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  • Print publication year: 2008
  • Online publication date: August 2009

13 - Complications of Cirrhosis

Summary

BACKGROUND

Chronic liver disease is one of the leading causes of death in the United States. As a result of the hepatitis C virus (HCV) epidemic 20–30 years ago, it is expected that by 2020 the proportion of chronic HCV patients with cirrhosis will double from 16% to 32%, and there will be a 180% increase in liver-related deaths. Although only liver transplantation is able to reverse the complications of advanced liver disease, the number of patients awaiting orthotopic liver transplantation has grown to 17,562 as of November 2006. Many patients with cirrhosis are not eligible for liver transplantation or may not receive an organ transplant during their lifetime.

Most patients with chronic liver disease receive their medical care from primary care physicians or gastroenterologists. A clear understanding of the pathophysiology of chronic liver disease, its possible complications, and management are important to deliver state of the art care to patients with chronic liver disease.

PROGNOSIS OF CIRRHOSIS

Most chronic liver diseases generally run a steady course with gradual deterioration over time. The natural history of cirrhosis is characterized by an asymptomatic phase, also known as “compensated cirrhosis,” followed by a rapidly progressive phase marked by the development of complications of portal hypertension and/or liver dysfunction, termed “decompensated cirrhosis.” Transition from a compensated to a decompensated stage occurs at a rate of approximately 5–7% per year. The development of decompensation is an important milestone in the natural history of cirrhosis.

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REFERENCES
Kochanek, KD, Murphy, SL, Anderson, RN. Deaths: Final data for 2002. In National Center for Health Statistics. National Vital Statistics Report. Vol 53, No. 5, Hyatsville, MD. National Center for Health Statistics 2004.
Davis, GL, Albright, JE, Cook, SF, Rosenberg, DM. Projecting future complications of chronic hepatitis C in the United States. Liver Transpl 2003;9:331–8.
,United Network for Organ Sharing and Organ Procurement and Transplant Network, Richmond, VA. Current U.S. waiting list for liver transplantation. In: United Network for Organ Sharing; 2006. Available at http://www.unos.org/data. Accessed on November 26, 2006.
D'Amico, G, Garcia-Tsao, G, Pagliaro, L. Natural history and prognostic indicators of survival in cirrhosis: A systematic review of 118 studies. J Hepatol 2006;44:217–31.
Fattovich, G, Giustina, G, Degos, F, et al. Morbidity and mortality in compensated cirrhosis type C: A retrospective follow-up study of 384 patients. Gastroenterology 1997;112:463–72.
Alberti, A, Chemelo, L, Benvegnu, L. Natural history of hepatitis C. J Hepatol 1999;31(Suppl. 1):17–24.
Christensen, E. Prognostic models including the Child-Pugh, MELD and Mayo risk scores – Where are we and where should we go?J Hepatol 2004;41:344–50.
Pugh, RN, Murray-Lyon, IM, Dawson, JL, Peitroni, MC, Williams, R. Transection of the esophagus for bleeding esophageal varices. Br J Surg 1973;60:646–49.
Kamath, PS, Wiesner, RH, Malinchoc, M, et al. A model to predict survival in patients with end-stage liver disease. Hepatology 2001;33:464–70.
Gores, GJ, Wiesner, RH, Dickson, ER, Zinsmeister, AR, Jorgensen, RA, Langworthy, A. Prospective evaluation of esophageal varices in primary biliary cirrhosis: development, natural history and influence on survival. Gastroenterology 1989;96:1552–9.
Kamath, PS. Esophageal variceal bleeding: Primary prophylaxis. Clinical Gastroenterol Hepatology 2005;3:90–3.
Thuluvath, PJ, Kirshnan, A. Primary prophylaxis of variceal bleeding. Gastrointest Endosc 2003;58:558–67.
D'Amico, G, Pagliaro, L, Bosch, J. The treatment of portal hypertension: a meta-analytic review. Hepatology 1995;22:332–54.
Poynard, T, Cales, P, Pasta, L, Ideo, G, Pascal, JP, Pagliaro, L, Lebrec, D. Beta-adrenergic antagonists in the prevention of first gastrointestinal bleeding in patiens with cirrhosis and esophageal varices. Analysis of data and prognostic factors in 589 patients from four randomized clinical trials. N Engl J Med 1991;324:1532–38.
Plevris, JN, Elliot, R, Mills, PR, Hislop, WS, Davies, JM, Bouchier, IA, Hayes, PC. Effect of propranolol on prevention of first variceal bleed and survival in patients with chronic liver disease. Aliment Pharmacol Ther 1994;8:63–70.
Groszmann, RJ, Garcia-Tsao, G, Bosch, J, et al. Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis. N Engl J Med 2005;353:2254–61.
Beppu, K, Inokuchi, K, Koyanagi, N, Nakayama, S, Sakata, H, Kitano, S, et al. Prediction of variceal hemorrhage by esophageal endoscopy. Gastrointest Endosc 1981;27: 213–8.
Adams, PC, Arthur, MJ, Boyer, TD, DeLeve, LD, Di Bisceglie, AM, Hall, M, et al. Screening in liver disease: Report of an AASLD workshop. Hepatology 2004;39:1204–12.
Grace, ND. Diagnosis and treatment of gastrointestinal bleeding secondary to portal hypertension. American College of Gastroenterology Practice Parameters Committee. Am J Gastroenterol 1997;92:1081–91.
,ASGE. ASGE Guideline: the role of endoscopy in the management of variceal hemorrhage, updated July 2005. Gastointest Endosc 2005;62:651–55.
D'Amico, G, Pasta, L, Madonia, S, Tarantino, G, Mancuso, A, Malizia, G, Giannuoli, GC, Pagliaro, L. The incidence of esophageal varices in cirrhosisGastroenterology 2001;120:A-2 (abstract).
Bosch, J, Abraldes, JG, Groszmann, R. Current management of portal hypertension. J Hepatol 2003;38:554–68.
Abraczinskas, DR, Ookubo, R, Grace, ND, Groszmann, RJ, Bosch, J, Garcia-Tsao, G, et al. Propranolol for prevention of first esophageal variceal hemorrhage – A lifetime commitment?Hepatology 2001;34:1096–102.
Jensen, DM. Endoscopic screening for varices in cirrhosis: Findings, implications and outcomes. Gastroenterology 2002;122:1620–30.
Carbonell, N, Pauwels, A, Serfaty, L, et al. Improved survival after variceal bleeding in patients with cirrhosis over the past two decades. Hepatology 2004;40:652–9.
Ejlersen, E, Melsen, T, Ingerslev, J, et al. Recombinant activated factor VIIa corrects prothrombin time in cirrhotic patients: a preliminary study. Gastroenterology 2001;36:1081–5.
Bernard, B, Grange, JD, Khac, EN, Amiot, X, Opolon, P, Poynard, T. Antibiotic prophylaxis for the prevention of bacterial infection in cirrhotic patients with gastrointestinal bleeding: a meta–analysis. Heptology 1999;29:1655–61.
Garica-Tsao, G. Bacterial infections in cirrhosis: treatment and prophylaxis. J Hepatol 2005;S85–92.
Corley, DA, Cello, JP, Adkisson, W, et al. Octreotide for acute esophageal variceal bleeding: a meta-analysis. Gastroenterology 2001;120:946–54.
Bosch, J, Lebrec, D, Jenkis, SA. Development of analogues: successes and failures. Scand J Gastroenterol Suppl 1998;226:3–13.
Lo, GH, Lai, KH, Cheng, JS, Lin, CK, Huang, JS, Hsu, PL, et al. Emergency banding ligation versus sclerotherapy for the control of active bleeding from esophageal varices. Hepatology 1997;25:1101–4.
D'Amico, G, Pagliaro, L, Bosch, J. The treatment of portal hypertension: a meta-analytic review. Hepatology 1995;22:332–54.
Garcia-Tsao, G. Current management of the complications of cirrhosis and portal hypetension: Variceal hemorrhage, ascites and spontaneous bacterial peritonitis. Gastroenterology 2001;120:726–48.
D'Amico, G, Plagiaro, L, Bosch, J. Pharmacological treatment of portal hypertension: an evidence-based approach. Semin Liv Dis 1999;19:475–505.
Patch, D, Sabin, CA, Goulis, J, et al. A randomized, controlled trial of medical therapy versus endoscopic ligation for the prevention of variceal rebleeding in patients with cirrhosis. Gastroenterology 2002;123:1013–19.
de la Peña, J, Brullet, E, Sanchez-Hernandez, E, et al. Variceal ligation plus nadolol compared with ligation for prophylaxis of variceal rebleeding: a multicenter trial. Hepatology 2005;41:572–8.
Abraldes, JG, Angermayr, B, Bosch, J. The management of portal hypertension. N A Clin Liv Dis 2005;9:685–713.
Lo, GH, Lai, KH, Cheng, JS, et al. A prospective randomized trial of butyl cyanoacrylate injection versus band ligation in the management of bleeding gastric varices. Hepatology 2001;33:1060–4.
Gines, P, Quintero, E, Arroyo, V, Teres, J, Bruguera, M, Rimola, A, Caballeria, J, et al. Com- pensated cirrhosis: natural history and prognostic factors. Hepatology 1987;7:12–18.
Schrier, RW, Arroyo, V, Bernaqrdi, M, et al. Peripheral arterial vasodilation hypothesis: a proposal for the initiation of renal sodium and water retention in cirrhosis. Hepatology 1988;8:1151–7.
Runyon, BA. Care of the patient with ascites. N Engl J Med 1994;330:337–42.
Pinzello, G, Simonetty, RG, Craxi, A, di Piazza, S, Spano, C, Pagliaro, L. Spontaneous bacterial peritonitis: a prospective investigation in predominantly nonalcoholic patients. Hepatology 1983;3:545–9.
Runyon, BA. Paracentesis of ascitic fluid: a safe procedure. Arch Intern Med 1986; 146:2259–61.
Lin, CH, Shih, FY, Ma, MH, et al. Should bleeding tendency deter abdominal paracentesis? Dig Liv Dis 2005;37:946–51.
Thomsen, TW, Shaffer, RW, White, B, Setnik, GS. Paracentesis. N Engl J Med 2006;355:e21.
Habeeb, KS, Herrera, JL. Management of ascites. Paracentesis as a Guide. Postgrad Med 1997;101:191–200.
Runyon, BA, Montano, AA, Akriviadis, EA, Antillon, MR, Irving, MA, McHutchison, JG. The serum-ascites albumin gradient is superior to the exudates-transudate concept in the differential diagnosis of ascites. Ann Intern Med 1992;117:215–20.
Llach, J, Rimola, A, Navasa, M, et al. Incidence and predictive factors of first episode of spontaneous bacterial peritonitis in cirrhosis with ascites: relevance of ascitic fluid protein concentration. Hepatology 1992;16:724–27.
Soriano, G, Guarner, C, Teixido, M, et al. Selective intestinal decontamination prevents spontaneous bacterial peritonitis. Gastroenterology 1991;100:477–81.
Runyon, BA, Hoefs, JC, Morgan, TR. Ascitic fluid analysis in malignancy-related ascites. Hepatology 1988;8:1104–9.
Stiehm, AJ, Mendler, MH, Runyon, BA. Detection of diuretic resistance or diuretic sensitivity by the spot urine Na/K ratio in 729 specimens from cirrhotics with ascites: approximately 80% accuracy as compared to 24 hour urine Na excretion. Hepatology 2002:36:222A [abstract]
Perez-Ayuso, RM, Arroyo, V, Plans, R, Gaya, J, Bory, F, Rimola, A, Rivea, F, et al. Randomized comparative study of efficacy of furosemide vs. spironolactone in nonazotemic cirrhosis with ascites. Gastroenterology 1983;84:961–8.
Santos, J, Planas, R, Pardo, A, Durandez, R, Cabre, E, Mrillas, RM, et al. Spironolactone alone or in combination with furosemide in the treatment of moderate ascites in nonazotemic cirrhosis. A randomized comparative study of efficacy and safety. J Hepatol 2003;39:187–92.
Runyon, BA. Management of adult patients with ascites due to cirrhosis. Hepatology 2004;39:841–56.
Fitzgerald, GA, Patrono, C. The coxibs, selective inhibitors of cyclooxygenase-2. N Engl J Med 2001;345:433–42.
Claria, J, Kent, JD, Lopez-Parra, M, Escolar, G, Ruiz, delArbol, L, Gines, P, et al. Effects of celecoxib and naproxen on renal function in nonazotemic patients with cirrhosis and ascites. Hepatology 2005;41:579–87.
Gines, P, Tito, L, Arroyo, V, Planas, R, Viver, J, et al. Randomized comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis. Gastroenterology 1988;94:1493–501.
Sanyal, A, Genning, C, Reddy, KR, Wong, F, Kowdley, KV, Benner, K, et al. The North American study for the treatment of refractory ascites. Gastroenterology 2003;124:634–41.
Gines, P, Arroyo, V, Vargas, V, Plans, R, Casafont, F, Panes, J, Hoyos, M, et al. Paracentesis with intravenous infusion of albumin as compared with peritoneovenous shunting in cirrhosis with refractory ascites. N Engl J Med 1991;325:829–35.
Moore, KP, Aithal, GP. Guidelines on the management of ascites in cirrhosis. Gut 2006;55:1–12.
Felisart, J, Rimola, A, Arroyo, V, Perez-Ayuso, RM, Quintero, E, Gines, P, et al. Cefotaxime is more effective than is ampicillin-tobramycin in cirrhotics with severe infections. Hepatology 1985;5:457–62.
Runyon, BA, McHutchison, JG, Antillon, MR, et al. Short-course versus long-course antibiotic treatment of spontaneous bacterial peritonitis: a randomized controlled study of 100 patients. Gastroenterology 1991;100:1737–42.
Llovet, JM, Rodriguez-Iglesias, P, Moitinho, E, Planas, R, Bataller, R, Navasa, M, et al. Spontaneous bacterial peritonitis in patients with cirrhosis undergoing selective intestinal decontamination. A retrospective study of 229 spontaneous bacterial peritonitis episodes. J Hepatol 1997;26:88–95.
Campillo, B, Richardet, JP, Kheo, T, Dupeyron, C. Nosocomial spontaneous bacterial peritonitis and bacteremia in cirrhotic patients: impact of isolate type on prognosis and characteristics of infection. Clin Infect Dis 2002;35:1–10.
Sort, P, Navasa, M, Arroyo, V, Aldeguer, X, Planas, R, Ruiz, delArbol, L, et al. Effects of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med 1999;341:403–9.
Gines, P, Rimola, A, Planas, R, Vargas, V, Marco, F, Almela, M. Norfloxacin prevents spontaneous bacterial peritonitis recurrence in cirrhosis: results of a double-blind, placebo-controlled trial. Hepatology 1990;12:716–24.
Bauer, TM. Follo, A, Navasa, M, Vila, J, Plans, R, Clemente, G, et al. Daily norfloxacin is more effective than weekly rufloxacin in prevention of spontaneous bacterial peritonitis recurrence. Dig Dis Sci 2002;47:1356–61.
Arroyo, V, Gines, P, Berges, A, et al. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. Hepatology 1996;23:164–76.
Gines, A, Escorsell, A, Gines, P, et al. Incidence, predictive factors and prognosis of hepatorenal syndrome in cirrhosis. Gastroenterology 1993;105:229–36.
Cardenas, A.Hepatorenal syndrome: A dreaded complication of end-stage liver disease. Am J Gastroenterol 2005;100:460–7.
Ortega, R, Gines, P, Uriz, J, et al. Terlipressin therapy with and without albumin for patients with hepatorenal syndrome. Results of a prospective, non-randomized study. Hepatology 2002;36:941–8.
Angeli, P, Volpin, R, Gerunda, G, Craighero, R, Roner, P, Merenda, R, et al. Reversal of type 1 hepatorenal syndrome with the administration of midodrine and octreotide. Hepatology 1999;29:1690–7.
Wong, F, Pantea, L, Sniderman, K. Midodrine, octreotide, albumin and TIPS in selected patiens with cirrhosis and type 1 hepatorenal syndrome. Hepatology 2004;40:55–64.
Butterworth, RF. The neurobiology of hepatic encephalopathy. Semin Liv Dis 1996;16:235–44.
Blei, AT, Cordoba, J. Hepatic Encephalopathy. Am J Gastroenterol 2001;96:1968–76.
Uribe, M, Campollo, A, Vargas, F, et al. Acidifying enemas (lactitol and lactose) vs. non-acidifiying enemas (tap water) to treat acute portal-systemic encephalopathy. A double-blind randomized clinical trial. Hepatology 1987;7:639–43.
Loft, S, Sonne, J, Dossing, M, Andreasen, PB. Metronidazole pharmacokinetics in patients with hepatic encephalopathy. Scand J Gastroenterol 1987;22:117–23.