Cirrhosis medical therapy: Difference between revisions
| Line 49: | Line 49: | ||
==Treatment of Underlying Causes== | ==Treatment of Underlying Causes== | ||
===Alcoholic Liver Disease=== | |||
:[[Alcoholic_liver_disease_medical_therapy|Alcoholic Liver Disease Medical Therapy]] | :[[Alcoholic_liver_disease_medical_therapy|Alcoholic Liver Disease Medical Therapy]] | ||
* Mild to moderate alcoholic hepatitis: | |||
** Abstinence from alcohol. | |||
** Aggressive enteral nutrition therapy. | |||
* Severe Alcoholic hepatitis: | |||
** Four week course of [[prednisolone]] (40 mg/day for 28 days), typically followed by discontinuation or a 2-week taper (if no contraindications for steroid use). | |||
** [[Pentoxifylline]] therapy (400 mg orally 3 times daily for 4 weeks) is an alternative in severe disease, especially if there are contraindications to [[steroid]] therapy | |||
:[[Hepatitis_C/Medical_Therapy|Hepatitis C Medical Therapy]] | :[[Hepatitis_C/Medical_Therapy|Hepatitis C Medical Therapy]] | ||
Revision as of 13:35, 7 September 2012
|
Cirrhosis Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Case studies |
|
Cirrhosis medical therapy On the Web |
|
American Roentgen Ray Society Images of Cirrhosis medical therapy |
|
Risk calculators and risk factors for Cirrhosis medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2]
Overview
Overview
The change that cirrhosis causes to the liver is irreversible, therefore treatment is mostly centered on the ameliorating the
Medical Therapy
Treatment of cirrhosis is directed most of the times towards treatment of complications like ascites, esophageal varices, hepatic encephalopathy, hepatorenal syndrome, spontaneous bacterial peritonitis. But some chronic constitutional symptoms, which include pruritus, hypogonadism, osteoporosis and anorexia should be treated as well.
Alcohol should be avoided by all patients with cirrhosis. Improvement in liver function is noticed in patients with alcohol induced cirrhosis after abstinence from alcohol.
Pruritus
Pruritus is a common symptom in chronic liver disease. Endogenous opioids have been proposed as the culprits for causing pruritus. Mild itching can be treated using antihistamines and ammonium lactate topical solution. Cholestyramine is the drug of choice for treating pruritus of chronic liver disease. Severe itching requires ultraviolet light therapy and/or plasmapheresis.
Other drugs that can be used include: diphenhydramine, hydroxyzine, ursodeoxycholic acid, rifampin and naltrexone (opiate).
Hypogonadism
Males with cirrhosis sometimes complain of loss of libido due to hypogonadism. The possible treatment option for these patients is topical testosterone preparations, but no studies exist to prove the efficacy of such preparations.
Osteoporosis
Cirrhosisis one of the major causes of osteoporosis[1]. Calcium and vitamin D supplementation is suggested for all the patients who are at risk for osteoporosis and also for patients who are on corticosteroids for autoimmune liver disease.
Pain management in Cirrhosis
Cirrhotic patients can develop pain from ascites (back pain and abdominal pain) and gynecomastia (mastalgia). Pain management in cirrhosis has a special consideration as many analgesic and anti-inflammatory drugs are metabolized by the liver and dosage regulations are required to prevent further liver damage and drug toxicity. Drug dosages should be titrated as per the level of hepatic function in the patient. Dosage changes are required in patients with cirrhosis when they have the following:
- Portal hypertension
- Renal failure
- Alcoholic patient on multiple medications.
Non-selective NSAIDs should be avoided in patients with cirrhosis because of the following complications:
- Increased bleeding from varices
- Impaired renal function
- Development of diuretic resistant ascites
As per a study in humans which involved 28 patients with cirrhosis and ascites celecoxib seemed to be a reasonable option for pain management and anti-inflammatory treatment. But further studies are needed to prove the potential advantage of celecoxib over other NSAIDs.
Opioids should be used cautiously in patients with cirrhosis because they are metabolized by the liver through oxidation and glucuronidation and in cirrhosis, because of the reduced liver blood flow, reduced protein binding and reduced hepatic enzyme capacity, these drugs accumulate and the patient is prone to develop opiate toxicity.
Nutrition
Anorexia is a common symptom in cirrhosis patients who have ascites because of the direct compression of the bowel by the ascitic fluid. Adequate calories and proteins should be added to the diet of the patient. Patients should consume a balanced diet and one multivitamin daily. Vitamin D and K supplementation is needed in patients with cholestasis.
Excessive proteins in the diet places the patient at risk for hepatic encephalopathy. Low protein diet causes muscle wasting. Therefore diet should be adequately titrated. Branched-chain amino acids (BCAA) can function as pharmacologic nutrients for patients with decompensated cirrhosis.
Zinc
Zinc deficiency is commonly observed in patients with cirrhosis. Supplementation with 220 mg Zinc twice a day orally may improve dysgeusia and also helps in stimulating appetite. Zinc supplementation can also help resolve muscle cramps. Low dose Zn supplementation could prevent deterioration of clinical status of cirrhosis and prevent excess Cu accumulation in non-alcoholic cirrhotic patients. Zn supplementation produces metabolic effects and trends towards improvements in liver function, hepatic encephalopathy, and nutritional status[2].
Treatment of Underlying Causes
Alcoholic Liver Disease
- Mild to moderate alcoholic hepatitis:
- Abstinence from alcohol.
- Aggressive enteral nutrition therapy.
- Severe Alcoholic hepatitis:
- Four week course of prednisolone (40 mg/day for 28 days), typically followed by discontinuation or a 2-week taper (if no contraindications for steroid use).
- Pentoxifylline therapy (400 mg orally 3 times daily for 4 weeks) is an alternative in severe disease, especially if there are contraindications to steroid therapy
Treatment of Complications
Ascites
- Abstinence from alcohol.
- Salt restriction to less than 2000 mg per day.
- Fluid restriction unless the serum sodium is less than 120 - 125 mmol/L.
- Diuretics are the first line drugs for the treatment of ascites.
- Therapeutic paracentesis in tense ascites. Serial therapeutic paracentesis is a treatment option for refractory ascites.
Esophageal Variceal Bleeding
For portal hypertension, propranolol is a commonly used agent to lower blood pressure over the portal system. In severe complications from portal hypertension, transjugular intrahepatic portosystemic shunting is occasionally indicated to relieve pressure on the portal vein. As this can worsen encephalopathy, it is reserved for those at low risk of encephalopathy, and is generally regarded only as a bridge to liver transplantation or as a palliative measure.
Hepatic Encephalopathy
High-protein food increases the nitrogen balance, and would theoretically increase encephalopathy; in the past, this was therefore eliminated as much as possible from the diet. Recent studies show that this assumption was incorrect, and high-protein foods are even encouraged to maintain adequate nutrition.
Hepatorenal Syndrome
The hepatorenal syndrome is defined as a urine sodium less than 10 mmol/L and a serum creatinine > 1.5 mg/dl (or 24 hourcreatinine clearance less than 40 ml/min) after a trial of volume expansion without diuretics.[3]
Spontaneous Bacterial Peritonitis
Cirrhotic patients with ascites are at risk of spontaneous bacterial peritonitis.
References
- ↑ Giouleme OI, Vyzantiadis TA, Nikolaidis NL; et al. (2006). "Pathogenesis of osteoporosis in liver cirrhosis". Hepatogastroenterology. 53 (72): 938–43. PMID 17153457.
- ↑ Somi MH, Rezaeifar P, Ostad Rahimi A, Moshrefi B (2012). "Effects of Low Dose Zinc Supplementation on Biochemical Markers in Non-alcoholic Cirrhosis: A Randomized Clinical Trial". Arch Iran Med. 15 (8): 472–6. doi:012158/AIM.006 Check
|doi=value (help). PMID 22827782. Unknown parameter|month=ignored (help) - ↑ Ginés P, Arroyo V, Quintero E; et al. (1987). "Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites. Results of a randomized study". Gastroenterology. 93 (2): 234–41. PMID 3297907.