Therapy for alcoholic liver disease

Table 4 Management of complications of cirrhosis, per professional society guidelines¹

Complication	Screening/diagnosis	Treatment	Long-term management surveillance
Ascites	Diagnostic paracentesis for new-onset ascites: ascitic fluid analyzed for cell count and differential, total protein, and SAAG	Alcohol cessation; dietary sodium restriction; oral diuretics; discontinuation of NSAIDs	Refractory ascites: periodic large-volume therapeutic paracenteses; TIPS; midodrine; or peritoneovenous shunts
Spontaneous bacterial peritonitis	Diagnostic paracentesis: ≥ 250 polymorphonuclear cells/mm3	Empiric antibiotic therapy with cefotaxime 2 g every 8 h, while awaiting culture results	Prophylaxis with norfloxacin or trimethoprim-sulfamethoxazole after one documented episode of SBP or if patient presents with variceal bleeding
Esophageal and gastric varices	Esophagogastroduodenoscopy	Treatment depends upon size of varices or risk of variceal bleeding: Prophylaxis with nadolol or propranolol for small varices at high risk of bleeding or for medium/large varices; EVL for medium/large varices at high risk of bleeding	No varices: EGD every 3 yr (earlier if hepatic decompensation occurs) Small varices: EGD every 2 yr Medium/large varices: EGD every 6-12 mo
Hepatic encephalopathy	Diagnosed by serum ammonia level and clinical findings of confusion, personality and mental status changes, and asterixis (exclude other causes of mental status changes)	Investigation and correction of precipitating factors; lactulose and/or rifaximin, supportive care	Secondary prophylaxis with lactulose and/or rifaximin indefinitely
Hepatorenal syndrome (type 1-rapidly progressive renal insufficiency; type 2-slowly progressive renal insufficiency)	Serum creatinine > 1.5 mg/dL, in the absence of other identifiable cause of renal failure (exclude other causes by urine chemistries, urine culture, and/or renal imaging)	Initial fluid challenge; albumin and terlipressin or albumin and combined octreotide plus midodrine; dialysis; LT definitive	Serial serum creatinine monitoring
Hepatocellular carcinoma (HCC)	Abdominal ultrasound every 6 mo; alpha fetoprotein determination every 6 mo no longer recommended, but optional	For HCC treatment[124]	Abdominal ultrasound every 6 mo
Hepatopulmonary syndrome	Screening by arterial blood gas; Confirmation by CEE	Symptomatic management with long-term oxygen therapy; LT definitive
Portopulmonary hypertension	Screening by transthoracic Doppler echocardiography; Confirmation by right heart catheterization	Intravenous or inhaled prostacyclin; long-term oxygen therapy

¹American Association for the Study of Liver Diseases[124,128,129]; American College of Gastroenterology[125,126]; Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program[127]; European Association for the Study of the Liver[130]; and European Respiratory Society[131]. SAAG: Serum-ascites albumin gradient; NSAID: Non-steroidal anti-inflammatory drugs; TIPS: Transjugular intrahepatic portosystemic shunt; SBP: Spontaneous bacterial peritonitis; GI: Gastrointestinal; EGD: Esophagogastroduodenoscopy; EVL: Endoscopic variceal ligation; CEE: Transthoracic echocardiography with contrast enhancement.