Major complications of
cirrhosis include
ascites, spontaneous bacterial
peritonitis,
hepatic encephalopathy,
portal hypertension, variceal
bleeding, and
hepatorenal syndrome. Diagnostic studies on ascitic fluid should include a differential leukocyte count, total
protein level, a serum-
ascites albumin gradient, and fluid cultures.
Therapy consists of
sodium restriction,
diuretics, and complete abstention from alcohol. Patients with ascitic fluid polymorphonuclear leukocyte counts of 250 cells per mm3 or greater should receive empiric prophylaxis against spontaneous bacterial
peritonitis with
cefotaxime and
albumin. Patients who survive an episode of spontaneous bacterial
peritonitis should receive long-term prophylaxis with
norfloxacin or
trimethoprim/sulfamethoxazole. Patients with
gastrointestinal hemorrhage and
cirrhosis should receive
norfloxacin or
trimethoprim/sulfamethoxazole twice daily for seven days. Treatment of
hepatic encephalopathy is directed toward improving mental status levels with
lactulose;
protein restriction is no longer recommended. Patients with
cirrhosis and evidence of gastrointestinal
bleeding should undergo upper endoscopy to evaluate for
varices. Endoscopic banding is the standard treatment, but
sclerotherapy with
vasoconstrictors (e.g.,
octreotide) also may be used. Prophylaxis with
propranolol is recommended in patients with
cirrhosis once
varices have been identified. Transjugular intrahepatic
portosystemic shunt has been effective in reducing
portal hypertension and improving symptoms of
hepatorenal syndrome, and can reduce gastrointestinal
bleeding in patients with refractory variceal
hemorrhage. When medical
therapy for treatment of
cirrhosis has failed,
liver transplantation should be considered. Survival rates in transplant recipients have improved as a result of advances in immunosuppression and proper risk stratification using the Model for
End-Stage Liver Disease and Child-Turcotte-Pugh scoring systems.