(a) Removal of causative factors
For cirrhosis with clear causes, the causes should be removed: (1) Alcoholic cirrhosis should be treated by absolute abstinence from alcohol, and other causes of cirrhosis should also be abstained from alcohol; those with a history of schistosomiasis infection should be treated with anti-bilharzia therapy. (2) Cirrhosis caused by viral hepatitis: Hepatitis B infection is the main cause of cirrhosis in China. Patients with HBV-DNA positive cirrhosis need antiviral treatment (oral nucleoside antiviral drugs), and if HBV-DNA negative, but there is persistent abnormal liver function or progression of cirrhosis still need antiviral treatment. Patients with cirrhosis C who are in the compensated phase and HCV-RNA positive can be treated with antiviral therapy with interferon combined with ribavirin under close monitoring; patients in the decompensated phase can only be treated symptomatically at this time. (Existing reports have reported low-dose interferon therapy under control of the patient’s condition, but the risk is high.) (3) Drug-related hepatitis requires discontinuation of all liver-damaging drugs.
(ii) General supportive therapy
Patients with cirrhosis often have poor general nutritional status. The purpose of supportive therapy is to restore the general condition and supply the liver with sufficient nutrition to facilitate the repair and regeneration of liver cells.
(1) Rest: In compensated cirrhosis, work or labor may be appropriate, but attention should be paid to the combination of work and rest, so as not to feel fatigue. The decompensated stage of cirrhosis should stop working and rest or even basic bed rest to reduce the body’s demand for liver function. During the recovery period, work can be resumed appropriately, but it is appropriate to not feel fatigue.
(2) Diet: In principle, the diet of patients with cirrhosis should be high in calories, adequate protein, restricted sodium intake, and sufficient vitamins. Cirrhosis is a chronic wasting disease, so calories should be supplied adequately. The source of calories is mainly carbohydrates. Sugar is decomposed into glucose in the intestine and absorbed, and turned into liver glycogen in the liver, which is beneficial to the regeneration of liver cells to prevent damage to liver parenchyma by toxic substances. In severe cases, enteral nutrition preparations can be applied. These preparations are based on the principle of comprehensive and balanced nutritional formula, and the intake is regulated according to the condition, avoiding excessive protein and ammonia intake. For those who cannot eat, glucose solution can be given intravenously or intravenously.
A high-protein diet with 1-1.5g of protein per kg of body weight per day is appropriate. Lean meat, fish, chicken, soy products and dairy can be consumed, and food should contain less animal fat. It is advisable to eat vitamin-rich vegetables and fruits, and take oral multivitamin preparations if necessary. Alcohol consumption is strictly prohibited. For those who have the first symptoms of hepatic encephalopathy, protein intake should be limited. Those with esophageal varices should avoid hard and rough food to avoid damage to the esophageal mucosa causing bleeding, and those who are lean should increase their weight appropriately, but should not be too obese or gain weight too fast to avoid promoting fatty liver.
(3) Limit sodium intake: Patients with cirrhosis should have a low-salt diet, especially those with ascites should limit sodium intake.
(3) Active hepatitis period
If necessary, intravenous infusion therapy such as hepatocyte growth promoter, reduced glutathione, glycopyrrolate, etc. should be given.
(iv) Anti-fibrotic treatment
At present, western drugs against liver fibrosis have great side effects and poor efficacy. Traditional Chinese medicine has obvious advantages in anti-liver fibrosis and cirrhosis, which can be treated with traditional Chinese medicine on the basis of etiological treatment.
(E) Treatment of complications of liver cirrhosis
(1) Spontaneous peritonitis
Select antibacterial drugs that mainly target gram-negative bacilli and take into account gram-positive cocci. Such as triple cephalosporin, ciprofloxacin, etc. Adjust antibacterial drugs according to the drug sensitivity results and the patient’s response to treatment.
(2) Liver and kidney syndrome
The improvement of renal function depends on the improvement of liver function, so the treatment focuses on the treatment of the primary disease of the liver. On the basis of this, further treatment. (1) Rapidly control upper gastrointestinal haemorrhage, infection and other precipitating factors. ②Control the amount of infusion to maintain water, electrolytes and acid and base balance. ③The treatment of volume expansion selects dextrose, albumin, plasma, whole blood and its own peritoneal fluid concentration back into the transfusion, etc., with less or no saline. ④The application of vasoactive drugs such as dopamine and prostaglandin E2 can improve renal blood flow and increase glomerular filtration rate. ⑤ Dialysis treatment including hemodialysis and peritoneal dialysis is indicated for acute cases, those with the possibility of liver regeneration, or those with the possibility of liver transplantation. ⑥Surgical treatment with liver transplantation, transjugular intrahepatic portosystemic shunt is suitable for cirrhosis with intractable ascites complicated by hepatorenal syndrome, but the results are not yet satisfactory. Postoperative treatment with dialysis is still required. Liver transplantation is currently recognized as the most effective treatment method. (7) Other treatment: avoid strong diuresis, simple massive discharge of ascites and the use of drugs that impair renal function.
(3) Hepatic encephalopathy
(1) Eliminate causative factors and low protein diet. (2) Correction of ammonia toxicity: oral lactulose, which can acidify the intestine, keep the stool open and change the intestinal PH value, so that the amount of ammonia produced and absorbed by the intestine can be reduced, and can reduce endotoxemia and other toxic substances absorption. Menthyl ornithine and blood ammonia are metabolized to form urea and eliminated from the body, which has a clear clinical efficacy. ③Branched-chain amino acids treat and antagonize the toxic effects of aromatic amino acids. ④Actively prevent brain edema. (5) Various kinds of intractable and severe hepatic encephalopathy and end-stage liver disease are feasible for artificial liver and liver transplantation.
(4) Rupture of esophagogastric varices and bleeding
If not rescued in time, it can be life-threatening. Establish hemodynamic monitoring, volume expansion, blood transfusion, reduction of portal pressure (growth inhibitor, octreotide, nitroglycerin + posterior pituitary hormone), hemostasis, acid suppression, triple lumen tube compression hemostasis, endoscopic treatment, gastric coronary vein embolization, surgery, transjugular intrahepatic portal vein stent shunt.
(5) Treatment of peritoneal effusion
(1) General treatment includes bed rest and restriction of water and sodium intake. ②Diuretic treatment Mainly use the oral or intravenous treatment such as aminoglutethimide, tachyphylline, dihydrochlorothiazide and aminopterin. If the diuretic effect is not obvious, the amount can be gradually increased. Diuretic treatment is appropriate to reduce body weight by no more than 0.5 kg per day to avoid inducing hepatic encephalopathy and hepatorenal syndrome. If the ascites gradually subsides, the diuretic can be gradually reduced. ③Repeatedly put a large amount of peritoneal fluid plus intravenous infusion of albumin For the treatment of refractory peritoneal fluid. ④Increase plasma colloid osmotic pressure by intravenous infusion of plasma or albumin. ⑤Concentration of peritoneal fluid for the treatment of refractory peritoneal fluid, or patients with hypovolemia, hyponatremia, hypoproteinemia and hepatorenal syndrome, as well as patients with large amount of peritoneal fluid due to various reasons who need urgent relief of symptoms. (6) Abdominal-jugular venous drainage, or PVS, is an effective method for the management of cirrhosis and peritoneal effusion. However, its application is greatly limited because it has more complications, such as fever, bacterial infection, pulmonary edema, etc. (7) Transjugular intrahepatic portosystemic shunt (TIPS) can effectively reduce the portal pressure with little trauma and high safety. It is suitable for hemorrhage of esophageal varices and refractory peritoneal effusion, but it is easy to induce hepatic encephalopathy.
Treatment to reduce portal pressure
(a) Insulin should be given orally in small doses, incrementally, and discontinued when the heart rate is monitored below 60 beats per minute.
(b) Nitrates such as cardiac pain.
(c) calcium channel blockers such as cardiac pain, emergency administration can be sublingual.
(d) B vitamin and digestive enzyme supplementation.
(e) Treatment of hypersplenism: leukocyte- and platelet-raising drugs (e.g., leucovorin, shark’s liver alcohol, amineptin, etc.) may be given.
(f) Surgical treatment of portal hypertension Indications are ruptured esophagogastric variceal bleeding, which is not effective after non-surgical treatment; giant spleen with hypersplenism; patients at high risk of bleeding from esophageal varices. It includes portal-ventricular shunt, portal-archipelvic shunt and splenectomy, etc.
(6) Treatment of primary liver cancer
Currently, surgery, intervention (vascular embolization + CT-guided local ablation), local radiotherapy (γ-knife, linear gas pedal, 3D conformal radiotherapy) and other therapies can be applied to individualize the treatment of hepatocellular carcinoma. Licartin, sorafenib, gene therapy and biological therapy can prevent recurrence.
(vi) Liver transplantation
Applicable to end-stage liver disease for which conventional medical and surgical treatment is ineffective. It includes irreversible peritoneal effusion; portal hypertension with upper gastrointestinal bleeding; severe liver function impairment (Child grade C); hepatorenal syndrome; hepatic encephalopathy with progressive aggravation; liver cancer complicated by cirrhosis.