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 NICE CKS Mansour 2023. It is important to be aware that opiates and benzodiazepines may precipitate or aggravate hepatic encephalopathy and oversedation NICE CKS Ge 2016. Hepatic encephalopathy can present with non-specific, subtle symptoms of cognitive impairment in primary care NICE CKS Shawcross 2016. General practice staff should ensure people are aware of red flag symptoms, such as worsening encephalopathy NICE CKS.
• 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 NICE NG50. 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 NICE NG50. Primary healthcare professionals play an important role in the early recognition of complications, facilitating liaison with specialists for management and prevention NICE CKS 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 NICE CKS 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 NICE NG50. 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 NICE NG50. If medium or large varices are detected, simultaneous endoscopic variceal band ligation may be considered NICE NG50.
  • Medication Review and Safety: Medications should be reviewed, and any necessary changes to drugs or dosage in relation to liver function should be assessed NICE CKS. Specialist advice should be sought if there is uncertainty about drug prescribing NICE CKS. 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 NICE CKS 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 NICE CKS. 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 NICE CKS Mansour 2023.
  • Alcohol-Related Liver Disease: If the cirrhosis is alcohol-related, consider referral to specialist alcohol services for support NICE CKS. For suspected Wernicke's encephalopathy, offer parenteral thiamine for a minimum of 5 days, followed by oral thiamine NICE CG100.