Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina, USA.
PURPOSE OF REVIEW:
Chronic liver disease causes significant morbidity and mortality because of any number of complications including hepatic encephalopathy, ascites, hepatorenal syndrome (HRS), and esophageal variceal hemorrhage (EVH).
Predictors of response to lactulose, probiotics, and L-ornithine-L-aspartate therapy in minimal hepatic encephalopathy (MHE) have been reported. Although rifaximin was slightly more effective than lactulose in the maintenance of remission and decreased re-admission in patients with MHE, it was not as cost-effective as lactulose. Beta-blockade has been associated with paracentesis-induced circulatory dysfunction. Those who respond to nonselective beta-blockers have a predictable overall lower probability of developing ascites and HRS. Noradrenaline was as effective as terlipressin for the treatment of type 1 HRS and was less costly. Hemorrhagic ascites, defined as an ascitic fluid red blood cell (RBC) count of at least 10 000/μl, appeared to be a marker for poor outcome in patients with cirrhosis. In patients with acute EVH, band ligation, pharmacologic vasoconstrictors, and antibiotics are effective; notably, intravenous proton pump inhibitor therapy in lieu of vasoconstrictors achieved similar hemostatic effects with fewer side-effects.
Refinement in the clinical management strategies for patients with cirrhosis and its complications appear to continue to contribute to improved patient outcomes.