Cirrhosis medical therapy

Jump to navigation Jump to search

Cirrhosis Microchapters


Patient Information


Historical Perspective




Differentiating Cirrhosis from other Diseases

Epidemiology and Demographics

Risk Factors


Natural History, Complications and Prognosis


Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings


Chest X Ray



Echocardiography or Ultrasound

Other Imaging Findings

Other Diagnostic Studies


Medical Therapy


Primary Prevention

Secondary Prevention

Tertiary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case studies

Case #1

Cirrhosis medical therapy On the Web

Most recent articles

cited articles

Review articles

CME Programs

Powerpoint slides


American Roentgen Ray Society Images of Cirrhosis medical therapy

All Images
Echo & Ultrasound
CT Images

Ongoing Trials at Clinical

US National Guidelines Clearinghouse

NICE Guidance

FDA on Cirrhosis medical therapy

CDC on Cirrhosis medical therapy

Cirrhosis medical therapy in the news

Blogs on Cirrhosis medical therapy

Directions to Hospitals Treating Cirrhosis

Risk calculators and risk factors for Cirrhosis medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]


The change that cirrhosis causes to the liver is irreversible, therefore treatment is mostly centered on ameliorating the complications of cirrhosis such as ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, esophageal varices, and hepatorenal syndrome. Chronic constitutional symptoms such as pruritus, hypogonadism, osteoporosis, and anorexia must be treated in patients. Maintenance of adequate nutrition (especially protein intake) is extremely important in cirrhosis patients. The underlying cause of cirrhosis needs to be managed and the treatment varies depending upon the cause of cirrhosis.

Medical Therapy




Pain management in cirrhosis

Nutrition and exercise

The following points need to be kept in mind regarding nutrition in cirrhosis patients:[6][7][8][9]




Treatment of Underlying Causes

Alcoholic Liver Disease

Alcoholic Liver Disease Medical Therapy
  • Mild to moderate alcoholic hepatitis:
    • Abstinence from alcohol
    • Preferred regimen (1): Aggressive enteral nutrition therapy
  • Severe Alcoholic hepatitis:
    • Preferred regimen (1): Four week course of prednisolone (40 mg/day for 28 days), typically followed by discontinuation or a 2-week taper (if no contraindications for steroid use).
    • Preferred regimen (2):Pentoxifylline therapy (400 mg orally 3 times daily for 4 weeks) is an alternative in severe disease, especially if there are contraindications to steroid therapy

Hepatitis C

Hepatitis C Medical Therapy[13][14][15][16][17][18]

Genotypes HCV 1 and 4

  • Preferred regimen (1): Peginterferon plus ribavirin for 48 weeks. The dose for peginterferon alfa-2a is 180 µg subcutaneously per week together with ribavirin using doses of 1,000 mg for those <75 kg in weight and 1,200 mg for those >75 kg; the dose for peginterferon alfa-2b is 1.5 µg/kg subcutaneously per week together with ribavirin using doses of 800 mg for those weighing <65 kg; 1,000 mg for those weighing >65 kg to 85 kg, 1,200 mg for >85 kg to 105 kg, and 1,400 mg for >105 kg.[19]

Genotypes HCV 2 and 3

Hepatitis B

Hepatitis B Medical Therapy[21][22][23][24][25][26][27][28][29][30][25]
a. ALT greater than 2 times normal or moderate/severe hepatitis on biopsy, and HBV DNA >20,000 IU/mL - treatment may be initiated with any of the 7 approved antiviral medications, but pegIFN-α, tenofovir or entecavir are preferred.
b. ALT persistently normal or minimally elevated (<2 times normal) - should not be initiated on treatment.
c. Children with elevated ALT greater than 2 times normal - treatment may be initiated with IFN-α or lamivudine if ALT levels remain elevated at this level for longer than 6 months.

Autoimmune Hepatitis

Autoimmune Hepatitis Medical Therapy

Primary Biliary Cirrhosis

Primary Biliary Cirrhosis Medical Therapy

Primary Sclerosing Cholangitis

Primary Sclerosing Cholangitis Medical Therapy

Wilson's Disease

Wilson's Disease Medical Therapy

Treatment of Complications


Ascites Treatment[35][36][37][38][39][40][41][42][43]
  • Abstinence from alcohol.
  • Salt restriction to less than 2000 mg per day.
  • Fluid restriction unless the serum sodium is less than 120 - 125 mmol/L.
  • Diuretics are the first line drugs for the treatment of ascites.
  • Therapeutic paracentesis in tense ascites. Serial therapeutic paracentesis is a treatment option for refractory ascites.
  • Intravenous albumin infusion may also be considered in refractory cases. [44]
  • TIPS may be used in refractory cases of ascites.[45]

Esophageal Variceal Bleeding

Esophageal Varices Treatment[46][47]


Hepatic Encephalopathy

The treatment of hepatic encephalopathy in cirrhosis is as follows: [82]

Hepatic Encephalopathy Treatment

Prevention of hepatic encephalopathy:

Hepatorenal Syndrome

Hepatorenal Syndrome Treatment[92][72][93][94]

Other treatment modalities:

Spontaneous Bacterial Peritonitis

Spontaneous Bacterial Peritonitis Medical Therapy[96][97][98][99][100][101]

Contraindicated medications

Cirrhosis is considered an absolute contraindication to the use of the following medications:


  1. Garcia-Tsao G (2001). "Current management of the complications of cirrhosis and portal hypertension: variceal hemorrhage, ascites, and spontaneous bacterial peritonitis". Gastroenterology. 120 (3): 726–48. PMID 11179247.
  2. Tsochatzis EA, Bosch J, Burroughs AK (2012). "New therapeutic paradigm for patients with cirrhosis". Hepatology. 56 (5): 1983–92. doi:10.1002/hep.25915. PMID 22729954.
  3. "Effects of ethanol consumption on hepatic hemodynamics in patients with alcoholic cirrhosis - Gastroenterology".
  4. "EASL clinical practical guidelines: management of alcoholic liver disease". J. Hepatol. 57 (2): 399–420. 2012. doi:10.1016/j.jhep.2012.04.004. PMID 22633836.
  5. Giouleme OI, Vyzantiadis TA, Nikolaidis NL; et al. (2006). "Pathogenesis of osteoporosis in liver cirrhosis". Hepatogastroenterology. 53 (72): 938–43. PMID 17153457.
  6. Kondrup J, Nielsen K, Hamberg O (1993). "[Nutritional therapy in patients with liver cirrhosis]". Ugeskr. Laeg. (in Danish). 155 (29): 2248–51. PMID 8328092.
  7. Silk DB, O'Keefe SJ, Wicks C (1991). "Nutritional support in liver disease". Gut. Suppl: S29–33. PMC 1405219. PMID 1916467.
  8. 8.0 8.1 Plank LD, Gane EJ, Peng S, Muthu C, Mathur S, Gillanders L, McIlroy K, Donaghy AJ, McCall JL (2008). "Nocturnal nutritional supplementation improves total body protein status of patients with liver cirrhosis: a randomized 12-month trial". Hepatology. 48 (2): 557–66. doi:10.1002/hep.22367. PMID 18627001.
  9. Plauth M, Cabré E, Riggio O, Assis-Camilo M, Pirlich M, Kondrup J, Ferenci P, Holm E, Vom Dahl S, Müller MJ, Nolte W (2006). "ESPEN Guidelines on Enteral Nutrition: Liver disease". Clin Nutr. 25 (2): 285–94. doi:10.1016/j.clnu.2006.01.018. PMID 16707194.
  10. O'Shea RS, Dasarathy S, McCullough AJ (2010). "Alcoholic liver disease". Am. J. Gastroenterol. 105 (1): 14–32, quiz 33. doi:10.1038/ajg.2009.593. PMID 19904248.
  11. Córdoba J, López-Hellín J, Planas M, Sabín P, Sanpedro F, Castro F, Esteban R, Guardia J (2004). "Normal protein diet for episodic hepatic encephalopathy: results of a randomized study". J. Hepatol. 41 (1): 38–43. doi:10.1016/j.jhep.2004.03.023. PMID 15246205.
  12. Somi MH, Rezaeifar P, Ostad Rahimi A, Moshrefi B (2012). "Effects of Low Dose Zinc Supplementation on Biochemical Markers in Non-alcoholic Cirrhosis: A Randomized Clinical Trial". Arch Iran Med. 15 (8): 472–6. PMID 22827782.
  13. Lai MY, Kao JH, Yang PM, Wang JT, Chen PJ, Chan KW, Chu JS, Chen DS (1996). "Long-term efficacy of ribavirin plus interferon alfa in the treatment of chronic hepatitis C". Gastroenterology. 111 (5): 1307–12. PMID 8898645.
  14. Everson GT (2005). "Management of cirrhosis due to chronic hepatitis C". J. Hepatol. 42 Suppl (1): S65–74. doi:10.1016/j.jhep.2005.01.009. PMID 15777574.
  15. Poynard T, McHutchison J, Manns M, Trepo C, Lindsay K, Goodman Z, Ling MH, Albrecht J (2002). "Impact of pegylated interferon alfa-2b and ribavirin on liver fibrosis in patients with chronic hepatitis C". Gastroenterology. 122 (5): 1303–13. PMID 11984517.
  16. Poynard T, McHutchison J, Manns M, Myers RP, Albrecht J (2003). "Biochemical surrogate markers of liver fibrosis and activity in a randomized trial of peginterferon alfa-2b and ribavirin". Hepatology. 38 (2): 481–92. doi:10.1053/jhep.2003.50319. PMID 12883493.
  17. McHutchison JG, Everson GT, Gordon SC, Jacobson IM, Sulkowski M, Kauffman R, McNair L, Alam J, Muir AJ (2009). "Telaprevir with peginterferon and ribavirin for chronic HCV genotype 1 infection". N. Engl. J. Med. 360 (18): 1827–38. doi:10.1056/NEJMoa0806104. PMID 19403902.
  18. Poordad F, McCone J, Bacon BR, Bruno S, Manns MP, Sulkowski MS, Jacobson IM, Reddy KR, Goodman ZD, Boparai N, DiNubile MJ, Sniukiene V, Brass CA, Albrecht JK, Bronowicki JP (2011). "Boceprevir for untreated chronic HCV genotype 1 infection". N. Engl. J. Med. 364 (13): 1195–206. doi:10.1056/NEJMoa1010494. PMC 3766849. PMID 21449783.
  19. Vierling JM, Zeuzem S, Poordad F, Bronowicki JP, Manns MP, Bacon BR, Esteban R, Flamm SL, Kwo PY, Pedicone LD, Deng W, Dutko FJ, DiNubile MJ, Koury KJ, Helmond FA, Wahl J, Bruno S (2014). "Safety and efficacy of boceprevir/peginterferon/ribavirin for HCV G1 compensated cirrhotics: meta-analysis of 5 trials". J. Hepatol. 61 (2): 200–9. doi:10.1016/j.jhep.2014.03.022. PMID 24747798.
  20. "Medscape Log In".
  21. Perrillo RP (1990). "Factors influencing response to interferon in chronic hepatitis B: implications for Asian and western populations". Hepatology. 12 (6): 1433–5. PMID 1701755.
  22. Hoofnagle JH, di Bisceglie AM (1997). "The treatment of chronic viral hepatitis". N. Engl. J. Med. 336 (5): 347–56. doi:10.1056/NEJM199701303360507. PMID 9011789.
  23. Dienstag JL, Perrillo RP, Schiff ER, Bartholomew M, Vicary C, Rubin M (1995). "A preliminary trial of lamivudine for chronic hepatitis B infection". N. Engl. J. Med. 333 (25): 1657–61. doi:10.1056/NEJM199512213332501. PMID 7477217.
  24. Dienstag JL, Goldin RD, Heathcote EJ, Hann HW, Woessner M, Stephenson SL, Gardner S, Gray DF, Schiff ER (2003). "Histological outcome during long-term lamivudine therapy". Gastroenterology. 124 (1): 105–17. doi:10.1053/gast.2003.50013. PMID 12512035.
  25. 25.0 25.1 Liaw YF, Sung JJ, Chow WC, Farrell G, Lee CZ, Yuen H, Tanwandee T, Tao QM, Shue K, Keene ON, Dixon JS, Gray DF, Sabbat J (2004). "Lamivudine for patients with chronic hepatitis B and advanced liver disease". N. Engl. J. Med. 351 (15): 1521–31. doi:10.1056/NEJMoa033364. PMID 15470215.
  26. Lok AS, McMahon BJ (2004). "Chronic hepatitis B: update of recommendations". Hepatology. 39 (3): 857–61. doi:10.1002/hep.20110. PMID 14999707.
  27. Hadziyannis SJ, Tassopoulos NC, Heathcote EJ, Chang TT, Kitis G, Rizzetto M, Marcellin P, Lim SG, Goodman Z, Ma J, Arterburn S, Xiong S, Currie G, Brosgart CL (2005). "Long-term therapy with adefovir dipivoxil for HBeAg-negative chronic hepatitis B". N. Engl. J. Med. 352 (26): 2673–81. doi:10.1056/NEJMoa042957. PMID 15987916.
  28. Chang TT, Gish RG, Hadziyannis SJ, Cianciara J, Rizzetto M, Schiff ER, Pastore G, Bacon BR, Poynard T, Joshi S, Klesczewski KS, Thiry A, Rose RE, Colonno RJ, Hindes RG (2005). "A dose-ranging study of the efficacy and tolerability of entecavir in Lamivudine-refractory chronic hepatitis B patients". Gastroenterology. 129 (4): 1198–209. doi:10.1053/j.gastro.2005.06.055. PMID 16230074.
  29. Schiff ER, Lai CL, Hadziyannis S, Neuhaus P, Terrault N, Colombo M, Tillmann HL, Samuel D, Zeuzem S, Lilly L, Rendina M, Villeneuve JP, Lama N, James C, Wulfsohn MS, Namini H, Westland C, Xiong S, Choy GS, Van Doren S, Fry J, Brosgart CL (2003). "Adefovir dipivoxil therapy for lamivudine-resistant hepatitis B in pre- and post-liver transplantation patients". Hepatology. 38 (6): 1419–27. doi:10.1016/j.hep.2003.09.040. PMID 14647053.
  30. "EASL Clinical Practice Guidelines: Management of chronic hepatitis B virus infection - Journal of Hepatology".
  31. Lai CL, Leung N, Teo EK, Tong M, Wong F, Hann HW, Han S, Poynard T, Myers M, Chao G, Lloyd D, Brown NA (2005). "A 1-year trial of telbivudine, lamivudine, and the combination in patients with hepatitis B e antigen-positive chronic hepatitis B". Gastroenterology. 129 (2): 528–36. doi:10.1016/j.gastro.2005.05.053. PMID 16083710.
  32. Manolakopoulos S, Triantos C, Theodoropoulos J, Vlachogiannakos J, Kougioumtzan A, Papatheodoridis G, Tzourmakliotis D, Karamanolis D, Burroughs AK, Archimandritis A, Raptis S, Avgerinos A (2009). "Antiviral therapy reduces portal pressure in patients with cirrhosis due to HBeAg-negative chronic hepatitis B and significant portal hypertension". J. Hepatol. 51 (3): 468–74. doi:10.1016/j.jhep.2009.05.031. PMID 19616339.
  33. Villeneuve JP, Condreay LD, Willems B, Pomier-Layrargues G, Fenyves D, Bilodeau M, Leduc R, Peltekian K, Wong F, Margulies M, Heathcote EJ (2000). "Lamivudine treatment for decompensated cirrhosis resulting from chronic hepatitis B". Hepatology. 31 (1): 207–10. doi:10.1002/hep.510310130. PMID 10613747.
  34. Fontana RJ, Hann HW, Perrillo RP, Vierling JM, Wright T, Rakela J, Anschuetz G, Davis R, Gardner SD, Brown NA (2002). "Determinants of early mortality in patients with decompensated chronic hepatitis B treated with antiviral therapy". Gastroenterology. 123 (3): 719–27. PMID 12198698.
  35. Pedersen JS, Bendtsen F, Møller S (2015). "Management of cirrhotic ascites". Ther Adv Chronic Dis. 6 (3): 124–37. doi:10.1177/2040622315580069. PMC 4416972. PMID 25954497.
  36. Ginès P, Cárdenas A, Arroyo V, Rodés J (2004). "Management of cirrhosis and ascites". N. Engl. J. Med. 350 (16): 1646–54. doi:10.1056/NEJMra035021. PMID 15084697.
  37. Runyon BA (2009). "Management of adult patients with ascites due to cirrhosis: an update". Hepatology. 49 (6): 2087–107. doi:10.1002/hep.22853. PMID 19475696.
  38. Hernández-Gea V, Aracil C, Colomo A, Garupera I, Poca M, Torras X, Miñana J, Guarner C, Villanueva C (2012). "Development of ascites in compensated cirrhosis with severe portal hypertension treated with β-blockers". Am. J. Gastroenterol. 107 (3): 418–27. doi:10.1038/ajg.2011.456. PMID 22334252.
  39. Angeli P, Fasolato S, Mazza E, Okolicsanyi L, Maresio G, Velo E, Galioto A, Salinas F, D'Aquino M, Sticca A, Gatta A (2010). "Combined versus sequential diuretic treatment of ascites in non-azotaemic patients with cirrhosis: results of an open randomised clinical trial". Gut. 59 (1): 98–104. doi:10.1136/gut.2008.176495. PMID 19570764.
  40. "EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis". J. Hepatol. 53 (3): 397–417. 2010. doi:10.1016/j.jhep.2010.05.004. PMID 20633946.
  41. Ginès P, Titó L, Arroyo V, Planas R, Panés J, Viver J, Torres M, Humbert P, Rimola A, Llach J (1988). "Randomized comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis". Gastroenterology. 94 (6): 1493–502. PMID 3360270.
  42. Runyon BA (2013). "Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012". Hepatology. 57 (4): 1651–3. doi:10.1002/hep.26359. PMID 23463403.
  43. Morando F, Maresio G, Piano S, Fasolato S, Cavallin M, Romano A, Rosi S, Gola E, Frigo AC, Stanco M, Destro C, Rupolo G, Mantoan D, Gatta A, Angeli P (2013). "How to improve care in outpatients with cirrhosis and ascites: a new model of care coordination by consultant hepatologists". J. Hepatol. 59 (2): 257–64. doi:10.1016/j.jhep.2013.03.010. PMID 23523582.
  44. Moreau R, Asselah T, Condat B, de Kerguenec C, Pessione F, Bernard B, Poynard T, Binn M, Grangé JD, Valla D, Lebrec D (2002). "Comparison of the effect of terlipressin and albumin on arterial blood volume in patients with cirrhosis and tense ascites treated by paracentesis: a randomised pilot study". Gut. 50 (1): 90–4. PMC 1773081. PMID 11772973.
  45. Salerno F, Cammà C, Enea M, Rössle M, Wong F (2007). "Transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis of individual patient data". Gastroenterology. 133 (3): 825–34. doi:10.1053/j.gastro.2007.06.020. PMID 17678653.
  46. de Franchis R, Dell'Era A, Iannuzzi F (2004). "Diagnosis and treatment of portal hypertension". Dig Liver Dis. 36 (12): 787–98. doi:10.1016/j.dld.2004.08.001. PMID 15646423.
  47. Garcia-Tsao G, Bosch J (2010). "Management of varices and variceal hemorrhage in cirrhosis". N. Engl. J. Med. 362 (9): 823–32. doi:10.1056/NEJMra0901512. PMID 20200386.
  48. Groszmann RJ, Garcia-Tsao G, Bosch J, Grace ND, Burroughs AK, Planas R, Escorsell A, Garcia-Pagan JC, Patch D, Matloff DS, Gao H, Makuch R (2005). "Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis". N. Engl. J. Med. 353 (21): 2254–61. doi:10.1056/NEJMoa044456. PMID 16306522.
  49. Hwang JH, Shergill AK, Acosta RD, Chandrasekhara V, Chathadi KV, Decker GA, Early DS, Evans JA, Fanelli RD, Fisher DA, Foley KQ, Fonkalsrud L, Jue T, Khashab MA, Lightdale JR, Muthusamy VR, Pasha SF, Saltzman JR, Sharaf R, Cash BD (2014). "The role of endoscopy in the management of variceal hemorrhage". Gastrointest. Endosc. 80 (2): 221–7. doi:10.1016/j.gie.2013.07.023. PMID 25034836.
  50. Merkel C, Marin R, Sacerdoti D, Donada C, Cavallarin G, Torboli P, Amodio P, Sebastianelli G, Bolognesi M, Felder M, Mazzaro C, Gatta A (2000). "Long-term results of a clinical trial of nadolol with or without isosorbide mononitrate for primary prophylaxis of variceal bleeding in cirrhosis". Hepatology. 31 (2): 324–9. doi:10.1002/hep.510310210. PMID 10655253.
  51. Gluud LL, Klingenberg S, Nikolova D, Gluud C (2007). "Banding ligation versus beta-blockers as primary prophylaxis in esophageal varices: systematic review of randomized trials". Am. J. Gastroenterol. 102 (12): 2842–8, quiz 2841, 2849. doi:10.1111/j.1572-0241.2007.01564.x. PMID 18042114.
  52. Poynard T, Calès P, Pasta L, Ideo G, Pascal JP, Pagliaro L, Lebrec D (1991). "Beta-adrenergic-antagonist drugs in the prevention of gastrointestinal bleeding in patients with cirrhosis and esophageal varices. An analysis of data and prognostic factors in 589 patients from four randomized clinical trials. Franco-Italian Multicenter Study Group". N. Engl. J. Med. 324 (22): 1532–8. doi:10.1056/NEJM199105303242202. PMID 1674104.
  53. Bosch J (2010). "Carvedilol for portal hypertension in patients with cirrhosis". Hepatology. 51 (6): 2214–8. doi:10.1002/hep.23689. PMID 20513005.
  54. Tripathi D, Ferguson JW, Kochar N, Leithead JA, Therapondos G, McAvoy NC, Stanley AJ, Forrest EH, Hislop WS, Mills PR, Hayes PC (2009). "Randomized controlled trial of carvedilol versus variceal band ligation for the prevention of the first variceal bleed". Hepatology. 50 (3): 825–33. doi:10.1002/hep.23045. PMID 19610055.
  55. "Primary prevention of variceal haemorrhage: A pharmacological approach - Journal of Hepatology".
  56. Merkel C, Marin R, Angeli P, Zanella P, Felder M, Bernardinello E, Cavallarin G, Bolognesi M, Donada C, Bellini B, Torboli P, Gatta A (2004). "A placebo-controlled clinical trial of nadolol in the prophylaxis of growth of small esophageal varices in cirrhosis". Gastroenterology. 127 (2): 476–84. PMID 15300580.
  57. Bernard B, Lebrec D, Mathurin P, Opolon P, Poynard T (1997). "Beta-adrenergic antagonists in the prevention of gastrointestinal rebleeding in patients with cirrhosis: a meta-analysis". Hepatology. 25 (1): 63–70. doi:10.1053/jhep.1997.v25.pm0008985266. PMID 8985266.
  58. Abraldes JG, Tarantino I, Turnes J, Garcia-Pagan JC, Rodés J, Bosch J (2003). "Hemodynamic response to pharmacological treatment of portal hypertension and long-term prognosis of cirrhosis". Hepatology. 37 (4): 902–8. doi:10.1053/jhep.2003.50133. PMID 12668985.
  59. Villanueva C, Aracil C, Colomo A, Hernández-Gea V, López-Balaguer JM, Alvarez-Urturi C, Torras X, Balanzó J, Guarner C (2009). "Acute hemodynamic response to beta-blockers and prediction of long-term outcome in primary prophylaxis of variceal bleeding". Gastroenterology. 137 (1): 119–28. doi:10.1053/j.gastro.2009.03.048. PMID 19344721.
  60. Ge PS, Runyon BA (2014). "The changing role of beta-blocker therapy in patients with cirrhosis". J. Hepatol. 60 (3): 643–53. doi:10.1016/j.jhep.2013.09.016. PMID 24076364.
  61. Lebrec D, Poynard T, Hillon P, Benhamou JP (1981). "Propranolol for prevention of recurrent gastrointestinal bleeding in patients with cirrhosis: a controlled study". N. Engl. J. Med. 305 (23): 1371–4. doi:10.1056/NEJM198112033052302. PMID 7029276.
  62. Pascal JP, Cales P (1987). "Propranolol in the prevention of first upper gastrointestinal tract hemorrhage in patients with cirrhosis of the liver and esophageal varices". N. Engl. J. Med. 317 (14): 856–61. doi:10.1056/NEJM198710013171403. PMID 3306385.
  63. Groszmann RJ, Garcia-Tsao G, Bosch J, Grace ND, Burroughs AK, Planas R, Escorsell A, Garcia-Pagan JC, Patch D, Matloff DS, Gao H, Makuch R (2005). "Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis". N. Engl. J. Med. 353 (21): 2254–61. doi:10.1056/NEJMoa044456. PMID 16306522.
  64. Gluud LL, Klingenberg S, Nikolova D, Gluud C (2007). "Banding ligation versus beta-blockers as primary prophylaxis in esophageal varices: systematic review of randomized trials". Am. J. Gastroenterol. 102 (12): 2842–8, quiz 2841, 2849. doi:10.1111/j.1572-0241.2007.01564.x. PMID 18042114.
  65. Bosch J, Abraldes JG, Berzigotti A, Garcia-Pagan JC (2008). "Portal hypertension and gastrointestinal bleeding". Semin. Liver Dis. 28 (1): 3–25. doi:10.1055/s-2008-1040318. PMID 18293274.
  66. Besson I, Ingrand P, Person B, Boutroux D, Heresbach D, Bernard P, Hochain P, Larricq J, Gourlaouen A, Ribard D (1995). "Sclerotherapy with or without octreotide for acute variceal bleeding". N. Engl. J. Med. 333 (9): 555–60. doi:10.1056/NEJM199508313330904. PMID 7623904.
  67. "Endoscopic management of acute esophageal variceal bleeding - Techniques in Gastrointestinal Endoscopy".
  68. Sung JJ, Chung SC, Lai CW, Chan FK, Leung JW, Yung MY, Kassianides C, Li AK (1993). "Octreotide infusion or emergency sclerotherapy for variceal haemorrhage". Lancet. 342 (8872): 637–41. PMID 8103145.
  69. Gimson AE, Ramage JK, Panos MZ, Hayllar K, Harrison PM, Williams R, Westaby D (1993). "Randomised trial of variceal banding ligation versus injection sclerotherapy for bleeding oesophageal varices". Lancet. 342 (8868): 391–4. PMID 8101900.
  70. Bañares R, Albillos A, Rincón D, Alonso S, González M, Ruiz-del-Arbol L, Salcedo M, Molinero LM (2002). "Endoscopic treatment versus endoscopic plus pharmacologic treatment for acute variceal bleeding: a meta-analysis". Hepatology. 35 (3): 609–15. doi:10.1053/jhep.2002.31354. PMID 11870374.
  71. Krige JE, Kotze UK, Bornman PC, Shaw JM, Klipin M (2006). "Variceal recurrence, rebleeding, and survival after endoscopic injection sclerotherapy in 287 alcoholic cirrhotic patients with bleeding esophageal varices". Ann. Surg. 244 (5): 764–70. doi:10.1097/01.sla.0000231704.45005.4e. PMC 1856595. PMID 17060770.
  72. 72.0 72.1 Williams EJ, Iredale JP (1998). "Liver cirrhosis". Postgrad Med J. 74 (870): 193–202. PMC 2360862. PMID 9683971.
  73. Stiegmann GV, Goff JS, Michaletz-Onody PA, Korula J, Lieberman D, Saeed ZA, Reveille RM, Sun JH, Lowenstein SR (1992). "Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices". N. Engl. J. Med. 326 (23): 1527–32. doi:10.1056/NEJM199206043262304. PMID 1579136.
  74. García-Pagán JC, Caca K, Bureau C, Laleman W, Appenrodt B, Luca A, Abraldes JG, Nevens F, Vinel JP, Mössner J, Bosch J (2010). "Early use of TIPS in patients with cirrhosis and variceal bleeding". N. Engl. J. Med. 362 (25): 2370–9. doi:10.1056/NEJMoa0910102. PMID 20573925.
  75. Boyer TD (2003). "Transjugular intrahepatic portosystemic shunt: current status". Gastroenterology. 124 (6): 1700–10. PMID 12761727.
  76. Patel NH, Chalasani N, Jindal RM (1998). "Current status of transjugular intrahepatic portosystemic shunts". Postgrad Med J. 74 (878): 716–20. PMC 2431632. PMID 10320885.
  77. Loffroy R, Estivalet L, Cherblanc V, Favelier S, Pottecher P, Hamza S, Minello A, Hillon P, Thouant P, Lefevre PH, Krausé D, Cercueil JP (2013). "Transjugular intrahepatic portosystemic shunt for the management of acute variceal hemorrhage". World J. Gastroenterol. 19 (37): 6131–43. doi:10.3748/wjg.v19.i37.6131. PMC 3787342. PMID 24115809.
  78. McCormick PA, Dick R, Burroughs AK (1994). "Review article: the transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of portal hypertension". Aliment. Pharmacol. Ther. 8 (3): 273–82. PMID 7918921.
  79. Conn HO, Grace ND, Bosch J, Groszmann RJ, Rodés J, Wright SC, Matloff DS, Garcia-Tsao G, Fisher RL, Navasa M (1991). "Propranolol in the prevention of the first hemorrhage from esophagogastric varices: A multicenter, randomized clinical trial. The Boston-New Haven-Barcelona Portal Hypertension Study Group". Hepatology. 13 (5): 902–12. PMID 2029994.
  80. Bosch J, García-Pagán JC (2003). "Prevention of variceal rebleeding". Lancet. 361 (9361): 952–4. doi:10.1016/S0140-6736(03)12778-X. PMID 12648985.
  81. Gonzalez R, Zamora J, Gomez-Camarero J, Molinero LM, Bañares R, Albillos A (2008). "Meta-analysis: Combination endoscopic and drug therapy to prevent variceal rebleeding in cirrhosis". Ann. Intern. Med. 149 (2): 109–22. PMID 18626050.
  82. Butterworth RF (1992). "Pathogenesis and treatment of portal-systemic encephalopathy: an update". Dig. Dis. Sci. 37 (3): 321–7. PMID 1346515.
  83. Kersh ES, Rifkin H (1973). "Lactulose enemas". Ann. Intern. Med. 78 (1): 81–4. PMID 4682313.
  84. Ratnaike RN, Hicks EP, Hislop IG (1975). "The rectal administration of lactulose". Australian and New Zealand journal of medicine. 5 (2): 137–40. PMID 240347.
  85. Uribe M, Campollo O, Vargas F; et al. (1987). "Acidifying enemas (lactitol and lactose) vs. nonacidifying enemas (tap water) to treat acute portal-systemic encephalopathy: a double-blind, randomized clinical trial". Hepatology. 7 (4): 639–43. PMID 3301614.
  86. Blei AT, Córdoba J (2001). "Hepatic Encephalopathy". Am. J. Gastroenterol. 96 (7): 1968–76. doi:10.1111/j.1572-0241.2001.03964.x. PMID 11467622.
  87. Bass NM, Mullen KD, Sanyal A, Poordad F, Neff G, Leevy CB, Sigal S, Sheikh MY, Beavers K, Frederick T, Teperman L, Hillebrand D, Huang S, Merchant K, Shaw A, Bortey E, Forbes WP (2010). "Rifaximin treatment in hepatic encephalopathy". N. Engl. J. Med. 362 (12): 1071–81. doi:10.1056/NEJMoa0907893. PMID 20335583.
  88. Bajaj JS, Heuman DM, Wade JB, Gibson DP, Saeian K, Wegelin JA, Hafeezullah M, Bell DE, Sterling RK, Stravitz RT, Fuchs M, Luketic V, Sanyal AJ (2011). "Rifaximin improves driving simulator performance in a randomized trial of patients with minimal hepatic encephalopathy". Gastroenterology. 140 (2): 478–487.e1. doi:10.1053/j.gastro.2010.08.061. PMC 3020996. PMID 20849805.
  89. Bucci L, Palmieri GC (1993). "Double-blind, double-dummy comparison between treatment with rifaximin and lactulose in patients with medium to severe degree hepatic encephalopathy". Current medical research and opinion. 13 (2): 109–18. PMID 8325041.
  90. Pedretti G, Calzetti C, Missale G, Fiaccadori F (1991). "Rifaximin versus neomycin on hyperammoniemia in chronic portal systemic encephalopathy of cirrhotics. A double-blind, randomized trial". The Italian journal of gastroenterology. 23 (4): 175–8. PMID 1751811.
  91. Kalambokis GN, Mouzaki A, Rodi M, Pappas K, Fotopoulos A, Xourgia X, Tsianos EV (2012). "Rifaximin improves systemic hemodynamics and renal function in patients with alcohol-related cirrhosis and ascites". Clin. Gastroenterol. Hepatol. 10 (7): 815–8. doi:10.1016/j.cgh.2012.02.025. PMID 22391344.
  92. Epstein M (1992). "The hepatorenal syndrome--newer perspectives". N. Engl. J. Med. 327 (25): 1810–1. doi:10.1056/NEJM199212173272509. PMID 1435935.
  93. Ginès P, Guevara M, Arroyo V, Rodés J (2003). "Hepatorenal syndrome". Lancet. 362 (9398): 1819–27. doi:10.1016/S0140-6736(03)14903-3. PMID 14654322.
  94. Angeli P, Volpin R, Gerunda G, Craighero R, Roner P, Merenda R, Amodio P, Sticca A, Caregaro L, Maffei-Faccioli A, Gatta A (1999). "Reversal of type 1 hepatorenal syndrome with the administration of midodrine and octreotide". Hepatology. 29 (6): 1690–7. doi:10.1002/hep.510290629. PMID 10347109.
  95. Ginés P, Arroyo V, Quintero E; et al. (1987). "Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites. Results of a randomized study". Gastroenterology. 93 (2): 234–41. PMID 3297907.
  96. Toledo C, Salmerón JM, Rimola A, Navasa M, Arroyo V, Llach J, Ginès A, Ginès P, Rodés J (1993). "Spontaneous bacterial peritonitis in cirrhosis: predictive factors of infection resolution and survival in patients treated with cefotaxime". Hepatology. 17 (2): 251–7. PMID 8428722.
  97. Solà R, Andreu M, Coll S, Vila MC, Oliver MI, Arroyo V (1995). "Spontaneous bacterial peritonitis in cirrhotic patients treated using paracentesis or diuretics: results of a randomized study". Hepatology. 21 (2): 340–4. PMID 7843703.
  98. Runyon BA, McHutchison JG, Antillon MR, Akriviadis EA, Montano AA (1991). "Short-course versus long-course antibiotic treatment of spontaneous bacterial peritonitis. A randomized controlled study of 100 patients". Gastroenterology. 100 (6): 1737–42. PMID 2019378.
  99. Novella M, Solà R, Soriano G, Andreu M, Gana J, Ortiz J, Coll S, Sàbat M, Vila MC, Guarner C, Vilardell F (1997). "Continuous versus inpatient prophylaxis of the first episode of spontaneous bacterial peritonitis with norfloxacin". Hepatology. 25 (3): 532–6. doi:10.1002/hep.510250306. PMID 9049193.
  100. Saab S, Hernandez JC, Chi AC, Tong MJ (2009). "Oral antibiotic prophylaxis reduces spontaneous bacterial peritonitis occurrence and improves short-term survival in cirrhosis: a meta-analysis". Am. J. Gastroenterol. 104 (4): 993–1001, quiz 1002. doi:10.1038/ajg.2009.3. PMID 19277033.
  101. Fernández J, Ruiz del Arbol L, Gómez C, Durandez R, Serradilla R, Guarner C, Planas R, Arroyo V, Navasa M (2006). "Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage". Gastroenterology. 131 (4): 1049–56, quiz 1285. doi:10.1053/j.gastro.2006.07.010. PMID 17030175.
  102. Lewis JH, Stine JG (2013). "Review article: prescribing medications in patients with cirrhosis - a practical guide". Aliment. Pharmacol. Ther. 37 (12): 1132–56. doi:10.1111/apt.12324. PMID 23638982.

Template:WH Template:WS