Figure A-1.

Treatment flow sheet for patients with cirrhosis

Table A-1. Recommended management of variceal hemorrhage

Treatment Indications Recommendations Comment
Type
Primary Medium/large First-line therapy Goal of beta-blocker
Prophylaxis esophageal varices Nonselective beta- therapy
blockers Maximal tolerable
Gastric varices (propranolol, dose to reduce heart
nadolol) rate to 55-60
beats/minute
Alternative therapy
Endoscopic variceal
band ligation

Not recommended
Nitrates alone,
sclerotherapy, shunt
surgery, TIPS

Acute Upper GI First-line therapy An additional

Variceal hemorrhagewith the Endoscopic therapy benefit may be
Hemorrhage following (sclerotherapy or derived by
endoscopic findings: band ligation) ± drug associating
 Active bleeding therapy endoscopic therapy
from a varix or with drug therapy
Short-term antibiotic (see text)
Stigmata of prophylaxis (see
variceal Table 2) Cautious
bleeding or transfusion of fluid
Rescue therapy and blood products
Presence of gastro- Shunt surgery or is recommended
esophageal varices TIPS (goal hematocrit 25
without other to 30 percent)
sources of Not recommended
bleeding Balloon tamponade
(except as a bridge to
rescue therapy)

Secondary Prior history of First-line therapy In patients

Prophylaxis variceal hemorrhage Nonselective beta-
(with hemo- blockers + nitrates
dynamic stability for
24 hours) Alternative therapy
Endoscopic variceal
band ligation
Rescue therapy
Shunt surgery or
TIPS
Not recommended
Sclerotherapy
intolerant to
combination
pharmacological
therapy, treat with
beta-blockers alone
In patients who
failed
pharmacological
therapy or ligation,
a combination of
both can be
considered

TIPS: transjugular intrahepatic portosystemic shunt

Table A-2. Recommended management of spontaneous bacterial
peritonitis (SBP)
Treatment Recommendations Comment
Type
Primary Long-term prophylaxis not Short-term antibiotic
Prophylaxis recommended, regardless of ascites prophylaxis should be
protein levels performed
independent of the
Short-term (7-day) prophylaxis with presence or absence of
aquinolone (norfloxacin,ciprofloxacin, ascites, although
orlevofloxacin) is recommended in patients with ascites
patients admitted with GI hemorrhage and severe liver
disease are the ones
most likely to benefit
Active Recommended therapy Recommended
Spontaneous Intravenous cefotaxime or other third- duration of
Bacterial generation cephalosporin (ceftriaxone) treatment is 8 days
Peritonitis
Intravenousampicillin/sulbactam In case of no obvious
improvement
Alternative therapy despite antibiotics, a
Oral ofloxacin or other fully absorbed followup
quinolones (levofloxacin) (depending on paracentesis at 48
prevalence of quinolone-resistant hours is
organisms at each institution) recommended

Adjunctive therapy Oral therapy may be

Intravenous albumin in selected patients considered in
community-acquired
Not recommended SBP in the absence of
Aminoglycosides renal dysfunction and
encephalopathy

Albumin is
recommended in
patients with renal
dysfunction and
hyperbilirubinemia
(bilirubin >4 mg/dL)
at time of SBP
diagnosis

Avoid interventions
that may further
decrease intravascular
volume (e.g. large
volume paracentesis,
diuretics)
Secondary Recommended therapy Prophylaxis should be
Prophylaxis Oral norfloxacin 400 mg PO QD; oral given until the
ciprofloxacin 250 mg QD; oral disappearance of
levofloxacin 250 mg QD ascites, time of
transplantation, or
Alternative therapy death
Trimethoprim-sulfamethoxazole
onedouble-strength tab PO every day Patients who develop
quinolone-resistant
Not recommended organism may also
have resistance to
Weekly ciprofloxacin trimethoprim-
sulfamethoxazole
Table A-3. Recommended management of ascites
 Ascites Type Recommendations
Uncomplicated Recommended therapy
Ascites Sodium (salt) restriction +/-
Diuretics (spironolactone +/-
furosemide)
Initial LVP plus albumin
infusion in hospitalized
patients with moderate or
tense ascites
Not recommended
Furosemide alone
Refractory Recommended therapy
Ascites LVP plus albumin (continue
with salt restriction and
diuretic therapy as tolerated)
Alternative therapy  
TIPS in patients who require
frequent LVP
PVS in patients who are not
TIPS or transplant candidates
Not recommended  
TIPS or PVS as first-line
therapy
LVP: large volume paracentesis
TIPS: transjugular intrahepatic portosystemic shunt 
Comment
Recommended sodium
restriction of no less than 2
g/day
Dose of diuretics:
spironolactone 100-400
mg/day, furosemide 40-160
mg/day
Dose of albumin 6-8 g/L of
ascites removed
Amiloride may be used in
patients who do not tolerate
spironolactone
Adjustment in diuretic
dosage should be performed
every 4-7 days
NSAID use should be
avoided
If less than 5 liters of ascites
is extracted, a synthetic
plasma volume expander
may be used instead of
albumin or may not be
necessary particularly in
patients with normal renal
function
PVS: peritoneovenous shunt 
NSAID: non-steroidal anti-inflammatory drugs
 
Table A-4. Recommended management of hepatorenal syndrome
Treatment of Hepatorenal Syndrome (HRS)
Recommended Liver transplantation
Therapy
Rescue Therapy (as These therapies are still considered experimental
a bridge to Albumin plus vasoconstrictors: midodrine plus octreotide,
transplantation) norepinephrine, ornipressin, or terlipressin (last two not
available in the U.S.)

TIPS (transjugular intrahepatic portosystemic shunt)

MARS (molecular adsorbent recirculating system)

Not Recommended Prostaglandins

Dopamine

Dialysis

Table A-5. Recommended treatment of hepatic encephalopathy (HE)

Treatment Type Recommendations Comment
General Identification and treatment of Protein from dairy or
Measures the precipitating cause(s) vegetable sources are
Avoidance of sedatives and preferable to animal protein
tranquilizers

Nutritional support

Acute Hepatic Recommended therapy Lactulose enemas (300 cc in

Encephalopathy Lactulose 45 cc PO every hour 1 liter of water) in patients
until bowel evacuation then who are unable to take it by
adjust to a dose that will result mouth.
in two to three bowel
movements/day (usually 15- Short-term (<72 hours)
30 cc PO BID) protein restriction may be
considered in severe HE
Alternative therapy
Neomycin 3-6 g PO every day
in three doses plus milk of
magnesia

Metronidazole starting at 250

 mg PO BID

Chronic Hepatic Recommended therapy Patients on chronic

Encephalopathy Lactulose dosage that antibiotics need to be
produces two to three bowel monitored for
movements/day, starting at nephrotoxicity, ototoxicity,
15-30 cc PO BID and neurotoxicity

Alternative therapy Protein from dairy or

Neomycin starting at 1-3 g PO vegetable sources may be
QD (three divided doses) preferable to animal protein

Metronidazole starting at 250

mg PO BID

Not recommended
Long-term protein restriction

Helicobacter
pylori eradication

Table A-6. Modified Child-Pugh-Turcotte (CPT) classification

Parameters Points
1 2 3
Bilirubin (mg/dL) <2 2-3 >3

Prothrombin time* or INR <4 4-6 >6

Albumin (g/L) >3.5 2.8-3.5 <2.8

Hepatic Encephalopathy Absent Controlled Uncontrolled

Ascites Absent Controlled Uncontrolled

*seconds above control

CPT Classes:
A = 5-6 points
B = 7-9 points
C = 10-15 points