Versorgung bei kompensierter Leberzirrhose 2018 – Evidenzbasierte prophylaktische Maßnahmen

Abstract

In 2015, more than 13 000 people died due to the consequences of liver cirrhosis in Germany. Frequently, relevant liver fibrosis is diagnosed by non-invasive methods (e. g., ultrasound-based measurement of liver stiffness) already in the compensated stage. Following diagnosis of liver fibrosis, a thorough investigation of the underlying chronic liver disease and effective treatment are important to prevent progression to decompensated cirrhosis. Since morbidity and mortality dramatically increase in the decompensated stage (patients may present with jaundice, ascites, hepatic encephalopathy, gastrointestinal bleeding) with an upsurge in 1-year-mortality from 1 - 3.4 % to 20 - 57 %, prophylactic measures to prevent decompensation are indicated. Based on a risk stratification, these measures include propranolol or carvedilol as non-selective betablockers, as well as endoscopic band ligations as primary prophylaxis to prevent variceal bleeding. Because of the high risk for malignant transformation (2 - 8 % per year depending on the underlying etiology), surveillance by liver ultrasound every six months is essential to detect liver cancer in an early stage and to facilitate curative therapy. Currently under debate is the administration of antibiotics to prevent bacterial infections, which commonly trigger acute decompensation. To this regard, studies are not convincing and the risk to induce drug resistance has to be observed. However, health care providers should check the vaccination status and recommend missing vaccinations. The management of compensated liver cirrhosis also includes counseling and potentially also a drug therapy to prevent osteoporosis and muscle wasting. In this review, we will discuss specific prophylactic measures in the management of compensated liver cirrhosis based on the pathophysiological background and central clinical studies. If a patient decompensates despite these prophylactic measures (approximately 15 % of patients with liver cirrhosis per year), liver transplantation has to be discussed as definitive therapy (especially in patients with MELD > 15).

Emerging Gram‑positive bacteria and drug resistance in cirrhosis patients with spontaneous bacterial peritonitis: A retrospective study

“…Furthermore, SBP is a severe complication of LC, and all patients should be considered for inchoate diagnosis and curative treatment in order to lower the amount of fatalities (22). High vigilance in patients with ascites presenting with acute clinical deterioration is imperative.…”

The liver fibrosis index is superior to the APRI and FIB-4 for predicting liver fibrosis in chronic hepatitis B patients in China

“…Liver fibrosis (LF) is important in determining whether, when and how to initiate antiviral therapy. The degree of LF or cirrhosis is an independent factor to predict the mortality in chronic hepatitis B (CHB) patients [2]. The 1-year mortality rates decreased from 57% in those with severe cirrhosis to 1% in patients with early-stage LF.…”

“…The 1-year mortality rates decreased from 57% in those with severe cirrhosis to 1% in patients with early-stage LF. Moreover, about 10–17% liver cirrhosis patient will develop HCC in 5 years [2]. Early accurate assessment of LF in patients infected with HBV is essential not only for the better outcomes associated with early initiation of antiviral treatment, but also for predicting the long-term clinical prognosis [2, 3].…”

Beurteilung der Leberfibrose

“…Die portale Hypertension ist die pathophysiologische Ursache für die meisten und häufigsten frühen Komplikationen der Leberzirrhose wie Ösophagusvarizen und die Entwicklung von Aszites. Zusätzlich steigt mit zunehmender Fibrosierung auch das Risiko der Entstehung eines hepatozellulären Karzinoms (HCC): Bei Patienten mit Leberzirrhose beträgt die HCC-Rate 2-8% pro Jahr [4].…”

“…Dadurch wird eine Leberzirrhose oftmals spät bei erstmaliger Dekompensation in Form von Blutungen aus Ösophagusvarizen oder dem Auftreten von Aszites diagnostiziert. Die mangelnde Früherkennung hat eine drastische Konsequenz: Im dekompensierten Stadium steigt die Mortalität der Patienten relevant an und beträgt unbehandelt über 2 Jahre 50 % [4]. Zusätzlich werden auch HCC erst in einem späten Stadium diagnostiziert, was kurative Therapieoptionen wie eine Resektion limitiert.…”