Cirrhosis (Liver)

  • Medical Author:
    Dennis Lee, MD

    Dr. Lee was born in Shanghai, China, and received his college and medical training in the United States. He is fluent in English and three Chinese dialects. He graduated with chemistry departmental honors from Harvey Mudd College. He was appointed president of AOA society at UCLA School of Medicine. He underwent internal medicine residency and gastroenterology fellowship training at Cedars Sinai Medical Center.

  • Medical Editor: Jay W. Marks, MD
    Jay W. Marks, MD

    Jay W. Marks, MD

    Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.

Quick GuideDigestive Disorders: Common Misconceptions

Digestive Disorders: Common Misconceptions

How is cirrhosis treated? (continued)

Treating the complications of cirrhosis

Edema and ascites. Retention of salt and water can lead to swelling of the ankles and legs (edema) or abdomen (ascites) in patients with cirrhosis. Doctors often advise patients with cirrhosis to restrict dietary salt (sodium) and fluid to decrease edema and ascites. The amount of salt in the diet usually is restricted to 2 grams per day and fluid to 1.2 liters per day. In most patients with cirrhosis, however, salt and fluid restriction is not enough, and diuretics have to be added.

Diuretics are medications that work in the kidneys to promote the elimination of salt and water into the urine. A combination of the diuretics spironolactone (Aldactone) and furosemide (Lasix) can reduce or eliminate the edema and ascites in most patients. During treatment with diuretics, it is important to monitor the function of the kidneys by measuring blood levels of blood urea nitrogen (BUN) and creatinine to determine if too much diuretic is being used. Too much diuretic can lead to kidney dysfunction that is reflected in elevations of the BUN and creatinine levels in the blood.

Sometimes, when the diuretics do not work (in which case the ascites is said to be refractory), a long needle or catheter is used to draw out the ascitic fluid directly from the abdomen, a procedure called abdominal paracentesis. It is common to withdraw large amounts (liters) of fluid from the abdomen when the ascites is causing painful abdominal distension and/or difficulty breathing because it limits the movement of the diaphragms.

Another treatment for refractory ascites is a procedure called transjugular intravenous portosystemic shunting (TIPS, see below).

Bleeding from varices. If large varices develop in the esophagus or upper stomach, patients with cirrhosis are at risk for serious bleeding due to rupture of these varices. Once varices have bled, they tend to rebleed and the probability that a patient will die from each bleeding episode is high (30% to 35%). Therefore, treatment is necessary to prevent the first (initial) bleeding episode as well as rebleeding. Treatments include medications and procedures to decrease the pressure in the portal vein, and procedures to destroy the varices.

  • Propranolol (Inderal), a beta blocker, is effective in lowering pressure in the portal vein and is used to prevent initial bleeding and rebleeding from varices in patients with cirrhosis. Another class of oral medications that lowers portal pressure is the nitrates, for example, isosorbide dinitrate (Isordil). Nitrates often are added to propranolol if propranolol alone does not adequately lower portal pressure or prevent bleeding.
  • Octreotide (Sandostatin) also decreases portal vein pressure and has been used to treat variceal bleeding.
  • During upper endoscopy (EGD) sclerotherapy or band ligation can be performed to obliterate varices and stop active bleeding and prevent rebleeding. Sclerotherapy is less commonly used in clinical practice due to a higher risk of complications as compared to band ligation. Band ligation involves applying rubber bands around the varices to obliterate them. (Band ligation of the varices is analogous to rubber banding of hemorrhoids.)
  • Transjugular intrahepatic portosystemic shunt (TIPS) is a non-surgical, radiologic procedure to decrease the pressure in the portal vein. TIPS is performed by a radiologist who inserts a stent (tube) through a neck vein, down the inferior vena cava and into the hepatic vein within the liver. The stent then is placed so that one end is in the high pressure portal vein and the other end is in the low pressure hepatic vein. This tube shunts blood around the liver and by so doing lowers the pressure in the portal vein and varices and prevents bleeding from the varices. TIPS is particularly useful in patients who fail to respond to beta blockers, variceal banding. (TIPS also is useful in treating patients with ascites that do not respond to salt and fluid restriction and diuretics.) TIPS can be used in patients with cirrhosis to prevent variceal bleeding while the patients are waiting for liver transplantation. The most common side effect of TIPS is hepatic encephalopathy. Another major problem with TIPS is the development of narrowing and occlusion of the stent, causing recurrence of portal hypertension and variceal bleeding and ascites. The estimated frequency of stent occlusion ranges from 30% to 50% in 12 months. Fortunately, there are methods to open occluded stents. Other complications of TIPS include bleeding due to inadvertent puncture of the liver capsule or a bile duct, infection, heart failure, and liver failure.
  • A surgical operation to create a shunt (passage) from the high-pressure portal vein to veins with lower pressure can lower blood flow and pressure in the portal vein and prevent varices from bleeding. One such surgical procedure is called distal splenorenal shunt (DSRS). It is appropriate to consider such a surgical shunt for patients with portal hypertension who have early cirrhosis. (The risks of major shunt surgery in these patients is less than in patients with advanced cirrhosis.) During DSRS, the surgeon detaches the splenic vein from the portal vein and attaches it to the renal vein. Blood is then shunted from the spleen around the liver, lowering the pressure in the portal vein and varices and preventing bleeding from the varices.
Reviewed on 10/11/2016
References
Medically reviewed by John A. Daller, MD; American Board of Surgery with subspecialty certification in surgical critical care

REFERENCE:

UpToDate. Patient information: Cirrhosis (Beyond the Basics).

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