Management and Treatment of Patients With Cirrhosis and Portal Hypertension: Recommendations From the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program

ArticleinThe American Journal of Gastroenterology 104(7):1802-29 · June 2009with47 Reads
DOI: 10.1038/ajg.2009.191 · Source: PubMed
Cirrhosis represents the end stage of any chronic liver disease. Hepatitis C and alcohol are currently the main causes of cirrhosis in the United States. Although initially cirrhosis is compensated, it eventually becomes decompensated, as defined by the presence of ascites, variceal hemorrhage, encephalopathy, and/or jaundice. These management recommendations are divided according to the status, compensated or decompensated, of the cirrhotic patient, with a separate section for the screening, diagnosis, and management of hepatocellular carcinoma (HCC), as this applies to patients with both compensated and decompensated cirrhosis. In the compensated patient, the main objective is to prevent variceal hemorrhage and any practice that could lead to decompensation. In the decompensated patient, acute variceal hemorrhage and spontaneous bacterial peritonitis are severe complications that require hospitalization. Hepatorenal syndrome is also a severe complication of cirrhosis but one that usually occurs in patients who are already in the hospital and, as it represents an extreme of the hemodynamic alterations that lead to ascites formation, it is placed under treatment of ascites. Recent advances in the pathophysiology of the complications of cirrhosis have allowed for a more rational management of cirrhosis and also for the stratification of patients into different risk groups that require different management. These recommendations are based on evidence in the literature, mainly from randomized clinical trials and meta-analyses of these trials. When few or no data exist from well-designed prospective trials, emphasis is given to results from large series and consensus conferences with involvement of recognized experts. A rational management of cirrhosis will result in improvements in quality of life, treatment adherence, and, ultimately, in outcomes.
    • "However, little is known about the tolerance and efficacy of DAA regimens in patients with decompensated cirrhosis. Although eradication of HCV may stop inflammation and disease progression, patients with decompensated cirrhosis are already having portal hypertension and hepatic insufficiency [10] . Thus they may develop jaundice , variceal hemorrhage, ascites, encephalopathy, or HCC, and need liver transplantation over time even if HCV infection is cured. "
    [Show abstract] [Hide abstract] ABSTRACT: Little is known about the tolerance and effectiveness of novel oral direct acting antivirals (DAA) in hepatitis C patients with decompensated cirrhosis. To examine the studies relevant to the treatment of hepatitis C virus(HCV)-related decompensated liver disease, we performed computer–based searches for English articles between 1947 and August 2015. Fourteen articles including HCV patients with decompensated cirrhosis were reviewed. The combinations of ledipasvir(LDV)/sofosbuvir(SOF)/ribavirin(RBV) for 12 weeks, or daclatasvir/SOF/RBV for 12 weeks are safe and effective for HCV genotype 1 or 4 infection, and daclatasvir/SOF/RBV for 12 weeks or SOF/RBV for 48 weeks might be effective and safe for HCV genotype 2 or 3 infection. In conclusion, current evidence supports the use of all oral DAA regimens in HCV patients with decompensated cirrhosis.
    Full-text · Article · Jan 2016
    • "cirrhosis represents the end stage of most chronic liver diseases, which can remain compensated for many years [1]. Decompensated cirrhosis can be characterized by the development of major complications like jaundice, variceal hemorrhage, ascites, or encephalopathy [2], of which ascites is the most common [3]. "
    [Show abstract] [Hide abstract] ABSTRACT: Hepatic cirrhosis is one of the leading causes of death worldwide, especially if complicated by ascites. This chronic condition can be related to the classical disease entity jalodara in Traditional Indian Medicine (Ayurveda). The present paper aims to evaluate the general potential of Ayurvedic therapy for overall clinical outcomes in hepatic cirrhosis complicated by ascites (HCcA). In form of a nonrandomized, uncontrolled, single group, open-label observational clinical study, 56 patients fulfilling standardized diagnostic criteria for HCcA were observed during their treatment at the P. D. Patel Ayurveda Hospital, Nadiad, India. Based on Ayurvedic tradition, a standardized treatment protocol was developed and implemented, consisting of oral administration of single and compound herbal preparations combined with purificatory measures as well as dietary and lifestyle regimens. The outcomes were assessed by measuring liver functions through specific clinical features and laboratory parameters and by evaluating the Child-Pugh prognostic grade score. After 6 weeks of treatment and a follow-up period of 18 weeks, the outcomes showed statistically significant and clinically relevant improvements. Further larger and randomized trials on effectiveness, safety, and quality of the Ayurvedic approach in the treatment of HCcA are warranted to support these preliminary findings.
    Full-text · Article · Sep 2015
    • "Surveillance practices for complications of cirrhosis have been developed on the basis of large number of randomized control trials. Compliance with the practice guidelines for surveillance has shown to be associated with a significant improvement in survival in patients with variceal bleeding and HCC (Tsochatzis et al., 2012)(Garcia-Tsao et al., 2009; Garcia-Tsao et al., 2007; Garcia-TsaoG and Bosch, 2010; Mellinger and Volk, 2013) (European Association for the Study of the Liver (EASL), 2010; Runyon, 2013; Amarapurkar, 2012). In spite of this overwhelming evidence, the guidelines in the management of cirrhosis are not followed properly (Mellinger and Volk, 2013). "
    [Show abstract] [Hide abstract] ABSTRACT: Cirrhosis carries high morbidity and mortality due to various complications and decompensation, which can be decreased by following various practice guidelines, which are variedly followed in actual practice. This multicentric prospective/retrospective study was conducted over a 3 month period to assess actual care of patients with cirrhosis. 416 patients with cirrhosis (median age 53 years, 316 males) were included in the study. A comprehensive protocol was devised taking into account various practice guidelines. Patients were divided into 3 groups. Group 1: Newly diagnosed patients evaluated as per protocol. Group 2: Patients previously diagnosed at the study centers, past practices assessed. Group 3: patients diagnosed previously at non-study centers, their surveillance practices were assessed. Patients in the 3 groups were similar in terms of age and gender ratio. There was significant difference between varices screening practices amongst 3 groups, however there was similar nonselective beta blockers (NSBB)/endoscopic variceal ligation (EVL) prophylaxis practices. Ultrasound surveillance for ascites varied significantly amongst 3 groups. There was significant difference between antibiotic prophylaxis practice in high risk ascites patients between groups 1 and 2. Evaluation of renal function at baseline and ultrasound surveillance for hepatocellular carcinoma was significantly different in 3 groups. All patients in group 1 underwent SpO2 monitoring, however none in groups 2 or 3 previously had SpO2 monitoring. Surveillance and treatment practices for various complications of cirrhosis vary widely in real life and falls well short of goals. Presence of dedicated protocols helps in improving the way we care for our patients with cirrhosis.
    Full-text · Article · Mar 2015
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