Table 9.12. Treatment of complications of cirrhosis

A. Variceal Hemorrhage

Initial hemostasis

• Pharmacological therapy

Vasopressin (0.1-0.4 U/min) and nitroglycerin (start with 1 mg/kg/min iv). Octreotide [100 ucg bolus, 50 ucg/hr infusion (still unproven when given alone)]

• Endoscopic therapy

Variceal band ligation preferred over endoscopic sclerotherapy. Fundic varices not amenable to endoscopic therapy in the US.

• Mechanical tamponade

Sengstaken-Blakemore tube requires knowledge of potential complications. Prevention of early rebleeding

• Octreotide infusion for 5 days

• Treatment of bacterial translocation: Norfloxacin 400 mg/day. Maintenance therapy

• Pharmacological therapy

Propranolol, to reduce portal pressure by 20%, start with 20 mg bid (requires hepatic vein catheterization) or

Maximal dosage that reduces heart rate to 25% of baseline or not<55 beats/minute. If portal pressure reduction not attained, add isosorbide mononitrate 5 mg bid.

• Endoscopic therapy

Continue variceal band ligation until erradication of varices (achieved with 4-5 sessions in 40-50% of patients). Failure of therapy

• Shunt surgery, especially distal splenorenal shunt

For patients with good liver function (Child 5-7 and no ascites).

• Transjugular intrahepatic portal-systemic shunt (TIPS) Rescue therapy, for patients with poor liver function

B. Hepatic Encephalopathy

1. Correct precipitating event

Cleansing enemas for GI bleeding Volume expansion/electrolyte correction Treatment of infection, (without aminogylcosides !) Antagonism of sedatives (flumazenil, Narcan)

2. Diet

Protein intake should be at least 0.75-1 g/kg (counteract catabolic state).

3. Non-absorbable disaccharides

Lactulose po 20-30 cc q 8-12 hours (via NG in ICU)

4. Zinc sulfate, 300 mg q 12 hours (to increase urea synthesis in liver)

5. Antibiotics on intestinal flora

Neomycin (3-6 g/day) for short periods (to avoid toxicity) Metronidazole, start at 250 mg bid.

6. In stage III-IV encephalopathy, Endotracheal intubation to prevent aspiration

C. Ascites

1. Diet and fluid balance

Bed rest and low sodium diet (2-4 g/d)

Fluid restriction (1L/day) for serum sodium <130 mEq/l

Daily weight, urinary output and fluid balance

2. Diuretics

With no response to a low sodium diet and a low UNa (r/o dietary non-compliance)^ Spironolactone (100-400 mg/d) alone or with furosemide (20-160 mg/day) Restrict weight loss to not > 1kg/d when no peripheral edema Careful with diuretic complications Renal impairment Hepatic encephalopathy

Hyperkalemia with renal failure (Spironolactone)

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