-Abdominal paracentesis
Treatment
-D/c alcohol and consider Baclofen treatment to increase abstinence.
-D/c all medications that can decrease renal perfusion (NSAIDs, Beta-blockers, ACE-I, ARBS)
-Treat any underlying liver disease when possible.
-Sodium-restricted diet (2g per day)
-Diuretics: Spironolactone 100 mg per day plus Furosemide 40 mg PO qAM. May titrate the doses to a maximum of Spironolactone 400 and Furosemide 160 mg per day.
-For patients with a small amount of ascites, start with Spironolactone 50 mg per day plus furosemide 20 mg per day po.
Monitoring
-Daily weights
***
Treatment with Baclofen has been shown to improve abstinence (from alcohol) in patients with alcoholic liver disease.
Baclofen 10 mg three times daily. Start Baclofen 5 mg three times per day for three days. Then increase to 10 mg three times per day.
*Avoid Propranol. “In patients with cirrhosis, lower arterial blood pressures are associated with lower survival rates, so medications that decrease blood pressure might decrease survival.”
“Fluid restriction is not recommended unless the serum sodium level is <120 mEq/L, and it is extremely difficult to achieve. Patients would need to limit fluid intake to less than their urinary output, which is often reduced.
Up to 60% of patients with cirrhosis suffer from malnutrition, so a high-protein diet is recommended (1.0–1.5 g/kg dry body weight). High-protein diets are tolerated well and result in improved mental status (SOR B). Protein restriction does not benefit those with hepatic encephalopathy.” ABFM critique.
“Dietary counseling is key in the management of cirrhosis. Patients with ascites should be limited to 2000 mg of sodium daily (SOR A). Fluid restriction is not recommended unless the serum sodium level is <120 mEq/L, and it is extremely difficult to achieve. Patients would need to limit fluid intake to less than their urinary output, which is often reduced. Up to 60% of patients with cirrhosis suffer from malnutrition, so a high-protein diet is recommended (1.0–1.5 g/kg dry body weight). High-protein diets are tolerated well and result in improved mental status (SOR B). Protein restriction does not benefit those with hepatic encephalopathy. β-Blockers should be stopped when the patient’s mean arterial pressure is <82 mm Hg (blood pressure 100/73 mm Hg) (SOR B). β-Blockers are used in early cirrhosis for hypertension, reducing portal pressures, and prevention of varices. They are no longer effective when the patient becomes hypotensive or has refractory ascites, spontaneous bacterial peritonitis, or other conditions associated with significant changes in hemodynamic status. This patient is normotensive on his current dosage of metoprolol. As his cirrhosis progresses the metoprolol will likely need to be discontinued. Statins can be safely used in patients with cirrhosis. Their cardiovascular benefits are well established and the risk of associated liver failure is extremely low (SOR A).“ ABFM Critique
MELD Score
References
N Engl J Med 2016;375(8):767-777. Treatment of patients with cirrhosis.
Am Fam Physician. 2011 Dec 15;84(12):1353-1359. http://www.aafp.org/afp/2011/1215/p1353.html