Alcoholic Cirrhosis

Alcoholic Cirrhosis – Treatment Options

Introduction
Alcoholic cirrhosis is the end-stage of chronic alcohol-related liver disease, characterized by irreversible fibrosis and regenerative nodule formation that distorts normal hepatic architecture. It develops after years of heavy alcohol consumption and leads to portal hypertension, impaired liver function, and increased risk of hepatocellular carcinoma (HCC). Symptoms include jaundice, ascites, variceal bleeding, hepatic encephalopathy, and coagulopathy. Management focuses on alcohol abstinence, complication control, and liver transplantation in advanced cases.

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1. Lifestyle and Causal Management

• Absolute alcohol abstinence:

  • The most important intervention; improves survival and may slow disease progression.

• Nutritional support:

  • High-calorie (30–35 kcal/kg/day) and high-protein (1.2–1.5 g/kg/day) diet.

  • Vitamin supplementation (thiamine, folate, vitamin D, zinc, fat-soluble vitamins).

• Avoid hepatotoxins: NSAIDs, unnecessary sedatives, and other liver-damaging drugs.

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2. Management of Portal Hypertension and Complications

• Ascites:

  • Sodium restriction (<2 g/day).

  • Diuretics: spironolactone ± furosemide.

  • Large-volume paracentesis for tense ascites (with albumin infusion to prevent renal dysfunction).

  • Refractory ascites → consider TIPS (transjugular intrahepatic portosystemic shunt).

• Variceal bleeding:

  • Primary prophylaxis: non-selective beta-blockers (propranolol, nadolol, carvedilol) or endoscopic variceal ligation (EVL).

  • Acute bleed: Resuscitation, IV octreotide/terlipressin, antibiotics, urgent endoscopic band ligation.

  • Secondary prophylaxis: Combination of non-selective beta-blockers + EVL.

• Hepatic encephalopathy:

  • Lactulose (first-line) titrated to 2–3 soft stools/day.

  • Rifaximin as add-on therapy to reduce recurrence.

  • Correct precipitating factors (GI bleed, infection, constipation, electrolyte imbalance).

• Spontaneous bacterial peritonitis (SBP):

  • Treat with IV cefotaxime or ceftriaxone.

  • Long-term prophylaxis: Norfloxacin or trimethoprim-sulfamethoxazole in high-risk patients.

• Hepatorenal syndrome (HRS):

  • Volume expansion with albumin.

  • Vasoconstrictors: terlipressin, norepinephrine, or midodrine + octreotide.

  • Definitive treatment: Liver transplantation.

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3. Surveillance and Preventive Care

• HCC surveillance: Abdominal ultrasound ± alpha-fetoprotein every 6 months.

• Vaccinations: Hepatitis A, hepatitis B, pneumococcal, and annual influenza vaccines.

• Bone health: Monitor for osteoporosis; calcium/vitamin D supplementation as needed.

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4. Liver Transplantation

• Only curative option for decompensated cirrhosis.

• Selection criteria: Advanced liver disease (high MELD/Child-Pugh score), failure of medical therapy, and documented sustained alcohol abstinence (often ≥6 months, though evolving policies allow exceptions in select cases).

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5. Long-Term Support and Rehabilitation

• Alcohol cessation programs: Counseling, CBT, AA, pharmacotherapy (naltrexone, acamprosate, disulfiram if appropriate).

• Psychiatric support for comorbid depression and anxiety.

• Regular monitoring: Labs (LFTs, coagulation, renal function), imaging, and endoscopy for varices