Update in the Treatment of the Complications of Cirrhosis

Cirrhosis consists of 2 main stages: compensated and decompensated, the latter defined by the development/ presence of ascites, variceal hemorrhage, and hepatic en-cephalopathy. The survival rate is entirely different, depending on the stage. Treatment with nonselective b- blockers prevents decompensation in patients with clini-cally significant portal hypertension, changing the previous paradigm based on the presence of varices. In patients with acute variceal hemorrhage at high risk of failure with standard treatment (defined as those with a Child-Pugh score of 10-13 or those with a Child-Pugh score of 8-9 with active bleeding at endoscopy), a pre-emptive trans -jugular intrahepatic portosystemic shunt (TIPS) improves the mortality rate and has become the standard of care in many centers. In patients with bleeding from gastrofundal varices, retrograde transvenous obliteration (in those with a gastrorenal shunt) and/or variceal cyanoacrylate injec-tion have emerged as alternatives to TIPS. In patients with ascites, emerging evidence suggests that TIPS might be used earlier, before strict criteria for refractory ascites are met. Long-term albumin use is under assessment for improving the prognosis of patients with uncomplicated ascites and confirmatory studies are ongoing. Hepatorenal syndrome is the least common cause of acute kidney injury in cirrhosis, and first-line treatment is the combination of terlipressin and albumin. Hepatic encephalopathy has a profound impact on the quality of life of patients with cirrhosis. Lactulose and rifaximin are first-and second-line treatments for hepatic encephalopathy, respectively. Newer therapies such as L-ornithine L-aspartate and albumin require further assessment.

Automated summary

Cirrhosis has two stages: compensated and decompensated. Decompensated stage is characterized by the development or presence of ascites, variceal hemorrhage, and hepatic encephalopathy. Treatment options vary depending on the specific complications, such as using nonselective b-blockers to prevent decompensation in patients with clinically significant portal hypertension or using trans-jugular intrahepatic portosystemic shunt (TIPS) for high-risk variceal hemorrhage. Other treatments like retrograde transvenous obliteration and variceal cyanoacrylate injection are emerging alternatives for specific conditions.