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Viral Hepatitis and Liver Disease

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Stages of Cirrhosis

for Health Care Providers

Stages of Cirrhosis - Cirrhosis

Appropriate timing of the initial referral for transplant evaluation is critical for optimal care of patient with cirrhosis.

Key concepts

  • Cirrhosis is the end stage of any chronic liver disease
  • There are 2 clinical stages of cirrhosis: compensated and decompensated
  • The diagnosis of cirrhosis can be made by clinical, laboratory, imaging, or liver stiffness findings
  • For compensated cirrhosis patients, non-invasive parameters all may be normal and liver biopsy would be required for diagnosis
  • Patients with compensated cirrhosis are asymptomatic and overall have median survival times of > 12 years
  • Patients with decompensated cirrhosis have had at least one complication including ascites, jaundice, variceal hemorrhage or hepatic encephalopathy, and overall they have median survival times of 2 years

Key recommendations

  • Management of patients with any chronic liver disease should include regular assessments for the development of cirrhosis
  • Clinicians should not rule out the presence of compensated cirrhosis on the basis of normal lab or imaging findings; liver biopsy may be necessary for diagnosis
  • The care of patients with compensated cirrhosis should be aimed at the prevention of decompensation
  • Clinicians should recognize decompensated cirrhosis based on overt history, in conjunction with physical and laboratory findings
  • It is critical to understand that decompensating events place patients at higher risk of further complications and death

Stages of Cirrhosis

  • There are 2 stages of cirrhosis: compensated cirrhosis and decompensated cirrhosis (clinical stages)
  • The stages are dynamic and progressive, but there is potential reversibility from the decompensated to compensated stage
  • Compensated cirrhosis is the asymptomatic stage
    • Compensated patients do not have ascites, variceal hemorrhage, hepatic encephalopathy, or jaundice
    • Median survival time of patients with compensated cirrhosis is > 12 years
    • Subpopulations can be identified based on the presence or absence of varices
    • Presence of varices is the key prognostic factor for compensated patients, and indicates higher likelihood of decompensation
  • Decompensated cirrhosis is the symptomatic stage
    • Decompensated cirrhosis is characterized by the presence or development of overt complications: ascites, jaundice, variceal hemorrhage, or hepatic encephalopathy
    • Median survival time of patients with decompensated cirrhosis is approximately 2 years
    • Subpopulations can be identified based on type or number of decompensating events
    • The MELD-Na score is the best predictor of death in patients with decompensated cirrhosis
    • Decompensation may improve and can regress to a compensated stage if the etiology of the liver disease is resolved (eg, alcohol abstinence)

Making the Diagnosis of Compensated vs. Decompensated Cirrhosis

  • Cirrhosis can be diagnosed with clinical, laboratory, radiologic, elastographic, or biopsy findings (see Diagnosis of Cirrhosis for details)
  • The diagnosis of compensated cirrhosis is more challenging since patients may lack clinical, laboratory, and radiologic findings and may require biopsy for diagnosis
  • The diagnosis of decompensated cirrhosis is easier as the patient history, physical exam, and laboratory findings are usually more evident

Child-Turcotte-Pugh score

  • The Child-Turcotte-Pugh (CTP) score is used as a prognostic scoring system in cirrhosis based on 2 clinical and 3 laboratory parameters:
    • Ascites: none (1 point); diuretic-sensitive or mild/moderate (2 points); diuretic-refractory or tense (3 points)
    • Encephalopathy: none (1 point); episodic or overt grade 2 (2 points); recurrent/chronic or grade 3-4 (3 points)
    • Albumin in g/dL: > 3.5 (1 point); 3.4-2.8 (2 points); < 2.8 (3 points)
    • Bilirubin in mg/dL: < 2 (1 point); 2-3 (2 points); > 3 (3 points)
    • INR: < 1.7 (1 point); 1.7-2.3 (2 points); > 2.3 (3 points)
  • In the original scoring system, nutritional status (normal, moderately altered, malnourished) was used instead of INR, which reflects the importance of sarcopenia in cirrhosis
  • CTP A patients (5-6 points) are mostly patients with compensated cirrhosis
    CTP B patients (7-9 points) are mostly decompensated but decompensation is "early"
    CTP C patients (10-15 points) are decompensated (late or "further" decompensation)

Primary Goals in Management of Compensated Cirrhosis

  • Treatment of the etiology of the underlying liver disease, for example:
    • Antiviral treatment of HCV or HBV
    • Abstinence from alcohol
  • Screening for varices (see Cirrhosis Quicknotes for details)
    • Prevention of first variceal hemorrhage
  • Screening for hepatocellular carcinoma
    • Screening should continue indefinitely once cirrhosis is diagnosed and even after removal of etiological factor
    • No difference in recommendations for compensated or decompensated patients
  • Prevention of decompensation
    • Alcohol use: complete abstinence
    • Obesity: management
    • Hepatotoxicity from drugs: careful dosing and selection of medications
    • NSAIDs: avoidance
    • Acute injury by viruses: appropriate vaccinations
    • Dyslipidemia: Do NOT avoid statins
    • Diabetes mellitus: optimize control

Primary Goals in Management of Decompensated Cirrhosis

  • Treatment of etiology of the underlying liver disease
    • Antiviral treatment of HCV or HBV is more complicated
    • Abstinence from alcohol
  • Screening for varices (if no history of variceal hemorrhage) (see Cirrhosis Quicknotes for details)
    • Prevention of first variceal hemorrhage
  • Screening for hepatocellular carcinoma
    • Screening should continue indefinitely, even with regression to compensated stage
    • No difference in recommendations for compensated or decompensated patients
  • Symptomatic management of complications (see Cirrhosis Quicknotes for details)
    • Ascites (diuretics → large-volume paracentesis → transjugular intrahepatic portosystemic shunt (TIPS), if refractory
    • Encephalopathy (lactulose → rifaximin, if recurrent)
    • Prevention of further decompensation and death
    • Prevention of recurrent variceal hemorrhage: beta-blockers + ligation, TIPS if recurrent
      • Alcohol use: complete abstinence
      • Obesity: management
      • Hepatotoxicity from drugs: careful dosing and selection of medications
      • Acute injury by viruses: appropriate vaccinations
      • Management of volume status (see Cirrhosis Quicknotes for details)
      • Vasodilators (see Cirrhosis Quicknotes for details)
      • NSAIDs: avoidance
      • Dyslipidemia: Do NOT avoid statins (but use lower dosages)
      • Diabetes mellitus: optimize control
    • Calculate MELD-Na score every 3-6 months

Refer for liver transplant evaluation when appropriate (see When to Refer for Transplant for details)