Cirrhosis complication	Screening	Intervention	Medication dosing and other considerations
Abdominal hernia	Clinical	Defer surgery until medically optimized and ascites controlled	High perioperative risk and hernia recurrence in presence of ascites⁴⁹
	Increased risk with ascites	Consult with multidisciplinary team
	Increased risk with ascites	Surgeon with experience in the care of patients with cirrhosis is best⁴⁹
Ascites	Clinical Paracentesis if new-onset moderate to severe ascites or if concern for spontaneous bacterial peritonitis	Moderate (grade 2) and severe (grade 3) ascites: Diuresis with mineralocorticoids for treatment and prophylaxis Salt restriction < 2 g per day 7; no added salt; avoid preprepared meals^49,53 Fluid restriction usually not helpful⁷ Large (grade 3) ascites: Paracentesis: large-volume paracentesis with albumin infusion⁵³	Spironolactone, 100 mg per day Titrate every three days to maximum of 400 mg daily Goal of no more than 1.1 to 2.2 lb (0.5 to 1 kg) daily of weight loss* Add furosemide (Lasix; or torsemide [Demadex]) if not responsive to spironolactone alone or if limiting adverse effects occur (e.g., hyperkalemia^49,53) Decrease to lowest effective dosage
Esophageal varices	EGD at diagnosis of cirrhosis⁹ May defer EGD if compensated, transient elastography with liver stiffness < 20 kPa, and platelets > 150,000 per mm³ (< 5% probability of high-risk varices)⁴⁶ Repeat EGD if decompensation develops; if no varices (every two to three years†); if small varices (every one to two years†); or if medium or large varices or high-risk timing of repeat EGD varies	Medium, large, or high-risk varices (red wale markings): Endoscopic band ligation or nonselective beta blocker for prophylaxis^7,9,46,53 Prophylaxis with nonselective beta blocker should be indefinite	Propranolol, 20 to 40 mg twice daily; maximum: 160 to 320 mg per day‡ Nadolol (Corgard), 20 to 40 mg daily; maximum: 80 to 160 mg per day‡ Carvedilol (Coreg), 6.25 mg daily; maximum: 12.5 mg per day Titrate every two to three days; goal 25% heart rate reduction, keep heart rate > 55 beats per minute^45,46,53 Discontinue if hemodynamic instability: sepsis, spontaneous bacterial peritonitis, acute gastrointestinal bleeding, refractory ascites, systolic blood pressure < 90 mm Hg, sodium concentration < 120 to 130 mEq per L (120 to 130 mmol per L), or acute kidney injury ^7,53
Hepatic encephalopathy	Clinical	Reverse precipitants	Lactulose syrup, 25 mL every one to two hours until two soft bowel movements per day Titrate to two to three soft bowel movements per day⁵⁴ Rifaximin, 550 mg orally twice per day ^7,54
	Exclude other causes	Nutritional support
	Ammonia levels should not be used for diagnosis or monitoring^7,54	Medications First episode: lactulose for treatment and prophylaxis Second episode: add rifaximin (Xifaxan) for prophylaxis
Hepatocellular carcinoma	Right upper quadrant ultrasonography every six months for all patients with cirrhosis and in certain patients with chronic hepatitis B virus infection without cirrhosis^43,55	Treat obesity, nonalcoholic steatohepatitis, nonalcoholic fatty liver disease, diabetes mellitus, and hepatitis B virus infection	Refer to hepatologist for suspicious findings
Leg cramps	Clinical	Manage electrolytes	Baclofen, 10 mg per day, titrate weekly up to 30 mg per day⁵³
Leg cramps	Especially if taking diuretics⁵³	Baclofen (Lioresal) as needed and tolerated⁵³
Malnutrition	Clinical	Multivitamin	Avoid protein restriction, even during hepatic encephalopathy Because of the increased risk of osteoporosis in chronic cholestasis and cirrhosis, performing a bone mineral density scan at the time of liver disease diagnosis or liver transplantation evaluation should be considered⁴⁵
	Especially if new hepatic encephalopathy	Small frequent meals and late-night snack
		Protein intake of 1 to 1.5 g per kg per day, with supplementation as needed^45,54
		Consider bone mineral density scan
Spontaneous bacterial peritonitis⁵³	Clinical Paracentesis if suspicion of disease (new or worsening ascites, gastrointestinal bleeding, hemodynamic instability, fever or signs of systemic inflammation, gastrointestinal symptoms, worsening liver or kidney function, new or worsening hepatic encephalopathy) Diagnosis Ascitic fluid neutrophil count > 250 per mm³	Treatment (empiric, IV antibiotics): Community-acquired bacterial peritonitis: third-generation cephalosporin or piperacillin/tazobactam (Zosyn) Prophylaxis per criteria: Ceftriaxone IV if acute gastrointestinal bleeding and Child-Pugh grade B/C Trimethoprim/sulfamethoxazole or ciprofloxacin oral if acute gastrointestinal bleeding and Child-Pugh grade A [corrected] History of spontaneous bacterial peritonitis, ascitic protein < 1.5 g per dL and advanced liver disease (Child-Pugh score ≥ 9 or bilirubin ≥ 3 mg per dL) or kidney disease (creatinine ≥ 1.2 mg per dL, sodium ≤ 130 mmol per L)^7,9,49,53	Treatment dosing: Cefotaxime, 2 g IV every eight to 12 hours Ceftriaxone, 2 g IV every 24 hours Piperacillin/tazobactam, 3.375 g IV every six hours Prophylactic dosing: Ceftriaxone, 1 g IV per day for seven days Trimethoprim/sulfamethoxazole, one 800-mg/160-mg tablet per day Ciprofloxacin, 500 mg per day Norfloxacin, 400 mg per day (not available in United States) Routine use of antibiotic prophylaxis in ascites without spontaneous bacterial peritonitis or acute gastrointestinal bleeding is not recommended⁷