Rapid Clinical Updates: Inpatient Management of Cirrhosis-Slides

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This educational overview addresses inpatient management of cirrhosis, emphasizing key clinical challenges and interventions. Cirrhosis patients commonly present with complications such as ascites, spontaneous bacterial peritonitis (SBP), hepatic encephalopathy, hepatorenal syndrome-acute kidney injury (HRS-AKI), hyponatremia, gastrointestinal (GI) bleeding, and coagulopathy.<br /><br />Initial evaluation for cirrhosis patients presenting with new or worsening ascites includes prompt diagnostic paracentesis to guide management and detect infection. Ascitic fluid analysis includes cell count, culture, protein, albumin levels, and serum-ascites albumin gradient (SAAG) to differentiate causes and identify SBP.<br /><br />Ascites treatment focuses on sodium restriction and diuretic therapy—maximizing spironolactone dosing and cautiously adding furosemide, aiming for no more than 1L fluid removal daily to avoid complications. Large-volume paracentesis requires intravenous albumin to prevent circulatory dysfunction.<br /><br />SBP management involves empiric broad-spectrum antibiotics (e.g., ceftriaxone) and intravenous albumin, with recommended follow-up paracentesis. Hepatic encephalopathy diagnosis is clinical as ammonia levels are unreliable; lactulose remains first-line therapy and rifaximin is used to prevent recurrence.<br /><br />HRS-AKI requires careful volume assessment, discontinuation of diuretics, intravenous albumin, and vasoconstrictors such as norepinephrine. Early renal ultrasound is advised to exclude obstruction. Management is nuanced and must balance risk of fluid overload.<br /><br />For upper GI bleeding from varices, key measures include vasoactive agents (octreotide), timely endoscopy with band ligation, prophylactic antibiotics, conservative transfusion strategies, and subsequent beta-blockers for prevention.<br /><br />Cirrhosis-related coagulopathy should not be routinely corrected with fresh frozen plasma before procedures like paracentesis due to increased portal pressure risk and lack of benefit. Instead, acknowledge rebalanced hemostasis.<br /><br />Perioperative risk assessment uses MELD and Child-Turcotte-Pugh scores to gauge surgical risk, emphasizing need for optimization and multidisciplinary care.<br /><br />Finally, palliative care and advance care planning are critical components across the disease course, alongside management of alcohol use disorder with medications like naltrexone and gabapentin. Early referral for liver transplantation evaluation is essential in appropriate candidates.<br /><br />Overall, this compendium highlights a comprehensive, evidence-based approach to the complex inpatient care of cirrhosis patients.

Keywords

cirrhosis inpatient management

ascites diagnosis and treatment

spontaneous bacterial peritonitis (SBP)

hepatic encephalopathy therapy

hepatorenal syndrome-acute kidney injury (HRS-AKI)

gastrointestinal bleeding varices

cirrhosis-related coagulopathy

perioperative risk assessment MELD Child-Pugh

palliative care in cirrhosis

liver transplantation evaluation