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How to Treat Portal Hypertension And Cirrhosis?


Things to note:
  • 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.

Medical Treatment:
Ascites, oedema
If no response to strict bed rest after 2-3 days:
  • Spironolactone, oral, 50-200 mg daily.
    • Titrate to higher dosages with caution.
    • Maximum dose: 400 mg daily.
    • May cause hyperkalemia.
    • Can be combined with furosemide.
    • 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.
    • Titrate carefully to desired effect as rapid fluid shift may precipitate liver failure.
    • Optimal dose: 160 mg daily.
    • Measure response to diuretics. Aim for weight loss of:
      300-500 g/day patients without oedema
      800-1000 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.
  • 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.