Cirrhosis Complications: Variceal Bleeding, Ascites, and Hepatic Encephalopathy Management

Variceal Hemorrhage: Primary Prophylaxis and Acute Management

Esophageal varices are present in approximately 50% of patients with cirrhosis, with annual bleeding risk of 5-15% for large varices. Primary prophylaxis with non-selective beta-blockers (carvedilol 6.25-12.5 mg daily, or propranolol/nadolol titrated to resting heart rate 55-60 bpm) reduces first variceal hemorrhage by 40-50%. The PREDESCI trial demonstrated that carvedilol also reduces decompensation events in patients with clinically significant portal hypertension (HVPG above 10 mmHg). Endoscopic variceal ligation (EVL) is an alternative for patients intolerant to beta-blockers. For acute variceal hemorrhage, management includes vasoactive therapy (octreotide 50 mcg bolus then 50 mcg/hour infusion for 3-5 days), emergent endoscopy with EVL within 12 hours, prophylactic antibiotics (ceftriaxone 1g IV daily for 7 days), and restrictive transfusion (target hemoglobin 7-8 g/dL).

Ascites: Diuretics, Paracentesis, and TIPS

First-line ascites management includes sodium restriction (less than 2g/day) and diuretic therapy with spironolactone 100 mg and furosemide 40 mg daily, maintaining the 100:40 ratio and titrating to a maximum of 400 mg and 160 mg respectively. Target weight loss is 0.5 kg/day without peripheral edema and 1 kg/day with peripheral edema. Refractory ascites (occurring in 5-10% of patients) is defined as diuretic-resistant or diuretic-intractable and requires serial large-volume paracentesis (LVP) with albumin replacement (6-8 g per liter removed for volumes above 5 liters). TIPS (transjugular intrahepatic portosystemic shunt) improves ascites control and transplant-free survival compared to LVP in selected patients without hepatic encephalopathy or severe hepatic dysfunction (MELD below 18).

Spontaneous Bacterial Peritonitis: Diagnosis and Prophylaxis

SBP affects 10-30% of hospitalized patients with ascites and carries 20-30% in-hospital mortality. Diagnostic paracentesis is mandatory for all cirrhotics admitted to hospital with ascites. SBP is defined as ascitic fluid PMN count of 250 cells/mm3 or above. Treatment: cefotaxime 2g IV every 8 hours for 5 days plus IV albumin (1.5 g/kg at diagnosis, 1 g/kg on day 3, per the Sort trial showing mortality reduction from 29% to 10%). Long-term prophylaxis with norfloxacin 400 mg daily or trimethoprim-sulfamethoxazole is indicated after SBP recovery and for patients with ascitic protein below 1.5 g/dL plus either renal dysfunction or liver failure.