactulose 30mg PO QID (at minimum) - target 3-4 bowel movements per day
Upper GI Bleed
- See our Basecamp page here!
Coagulopathy
- Rule out other causes of coagulopathy. Vitamin K can be trialled but is often not significant in improving INR.
- Platelet transfusion only recommended if significant bleeding and put <50.
Hepatorenal syndrome
- Albumin 25% in 100mL BID
- There is NO evidence for dialysis in hepatorenal syndrome, but may be in used in patients who are candidates for transplant
HCC screening
- Usually q6months by ultrasound if patient has established cirrhosis

Outpatient Follow-up

Gastroenterology/Hepatology follow-up recommended for further work-up and treatment (if possible) of underlying etiology of cirrhosis. Further, patients require regular screening for the development of esophageal varices and HCC. Some patients will require regular paracenteses.