Cirrhosis with or without ascites

1. Background/Cultural Points:

   Cirrhosis and end stage liver disease (ESLD) is fairly common finding in Cambodia. The significant prevalence of Chronic Hepatitis B (and C) in combination with alcohol abuse makes for this to be not uncommon. In addition some parasitic diseases like Schistosomiasis can lead to cirrhosis as well as other etiologies. Ascites is the most common complication of cirrhosis; other complications to be aware of are variceal hemorrhage, SBP, HCC, Hepatorenal syndrome and encephalopathy.

2. Diagnosis & Lab:

   1. History and physical (spider angiomata; palmar erythema; hepatomegaly; splenomegaly; nail bed changes; etc)
   2. Liver biopsy is standard in other countries (not available)
   3. Indirect diagnosis taken with H&P
   4. Ultrasound: Heteroechogenicity, irregular border, portal hypertension
   5. if ascites present the differential is as follows (US stats): Cirrhosis 81%; Cancer 10%; Congestive Heart Failure 3%; TB 2%; Pancreatic disease 1%
   6. Lab: CBC with diff, total bilirubin, albumin, AST, ALT, Hepatitis profile (HBsAg, HCV antibody); creatinine and sodium to help gauge severity

3. Management/Education/Treatment:

   1. Review with patient: 1) Is a chronic condition; 2) treatable but not cured 3) good management requires the patient’s willingness to adjust his/her lifestyle 4) prognosis dependent on co-morbidities.
   2. Lifestyle Points:
      1. Reduce sodium intake. Avoid too much salty fish. (<2 Gm per day)
      2. Change from white-rice-only diet to minimum 20% brown rice (less machine milled)
      3. Alcohol cessation
      4. Smoking cessation
      5. Fluid restriction if serum sodium is less than 125 mmol/day (hyponatremia is a poor prognostic indicator)
      6. Medications (with ascites):
         1. MVT
         2. Diuretics (spironolactone with or without furosemide)
         3. Serial therapeutic paracenteses are a treatment option for patients with refractory ascites.
      7. Prophylaxis of SBP (Spontaneous Bacterial Peritonitis) for:
         1. Cirrhosis and ascitic fluid total protein <1.5 g/dL with at least one of the following:
            1. (a) Child-Pugh ≥9 points and serum bilirubin ≥3 mg/dL or
            2. (b) Serum creatinine ≥1.2 mg/dL or blood urea nitrogen ≥25 mg/dL or serum sodium ≤130 mEq/L (prophylaxis indefinite)
         2. Norfloxacin (400 mg/day) or trimethoprim-sulfamethoxazole
      8. Gastrointestinal bleeding (prophylaxis for 7 days)
         1. Ceftriaxone 1 g daily or 400 mg of norfloxacin orally twice daily or trimethoprim- sulfamethoxazole (one double-strength tablet twice daily) for seven days
      9. Follow-Up: Initial follow-up at 1 month, then q3; Monitor labs appropriately, based on conditions and medications (every 3 to 6 months)