Current Management of the Complications of Cirrhosis and Portal Hypertension: Variceal Hemorrhage, Ascites, and Spontaneous Bacterial Peritonitis

Abstract

Cirrhosis is not a single entity but represents a disease progression across different prognostic stages, with the compensated and decompensated stages being the most important. Variceal hemorrhage (VH) and ascites are complications of cirrhosis that denote the presence of a decompensated stage. Spontaneous bacterial peritonitis (SBP) is a common bacterial infection unique to patients with cirrhosis that can precipitate the development of recurrent VH and hepatorenal syndrome (HRS), complications that denote the presence of a ‘further decompensated' stage of cirrhosis. Main current issues in the management of VH include identification of different prognostic stages that allow for individualized patient care. Management of VH cannot be performed in an isolated manner, and the presence of other complications of cirrhosis (ascites, encephalopathy) should be taken into account both in the management and in the design of clinical trials. Because management of ascites per se has not resulted in significant changes in mortality, main management issues consist of preventing further decompensating events by preventing factors that will lead to worsening vasodilatation and hemodynamic status (infections, vasodilators), preventing volume depletion (overdiuresis, GI hemorrhage) and preventing structural kidney injury (nephrotoxins). Prophylaxis of bacterial infections such as SBP currently consists of the administration of antibiotics. By preventing infections, there is evidence that recurrent VH and HRS can also be prevented. However, response to recommended empirical antibiotics in patients with suspected infection, such as SBP, is currently significantly lower than in the past because of an increase in infections secondary to multidrug resistant (MDR) organisms. One of the main predictors of the development of MDR organisms is antibiotic prophylaxis and unnecessary and prolonged use of antibiotics in hospital. Therefore, appropriate antibiotics should be used in patients with a high suspicion of infection, and antibiotic prophylaxis should be restricted to patients with the highest risk of infection.

Study of etiology, clinical profile and predictive factors of spontaneous bacterial peritonitis in cirrhosis of liver

“…After obtaining institute's Ethics committee approval and valid written informed consent patients were enrolled in the study. Patients above 12 year of age with diagnosed cirrhosis of liver and documented evidence of SBP in the form of ascitic fluid PMN>250 cells /mm 3 and ascitic fluid culture positive or ascitic fluid PMN count >250/mm 3 and ascitic fluid culture negative or ascitic fluid PMN count <250 cells/mm 3 and ascitic fluid culture positive were included. Pregnant females, patients who refused to give consent, patients with a documented evidence of intra-abdominal source of infection or patients with ascitis due to non-hepatic causes like nephrotic syndrome and congestive cardiac failure were excluded.…”

“…When first described, its mortality exceeded 90% but it has been reduced to approximately 20% with early diagnosis and treatment. 3,4 All the patients with cirrhosis and ascites are at risk of SBP. The prevalence of SBP varies in out-patients it is 1.5-3.5% and about 10%-30% in hospitalized patients.…”

Liver Specific Serum Micro RNA122 as a Prognostic Marker in Egyptian Patients with Liver Cirrhosis

“…Hepatorenal syndrome (HRS) a serious complication occurring mainly in patients with advanced cirrhosis and ascites, carries a grave prognosis [4]. Spontaneous bacterial peritonitis (SBP) is a complication of ascites in decompensated liver cirrhosis and is associated with a mortality rate exceeding 90% if untreated, while with early diagnosis and prompt treatment the mortality rate dropped to 20% [5].…”

Introductory Chapter: Treatment of Ascites Associated with Cirrhosis and Its Complications

“…Approximately 60% of cirrhotics end up exhibiting it during the course of their disease. The development of ascites indicates a clear decompensation of the disease and is generally associated with a bad prognosis, with an approximately 40% of 1-year mortality [1,2].…”