How can I effectively manage the complications of cirrhosis, such as hepatic encephalopathy?

Effective management of cirrhosis complications, such as hepatic encephalopathy (HE), involves a multi-faceted approach focusing on specific treatments, monitoring, and specialist referrals.

• Managing Hepatic Encephalopathy (HE): For people with persistent or unprovoked hepatic encephalopathy, lactulose and/or rifaximin antibiotic medication may be prescribed to reduce the risk of recurrent overt HE ¹ (Mansour, 2023b). It is important to be aware that opiates and benzodiazepines may precipitate or aggravate hepatic encephalopathy and oversedation ¹ (Ge, 2016). Hepatic encephalopathy can present with non-specific, subtle symptoms of cognitive impairment in primary care ¹ (Shawcross, 2016). General practice staff should ensure people are aware of red flag symptoms, such as worsening encephalopathy ¹.
• General Management of Cirrhosis Complications:
  • Specialist Referral and Monitoring: People who have, or are at high risk of, complications of cirrhosis should be referred to a specialist hepatology centre ². The Model for End-stage Liver Disease (MELD) score should be calculated every 6 months for people with compensated cirrhosis, with a score of 12 or more indicating a high risk of complications ². Primary healthcare professionals play an important role in the early recognition of complications, facilitating liaison with specialists for management and prevention ¹ (Muir, 2015).
  • Preventing Infections: Specialist treatment with prophylactic antibiotics may be considered to prevent spontaneous bacterial peritonitis (SBP) if a person has ascites and is at high risk of infection, or if the consequences of infection could severely impact their outcome ¹ (NICE, 2023).
  • Surveillance for Other Complications: Regular surveillance is crucial for other complications. This includes offering ultrasound every 6 months for hepatocellular carcinoma (HCC) surveillance for people with cirrhosis who do not have hepatitis B virus infection ². An upper gastrointestinal endoscopy should be offered after a cirrhosis diagnosis to detect oesophageal varices, and surveillance endoscopy every 3 years if no varices are found and the person is not taking carvedilol or propranolol ². If medium or large varices are detected, simultaneous endoscopic variceal band ligation may be considered ².
  • Medication Review and Safety: Medications should be reviewed, and any necessary changes to drugs or dosage in relation to liver function should be assessed ¹. Specialist advice should be sought if there is uncertainty about drug prescribing ¹. People should be advised to seek medical advice before taking any over-the-counter drugs or herbal remedies, as pathophysiological changes in cirrhosis can alter drug exposure and responses ¹ (Weersink, 2020).
  • Nutritional Support and Palliative Care: Assess the risk for malnutrition and refer to the local nutrition and dietetic team for assessment and advice, particularly for those with decompensated disease ¹. For people with end-stage liver disease, early referral to a multidisciplinary palliative care team is important, as they can provide support for symptoms and the psychosocial impact of the disease ¹ (Mansour, 2023b).
  • Alcohol-Related Liver Disease: If the cirrhosis is alcohol-related, consider referral to specialist alcohol services for support ¹. For suspected Wernicke's encephalopathy, offer parenteral thiamine for a minimum of 5 days, followed by oral thiamine ³.