Cirrhosis: Diagnosis and Management
Am Fam Physician. 2019 Dec 15;100(12):759-770.
Patient information: A handout on this topic is available at https://familydoctor.org/condition/cirrhosis-and-portal-hypertension.
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Cirrhosis is the 12th leading cause of death in the United States. Newer research has established that liver fibrosis is a dynamic process and that early cirrhosis may be reversible. Only one in three people with cirrhosis knows they have it. Most patients with cirrhosis remain asymptomatic until the onset of decompensation. When clinical signs, symptoms, or abnormal liver function tests are discovered, further evaluation should be pursued promptly. The most common causes of cirrhosis are viral hepatitis, alcoholic liver disease, and nonalcoholic steatohepatitis. Initial workup includes viral hepatitis serologies, ferritin, transferrin saturation, and abdominal ultrasonography as well as complete blood count, liver function tests, and prothrombin time/international normalized ratio, if not already ordered. Additional testing is based on demographics and risk factors. Common serum and ultrasound-based screening tests to assess fibrosis include the aspartate transaminase to platelet ratio index score, Fibrosis 4 score, FibroTest/FibroSure, nonalcoholic fatty liver fibrosis score, standard ultrasonography, and transient elastography. Generally, noninvasive tests are most useful in identifying patients with no to minimal fibrosis or advanced fibrosis. Chronic liver disease management includes directed counseling, laboratory testing, and ultrasound monitoring. Treatment goals are preventing cirrhosis, decompensation, and death. Varices are monitored with endoscopy and often require prophylaxis with nonselective beta blockers. Ascites treatment includes diuresis, salt restriction, and antibiotic prophylaxis for spontaneous bacterial peritonitis, when indicated. Hepatic encephalopathy is managed with lifestyle and nutritional modifications and, as needed, with lactulose and rifaximin. Hepatocellular carcinoma screening includes ultrasound screening every six months for patients with cirrhosis.
Cirrhosis is a diffuse process of liver damage considered irreversible in its advanced stages. In 2016, more than 40,000 Americans died because of complications related to cirrhosis, making it the 12th leading cause of death in the United States.1 Recent projections suggest that this number is likely to grow.2 An estimated 630,000 Americans have cirrhosis, yet less than one in three knows it.3 Important racial and socioeconomic disparities exist, with prevalence highest among non-Hispanic blacks, Mexican Americans, and those living below the poverty level.3 Cirrhosis and advanced liver disease cost the United States between $12 billion and $23 billion dollars in health care expenses annually.4,5
WHAT'S NEW ON THIS TOPIC
Estimates suggest that nonalcoholic steatohepatitis will become the leading cause of cirrhosis in U.S. patients awaiting liver transplantation sometime between 2025 and 2035.
Liver biopsy remains the reference standard; however, transient elastography has become more widely available and is rapidly replacing biopsy as the preferred method for liver fibrosis staging.
Newer guidelines suggest targeted screening for esophageal varices in patients with clinically significant portal hypertension rather than screening all patients with cirrhosis.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||Comments|
Further evaluation of patients with clinical signs or symptoms of liver disease or abnormal liver function tests should be pursued to determine the potential etiology, regardless of duration of the abnormality.19,20
Expert opinion and consensus guidelines in the absence of clinical trials
Expert opinion and consensus guidelines with low-quality trials
Patients with cirrhosis who have a Model for End-Stage Liver Disease score of 15 or more, or complications of cirrhosis that include ascites, hepatic encephalopathy, or variceal hemorrhage, should be referred to a transplant center.37
Randomized controlled trials demonstrate acceptable survival benefits based on clinical criteria and Model for End-Stage Liver Disease results with some variability
Data from multiple randomized controlled trials demonstrate more benefit than harm regarding patient comfort and reduced hospitalization times
Patients with cirrhosis who have medium, large, or high-risk varices (red wale markings) should be treated with nonselective beta blockers and/or endoscopic band ligation for primary prevention of variceal bleeds.7,9,46,53
Randomized controlled trials and meta-analyses comparing nonselective beta blockers, endoscopic band ligation, and placebo or no therapy, which generally show a reduction in variceal hemorrhage
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