Portal hypertension and cirrhosis

R18/K72.9/K74.6+ + (I98.2*/I98.3*)

DESCRIPTION

The complications of portal hypertension include:

  • variceal bleeds
  • ascites
  • hepatic encephalopathy (HE)
  • splenomegaly with hypersplenism
  • hepatorenal syndrome
  • hepato-pulmonary syndrome or porto-pulmonary hypertension

GENERAL MEASURES

Ascites: sodium restriction, i.e. ≤ 2 g/day or ≤ 88 mmol/day.
Monitor weight regularly.
Encephalopathy: with acute HE, protein restrict otherwise 1–1.5 mg/kg protein per day.
Exclude infection, high protein load, occult bleed, sedatives and electrolyte disturbances.
Variceal bleeding: endoscopic variceal ligation and/or immediate referral for advanced management.

MEDICINE TREATMENT

Ascites R18

  • Single morning dose of oral spironolactone, oral 100 mg and furosemide, oral, 40 mg.
    • Increase the dose by 100 mg and 40 mg, respectively, every 3–5 days, to a maximum dose of 400 mg spironolactone and 160 mg of furosemide.
    • Rapid fluid shifts may precipitate acute liver and/or renal failure.
    • Spironolactone may cause hyperkalaemia.

Monitoring of sodium, potassium and renal function is essential in patients taking spironolactone. Avoid spironolactone if eGFR <30 mL/minute.

LoEIII [16]

Measure response to diuretics by weighing patient daily. Aim for maximal weight loss of:

500 g/day - patients without oedema

1 000 g/day - patients with oedema

Tense ascites R18

Albumin replacement should be considered if ≥5 L of fluid is removed or pre-existing renal dysfunction:

LoEII [17]

  • Albumin, IV, 40 g (20%) , as an infusion.
    • Refer to specialist unit to consider transjugular intrahepatic portosystemic (TIP) shunt or potential transplant.
  • Introduce diuretics and titrate doses as necessary to prevent recurrence of ascites (see above).

Note:

  • Avoid NSAIDS and ACE-inhibitors.
  • Exclude spontaneous bacterial peritonitis in patients with new onset ascites.

Refractory ascites R18

  • No response to optimal diuretic therapy, despite sufficient sodium restriction (≤2 g/day or ≤88 mmol/day) with avoidance of NSAIDs.
  • Ascites recurs rapidly following therapeutic paracentesis.

Perform serial large volume paracentesis, as an outpatient, usually not more frequently than every 2 weeks.

Haemodynamic collapse is more likely in patients who are intravascularly volume depleted. Check renal function before paracentesis.

Albumin replacement should be considered if >5 L of fluid is removed:

LoEII [18]

  • Albumin, IV, 40 g (20%), as an infusion.

Encephalopathy

  • Lactulose, oral, 10–30 mL 8 hourly, depending on stool number and consistency (aim for 2 soft stools/day).

Look for precipitating factors: Sepsis, protein load, GIT bleed, over diuresis, sedation.

Oesophageal varices

To reduce the risk of bleeding:

  • Beta-blocker, e.g.:
  • Propranolol, oral, 20–40 mg 12 hourly. Titrate to resting pulse rate of 55-60 beats per minute (bpm). Monitor pulse and BP.

LoEII [19]

REFERRAL

Refer to specialist unit to consider TIP shunt or potential transplant.