In addition to today’s resource, please see and review:
Link To And Excerpts From MELD (Model For End-Stage Liver Disease) Score From Organ Procurement & Transplantation Network
Posted on September 30, 2024 by Tom Wade MD
Today, I review, link to, and excerpt from British Society of Gastroenterology Best Practice Guidance: outpatient management of cirrhosis – part 2: decompensated cirrhosis. [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Frontline Gastroenterol. 2023 Jul 28;14(6):462-473. doi: 10.1136/flgastro-2023-102431. eCollection 2023.
All that follows is from the above resource.
Abstract
There are two distinct phases in the natural history of cirrhosis: compensated disease (corresponding to Child Pugh A and early Child Pugh B disease)*, where the patient may be largely asymptomatic, progressing with increasing portal hypertension and liver dysfunction to decompensated disease (corresponding to Child Pugh late B-C)*, characterised by the development of overt clinical signs, including jaundice, hepatic encephalopathy (HE), ascites, renal dysfunction and variceal bleeding. The transition from compensated cirrhosis to decompensated cirrhosis (DC) heralds a watershed in the nature and prognosis of the disease. DC is a systemic disease, characterised by multiorgan/system dysfunction, including haemodynamic and immune dysfunction. In this second part of our three-part series on the outpatient management of cirrhosis, we address outpatient management of DC, including management of varices, ascites, HE, nutrition, liver transplantation and palliative care. We also introduce an outpatient DC care bundle. For recommendations on screening for osteoporosis, hepatocellular carcinoma surveillance and vaccination see part one of the guidance. Part 3 of the guidance focusses on special circumstances encountered in patients with cirrhosis, including surgery, pregnancy, travel, management of bleeding risk for invasive procedures and portal vein thrombosis.
Keywords: ASCITES; CIRRHOSIS; LIVER TRANSPLANTATION; OESOPHAGEAL VARICES.
*Use Of The Child Pugh Score In Liver Disease from StatPearls. Andrea Tsoris; Clinton A. Marlar. Last Update: March 13, 2023.
© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
Introduction
The transition from compensated cirrhosis (CC) to decompensated cirrhosis (DC) occurs at the rate of approximately 5%–7% per year,1 and median survival drops from over 12 years in CC to approximately 2 years in DC.1 People with DC should be managed by a specialist with expertise in the management of patients with liver disease. While removal of aetiological factors driving liver damage is important at all stages of liver disease, the management of CC, focused on surveillance and preventing further liver damage, differs significantly from that of DC, where the focus is on managing complications, identifying suitable candidates for transplantation and ensuring good palliative care (PC). The following recommendations are accompanied by a care bundle for use in the outpatient setting (see figure 1).
Screening, surveillance and prophylaxis of variceal bleeding
All patients with DC who are not on a non-selective beta blocker (NSBB) should undergo endoscopy to screen for varices. The risk of progression to high-risk varices is higher in decompensated disease,2 so we recommend annual surveillance in all patients not already receiving primary prophylaxis. Patients with Child-Pugh C disease and small varices should have primary prophylaxis with NSBB if tolerated. All patients with medium-to-large varices/red signs should have primary prophylaxis with NSBB or variceal band ligation (VBL) (figure 2). Patients on NSBB for primary prevention do not require further surveillance endoscopy. Those who have VBL for primary prevention should be scoped approximately every 4 weeks until the varices are eradicated and then have ongoing surveillance annually until they recompensate and the underlying aetiological driver for their liver disease is removed (eg, abstinence from alcohol).
Secondary prevention of variceal haemorrhage is important, as the risk of rebleeding can be as high as 60% with 20% mortality for each rebleeding episode.3 A combination of NSBB and VBL is recommended.2 4 Transjugular intrahepatic portosystemic shunting (TIPSS) has a role in secondary prevention in high-risk cases, where patients rebleed despite NSBB and VBL, or where there are additional indications such as refractory/recurrent ascites.5 Careful patient selection is necessary (see BSG guidelines on TIPSS in portal hypertension), including consideration of liver transplantation (LT) where appropriate.5
5. Tripathi D, Stanley AJ, Hayes PC, et al.. Transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension. Gut 2020;69:1173–92. 10.1136/gutjnl-2019-320221 [PMC free article] [PubMed] [CrossRef] [Google Scholar] [Ref list]
Management and assessment of chronic hepatic encephalopathy and driving
In cirrhosis, hepatic encephalopathy (HE) causes a range of neuropsychiatric disturbances from stupor and coma to subtle abnormalities in higher executive function. The annual risk of developing overt HE with cirrhosis is estimated at 20%, and 60%–80% have evidence of minimal HE on testing.6 Overt HE is diagnosed clinically utilising the West-Haven Criteria,7 whereas minimal HE requires specialised psychometric or neurophysiological testing.8 Recently, to simplify diagnosis, patients with West-Haven grade 0 (minimal) and 1 HE are said to have covert HE,9 which can be evident from a thorough history from the patient and their caregiver. Helpful clues include sleep-wake cycle reversal, short-term memory loss and loss of concentration such as they are no longer able to read the newspaper or follow their favourite TV programme. A summary of assessment and investigation in suspected HE is shown in table 1.
6. Bajaj JS, Wade JB, Sanyal AJ. Spectrum of neurocognitive impairment in cirrhosis: implications for the assessment of hepatic encephalopathy. Hepatology 2009;50:2014–21. 10.1002/hep.23216 [PubMed] [CrossRef] [Google Scholar] [Ref list]
7. Conn HO, Leevy CM, Vlahcevic ZR, et al.. Comparison of lactulose and neomycin in the treatment of chronic portal-systemic encephalopathy. A double blind controlled trial. Gastroenterology 1977;72:573–83. [PubMed] [Google Scholar] [Ref list]
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9. Bajaj JS. Introduction and setting the scene: new nomenclature of hepatic encephalopathy and American association for the study of liver diseases/European association for the study of the liver guidelines. Clin Liver Dis (Hoboken) 2017;9:48–51. 10.1002/cld.610 [PMC free article] [PubMed] [CrossRef] [Google Scholar] [Ref list]
The animal naming test is quick and easy to do in outpatient settings. Naming 15 animals in 1 min produced the best discrimination between unimpaired and minimal HE patients.10
Overt HE portends a poor prognosis and the probability of transplant-free survival after developing overt HE is only 42% at 1 year and 23% at 3 years,11 so early referral for LT should be considered.
Most HE treatments are directed towards the gut with lactulose as first line therapy.12 A 550 mg twice-daily rifaximin is recommended second line to reduce recurrent episodes of overt HE.13
Weight loss and sarcopenia can worsen HE. Therefore, low-protein nutrition should be avoided, and adequate protein and energy intake should be maintained.
HE develops in 35%–50% of patients after TIPSS and is associated with increased mortality.14 The risk of post-TIPSS HE can be reduced by using a smaller diameter (6–7 mm vs >8 mm) covered stent15 and by prophylactic use of rifaximin started 14 days before TIPSS.16
Simulation studies and on-road driving tests have demonstrated impaired driving ability in patients with cirrhosis and HE.17 Patients with cirrhosis and cognitive impairment have more traffic accidents and often overestimate their driving ability.18 19 Treatment with rifaximin in a randomised trial improved driving simulator performance in patients with covert HE.20 However, two studies found no increased rate of accidents in patients with cirrhosis and covert HE.21 22
No single psychometric test can currently reliably divide patients into safe and unsafe drivers, and there are no published guidelines on driving for patients with minimal/covert HE. Expert consensus recommends avoidance of driving within 3 months of an overt HE episode.23 UK patients diagnosed with overt HE must inform the Driver and Vehicle Licensing Agency (DVLA) and are advised not to drive. Even in the absence of overt HE, if there are concerns of poor short-term memory, disorientation, lack of insight/judgement or impaired attention, the patient is probably not safe to drive and the DVLA should be informed.24 If symptoms resolve (on or off treatment) and patients wish to resume driving, they should formally reapply to the DVLA—in some cases a driving assessment may be required. This includes patients with alcohol use disorder who have stopped drinking alcohol, recompensated and have had no recurrence of overt HE on or off lactulose and/or rifaximin for 12 months.
Outpatient management of ascites
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