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Liver cirrhosis

Key sources
The following summarized guidelines for the evaluation and management of liver cirrhosis are prepared by our editorial team based on guidelines from the European Association for the Study of the Liver (EASL/ILCA 2023), the American Gastroenterological Association (AGA 2023; 2021; 2017), the United European Gastroenterology (UEG/ESPEN 2023), the European Association for the Study of the Liver (EASL 2022; 2018; 2016; 2010), the International Society on Thrombosis and Haemostasis (ISTH 2022), the American College of Gastroenterology (ACG 2022; 2020), the American Association for the Study of Liver Diseases (AASLD 2021; 2018; 2017; 2014), the British Association for the Study of the Liver (BASL/BSG 2021), the Advancing Liver Therapeutic Approaches Consortium (ALTA 2021), the European Federation of Societies for Ultrasound (EFSU 2020), the Society of Critical Care Medicine (SCCM 2020), the European Society of Medical Oncology (ESMO 2018), the International Liver Transplantation Society (ILTS 2016), the Baveno VI Consensus Workshop (Baveno VI 2015), the British Society of Gastroenterology (BSG 2015), the American Society for Gastrointestinal Endoscopy (ASGE 2014), the European Association for the Study of the Liver (EASL/AASLD 2014), and the American College of Gastroenterology (ACG/AASLD 2007).
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Guidelines

1.Classification and risk stratification

Risk stratification: as per AASLD 2017 guidelines, describe, analyze, and manage cirrhosis in two distinct clinical stages, compensated and decompensated, defined by the presence or absence of overt clinical complications of cirrhosis (ascites, variceal hemorrhage, and hepatic encephalopathy).
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2.Diagnostic investigations

Evaluation of fibrosis, hepatitis C
Obtain vibration-controlled transient elastography with a cutoff of 12.5 kPa,
B
if available, rather than other nonproprietary, noninvasive serum tests, such as AST-to-platelet ratio index, FIB-4, or magnetic resonance elastography,
B
to detect cirrhosis in patients with chronic hepatitis C.
B
Consider obtaining post-treatment vibration-controlled transient elastography with a cutoff of 9.5 kPa to rule out advanced liver fibrosis in non-cirrhotic patients with hepatitis C achieved sustained virologic response after antiviral therapy.
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  • Evaluation of fibrosis (hepatitis B)

  • Evaluation of fibrosis (alcoholic liver disease)

  • Evaluation of fibrosis (NAFLD)

  • Evaluation of fibrosis (compensated cirrhosis)

  • Evaluation of fibrosis (preoperative assessment)

  • Evaluation of ascites

  • Evaluation of portal hypertension

  • Evaluation of gastroesophageal varices

  • Evaluation of variceal hemorrhage

  • Evaluation of portal vein thrombosis

  • Evaluation of DVT

  • Evaluation of SBP

  • Evaluation of hepatopulmonary syndrome

  • Evaluation of portopulmonary hypertension

  • Evaluation of renal impairment

  • Evaluation of hepatic encephalopathy

  • Evaluation of cardiac complications

  • Evaluation of relative adrenal insufficiency

  • Evaluation of sarcopenia and frailty

  • Evaluation of malignancy

3.Medical management

General principles: as per EASL 2018 guidelines, identify and treat etiological factors in patients with decompensated cirrhosis, particularly alcohol consumption and hepatitis B or C virus infection.
B

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  • Management of ascites (diuretic therapy)

  • Management of ascites (IV albumin)

  • Management of ascites (other agents)

  • Management of ascites (therapeutic paracentesis)

  • Management of ascites (TIPS)

  • Management of ascites (implantable peritoneal pump)

  • Management of ascites (refractory ascites)

  • Management of bacterascites

  • Management of hepatic hydrothorax

  • Management of portal hypertensive gastropathy

  • Prevention of gastroesophageal varices

  • Prevention of variceal hemorrhage (primary prevention)

  • Prevention of variceal hemorrhage (gastric varices)

  • Prevention of variceal hemorrhage (secondary prevention)

  • Management of variceal hemorrhage (pharmacotherapy)

  • Management of variceal hemorrhage (blood product transfusion)

  • Management of variceal hemorrhage (endoscopic therapy)

  • Management of variceal hemorrhage (TIPS)

  • Management of variceal hemorrhage (balloon-occluded retrograde transvenous obliteration)

  • Management of variceal hemorrhage (balloon tamponade)

  • Management of variceal hemorrhage (Sengstaken-Blakemore tube)

  • Management of variceal hemorrhage (gastric varices)

  • Management of variceal hemorrhage (surveillance)

  • Management of coagulopathy

  • Management of portal vein thrombosis

  • Prevention of DVT

  • Management of DVT

  • Prevention of SBP (primary prevention)

  • Prevention of SBP (secondary prevention)

  • Management of SBP (antibiotic therapy)

  • Management of SBP (IV albumin)

  • Management of SBP (vasoactive agents)

  • Management of SBP (medications to avoid)

  • Management of other infections

  • Management of hepatopulmonary syndrome

  • Management of portopulmonary hypertension

  • Management of hepatorenal syndrome (pharmacotherapy)

  • Management of hepatorenal syndrome (RRT)

  • Management of hepatorenal syndrome (therapeutic paracentesis)

  • Management of hepatorenal syndrome (TIPS)

  • Management of hepatic encephalopathy

  • Management of hyponatremia

  • Management of anemia

  • Management of relative adrenal insufficiency

  • Prevention of sarcopenia and frailty

  • Management of sarcopenia and frailty

  • Medications to avoid

4.Nonpharmacologic interventions

Physical activity: as per AASLD 2021 guidelines, offer physical activity-based interventions involving the following components to improve muscle contractile function and muscle mass in patients with cirrhosis:
assessment and reassessment of frailty and/or sarcopenia with standardized tools
a combination of aerobic and resistance exercises
tailored recommendations based on assessments.
E

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  • Weight loss

  • Nutrition (general principles)

  • Nutrition (calories)

  • Nutrition (proteins)

  • Nutrition (micronutrients)

  • Salt restriction

  • Fluid restriction

  • Inpatient nutrition

5.Perioperative care

Assessment of procedural bleeding risk: as per EASL 2022 guidelines, recognize that INR and aPTT do not predict post-procedural bleeding in patients with cirrhosis undergoing invasive procedures.
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  • Prevention of procedural bleeding

6.Surgical interventions

Liver transplantation: as per AASLD 2021 guidelines, consider referring patients with grade 2 or 3 ascites for evaluation for liver transplantation.
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  • Elective hernia repair

7.Specific circumstances

Pediatric patients: obtain a comprehensive evaluation of clinical history, physical examination, and diagnostic testing including abdominal ultrasound for the diagnosis of ascites and its cause in pediatric patients.
E
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  • Patients with obesity

  • Patients with acute-on-chronic liver failure (diagnosis)

  • Patients with acute-on-chronic liver failure (management)

8.Follow-up and surveillance

Surveillance for malignancy: as per EASL 2023 guidelines, consider obtaining abdominal ultrasound surveillance at 6-monthly intervals for the detection of intrahepatic cholangiocarcinoma at an early stage in patients with cirrhosis.
C