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Cirrhosis (Liver)

How is cirrhosis treated? (continued)

Hepatic encephalopathy. Patients with an abnormal sleep cycle, impaired thinking, odd behavior, or other signs of hepatic encephalopathy usually should be treated with a low protein diet and oral lactulose. Dietary protein is restricted because it is a source of toxic compounds that cause hepatic encephalopathy. Lactulose, which is a liquid, traps toxic compounds in the colon so they cannot be absorbed into the blood stream, and thuse causes encephalopathy. Lactulose is converted to lactic acid in the colon, and the acidic environment that results is believed to trap the toxic compounds produced by the bacteria. To be sure that adequate lactulose is present in the colon at all times, the patient should adjust the dose to produce 2 to 3 semiformed bowel movements a day. (Lactulose is a laxative, and the adequacy of treatment can be judged by loosening or increasing frequency of stools.) Rifaximin (Xifaxan) is an antibiotic taken orally that is not absorbed into the body but rather remains in the intestines. It is the preferred mode of treatment of hepatic encephalopathy. Antibiotics work by suppressing the bacteria that produce the toxic compounds in the colon.

Hypersplenism. The filtration of blood by an enlarged spleen usually results in only mild reductions of red blood cells (anemia), white blood cells (leukopenia) and platelets (thrombocytopenia) that do not require treatment. Severe anemia, however, may require blood transfusions or treatment with erythropoietin or epoetin alfa (Epogen, Procrit), hormones that stimulate the production of red blood cells. If the numbers of white blood cells are severely reduced, another hormone called granulocyte-colony stimulating factor is available to increase the numbers of white blood cells. An example of one such factor is filgrastim (Neupogen).

Neumega (Oprelvelkin) is used to increase the number of platelets. As a necessary precaution, patients with low platelets should not use aspirin or other nonsteroidal antiinflammatory drugs (NSAIDS) since these drugs can hinder the function of platelets. If a low number of platelets is associated with significant bleeding, transfusions of platelets usually should be given. Surgical removal of the spleen (called splenectomy) should be avoided, if possible, due to the risk of excessive bleeding during the operation and the risk of anesthesia in advanced liver disease.

Spontaneous bacterial peritonitis (SBP). Patients suspected of having spontaneous bacterial peritonitis usually will undergo paracentesis. Fluid that is removed is examined for white blood cells and cultured for bacteria. Culturing involves inoculating a sample of the ascites into a bottle of nutrient-rich fluid that encourages the growth of bacteria, thus facilitating the identification of even small numbers of bacteria. Blood and urine samples also are often obtained for culturing because many patients with spontaneous bacterial peritonitis also will have infection in their blood and urine. In fact, many doctors believe that infection may have begun in the blood and the urine and spread to the ascitic fluid to cause spontaneous bacterial peritonitis. Most patients with spontaneous bacterial peritonitis are hospitalized and treated with intravenous antibiotics such as cefotaxime. Patients usually treated with antibiotics include:

  • Ascites fluid cultures that contain bacteria.
  • Patients without bacteria in their blood, urine, and ascitic fluid but who have elevated numbers of white blood cells (neutrophils) in the asciticfluid (>250 neutrophils/cc). Elevated neutrophil numbers in ascitic fluid often means that there is bacterial infection. Doctors believe that the lack of bacteria with culturing in some patients with increased neutrophils is due either to a very small number of bacteria or ineffective culturing techniques.

Spontaneous bacterial peritonitis is a serious infection. It often occurs in patients with advanced cirrhosis whose immune systems are weak, but with modern antibiotics and early detection and treatment, the prognosis of recovering from an episode of spontaneous bacterial peritonitis is good.

In some patients oral antibiotics (norfloxacin [Noroxin] or sulfamethoxazole and trimethoprim [Bactrim]) can be prescribed to prevent spontaneous bacterial peritonitis. Not all patients with cirrhosis and ascites should be treated with antibiotics to prevent spontaneous bacterial peritonitis, but some patients are at high risk for developing spontaneous bacterial peritonitis and warrant preventive treatment:

  • Patients with cirrhosis who are hospitalized for bleeding varices have a high risk of developing spontaneous bacterial peritonitis and should be started on antibiotics early during the hospitalization to treat presumed spontaneous bacterial peritonitis
  • Patients with recurring episodes of spontaneous bacterial peritonitis
  • Patients with low protein levels in the ascitic fluid (Ascitic fluid with low levels of protein is more likely to become infected.)
Reviewed on 10/11/2016

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