Portal Hypertension and Cirrhosis

Description

General Measures

Medicine Treatment

Referral

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ICD-10 code: R18/K72.9/K74.6+(I98.2*/I98.3*)

DESCRIPTION

The complications of portal hypertension include:

• variceal bleeds,
• ascites,
• hepatic encephalopathy (HE),
• splenomegaly with hypersplenism,
• hepatorenal syndrome,
• hepato-pulmonary syndrome or porto-pulmonary hypertension

GENERAL MEASURES

• Ascites: Perform diagnostic paracentesis if indicated. Restrict sodium intake, i.e. ≤ 2 g/day or ≤ 88 mmol/day.
• Monitor weight regularly.
• Encephalopathy: with acute HE, protein restrict (ideally under advice of dietician), otherwise 1–1.5 g/kg protein per day.
• Exclude infection, high protein load, occult bleed, sedatives, electrolyte disturbances and hepatocellular carcinoma.
• Variceal bleeding: endoscopic variceal ligation and/or immediate referral for advanced management.

MEDICINE TREATMENT

Ascites R18

• Spironolactone, oral, 100 mg daily.

AND

• Furosemide, oral, 40 mg daily.

For spironolactone and furosemide:

• Increase spironolactone and furosemide dose by 100 mg and 40 mg, respectively, every 3–5 days, to a maximum dose of 400 mg spironolactone and 160 mg of furosemide depending on serum Na⁺ , K⁺ , urea and creatinine.
• Spironolactone may cause hyperkalaemia.
• Rapid fluid shifts may precipitate acute liver and/or renal failure.

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Monitoring of sodium, potassium and renal function is essential in patients taking spironolactone. Avoid spironolactone if eGFR <30 mL/minute.

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LoE:III^xvi

Measure response to diuretics by weighing patient daily. Aim for maximal weight loss of:

• Patients without oedema: 500 g/day
• Patients with oedema: 1 000 g/day

Tense ascites R18

Albumin replace ment must be given if ≥5 L of fluid is drained by paracentesis, or if there is pre-existing renal dysfunction:

LoE:II^xvii

• Albumin, IV, 40 g (20%), as an infusion.
  • Refer to specialist unit to consider transjugular intrahepatic portosystemic (TIP) shunt or potential transplant.
• Introduce diuretics and titrate doses as necessary to prevent recurrence of ascites (see above).

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Note:
Avoid NSAIDS and ACE-inhibitors.
Exclude spontaneous bacterial peritonitis in patients with new onset ascites.

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Refractory ascites R18

Defined as:

• No response to optimal diuretic therapy despite sufficient sodium restriction (≤2 g/day or ≤88 mmol/day) and avoidance of NSAIDs.
• Ascites that recurs rapidly following therapeutic paracentesis.

Perform serial large volume paracentesis, as an outpatient, usually not more frequently than every 2 weeks. Haemodynamic collapse is more likely in patients who have intravascular volume depletion. Check renal function before paracentesis.

Albumin replacement must be given if ≥5 L of fluid is removed by paracentesis:

• Albumin, IV, 40 g (20%), as an infusion.

LoE:II^xviii

Encephalopathy

• Lactulose, oral, 10–30 mL 8 hourly, depending on stool number and consistency (aim for 2 soft stools/day).

Look for precipitating factors: Sepsis, protein load, GIT bleed, over diuresis, sedation.

Oesophageal varices I85.0/I85.9

To reduce the risk of bleeding:

• Beta-blocker, e.g.:

LoE:III^xix

• Propranolol, oral, 20–40 mg 12 hourly. Titrate to resting pulse rate of 50– 60 beats per minute. Monitor pulse and BP.

REFERRAL

Refer to specialist unit to consider TIP shunt, endoscopic variceal ligation or potential transplant.

Click here for the pdf.

Click here for the NEMLC Recommendations for medicine treatement (2020-4 review cycle).

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Standard Treatment Guidelines And Essential Medicines List For South Africa, Adult Hospital level, 2020-4_Version 1_July 2024

Chapter 1: Alimentary tract; 1.2 Hepatic Disorders; 1.2.3 Portal Hypertension and Cirrhosis