Management of the major complications of cirrhosis: Beyond guidelines

Abstract

Along with a growing understanding of the pathophysiology of cirrhosis and its complications, new therapies and management strategies have emerged in recent years. Many of these advances have helped inform the current EASL clinical practice guidelines 1 on the management of some of the key complications of cirrhosis, such as ascites, variceal bleeding and infection. However, there are still some aspects of management where the evidence base is less clear, and/or where opinions amongst practitioners remain divided. Some of these more controversial areas are explored in this section, wherein we present evidence culminating in a suggested management approach based on expert opinion and extending beyond the current guidelines.

Recent Advances in the Management of Acute Variceal Hemorrhage

“…In patients receiving secondary prophylaxis for VH, assessment of baseline HVPG and its response to NSBBs may provide useful information and guide therapy [77][78][79]. In this setting, the "goal-standard" is to measure HVPG at baseline and then re-assess HVPG after chronic administration of NSBBs (i.e., after four to six weeks) [80].…”

“…In this setting, the "goal-standard" is to measure HVPG at baseline and then re-assess HVPG after chronic administration of NSBBs (i.e., after four to six weeks) [80]. However, the measurement of "acute" HVPG response to intravenous propranolol may be a preferred alternative as it would be quicker and has an acceptable correlation with chronic response [77]. In one seminal RCT by Villanueva et al, an HVPG-guided therapy based on acute response to intravenous NSBBs significantly lowered the risk of portal hypertension related complications and mortality compared with standard of care [78].…”

“…In another retrospective study including both candidates for primary and secondary prophylaxis, acute response to intravenous propranolol was independently correlated with a 50% decrease in the probability of re-bleeding (23% at 2 years vs. 46% in non-responders; p = 0.032) and a better survival (95% vs. 65%; p = 0.003) [79]. Although further evidence is required to evaluate benefits and cost of such approach, current data suggest that HVPG-guided therapy in patients who are not deemed candidates for pre-emptive TIPS, could improve the management of secondary prophylaxis by reducing costs and adverse events due to ineffective therapy [77].…”

Hepatic encephalopathy: issues relevant to clinical practice

“…[3]; 2) обзорная статья мировых экспертов в вопросах ПЭ «Новый взгляд на классификацию, патофизиологию и терапию ПЭ» [4]; положения консенсуса экспертов в ведении пациентов с декомпенсированным циррозом печени, подготовленные Европейской ассоциацией по изучению печени и опубликованные в J. Hepatology в 2021 г. [5]. Они положены в основу новых дополненных рекомендаций по ведению пациентов с циррозом печени Российского общества по изучению печени, которые сейчас готовятся к публикации и принятию МЗ РФ.…”

New concepts and perspectives in decompensated cirrhosis

“…9 The following chapter deals with the very common scenario where the clinical team is working beyond clinical guidelines to try and save the lives of the patients with decompensated cirrhosis. 10 This is a particularly difficult situation as the team is open to criticism and potential litigation. This is followed by a chapter detailing new concepts in the pathogenesis, assessment and management of sarcopenia and frailty, which have been shown to impact heavily on patients with cirrhosis.…”