PORTAL HYPERTENSION AND CIRRHOSIS

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DESCRIPTION

The complications of portal hypertension are:

» variceal bleeds

» ascites and fluid overload

» encephalopathy

» spontaneous bacterial peritonitis in patients with ascites

GENERAL MEASURES

Ascites: salt restriction, i.e. < 2 g/day.

Monitor weight regularly.

Bed rest.

Encephalopathy: low protein diet. Severe protein restriction may accentuate

catabolism. Use increments of 20 g protein per day as tolerated.

Exclude infection, high protein load, occult bleed, sedatives and electrolyte

disturbances.

Variceal bleeding: endoscopic sclerotherapy and/or banding.

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MEDICINE TREATMENT

Ascites, oedema

If no response to strict bed rest after 2–3 days:

• Spironolactone, oral, 50–200 mg daily.

o Titrate to higher dosages with caution.

o Maximum dose: 400 mg daily.

o May cause hyperkalemia.

o Can be combined with furosemide.

o Potassium supplementation is not necessary.

AND

If there is no response to spironolactone or if there is gross fluid retention:

• Furosemide, oral, 20–40 mg daily, initially for a few days to increase

natriuresis.

o Titrate carefully to desired effect as rapid fluid shift may precipitate

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liver failure.

o Optimal dose: 160 mg daily.

o Measure response to diuretics. Aim for weight loss of:

300–500 g/day patients without oedema

800–1 000 g/day patients with peripheral oedema

Resistant ascites

Patients not responding to optimal diuretic therapy, sufficient salt restriction

and avoiding NSAIDs.

These patients may require regular large volume paracentesis, i.e. > 5 L, as

outpatients, if possible.

Protect against haemodynamic collapse.

Crystalloid replacement.

Large-volume ascites

Large volume paracentesis is the method of choice as it is faster, more

effective and has fewer adverse effects compared to diuretics.

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Diuretics are indicated as maintenance therapy to prevent recurrence of

ascites.

Encephalopathy

• Lactulose, oral, 10–30 mL 8 hourly.

Oesophageal varices

To reduce the risk of bleeding:

• Propranolol, oral 10–20 mg 12 hourly.

Reference and further reading

Standard Treatment Guidelines and Essential Medicines List for South Africa 2012 Edition

 

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