Compensated Cirrhosis

Compensated cirrhosis is cirrhosis (fibrosis with nodular regeneration and architectural distortion) without ascites, variceal bleeding, encephalopathy or jaundice.

• It may be silent for years; median survival exceeds 12 years if it remains compensated, with about 5 to 7 percent per year progressing to decompensation.
• Causes: chronic hepatitis B and C, alcohol, metabolic associated fatty liver disease, autoimmune hepatitis, primary biliary cholangitis, primary sclerosing cholangitis, haemochromatosis, Wilson disease, and alpha-1 antitrypsin deficiency.
• Clinically significant portal hypertension (hepatic venous pressure gradient above 10 mmHg) predicts decompensation.

Often asymptomatic; fatigue, anorexia, weight loss, muscle cramps, pruritus.

• Spider naevi, palmar erythema, leuconychia, clubbing, firm nodular liver edge, splenomegaly, gynaecomastia, testicular atrophy, bruising.
• Differential diagnosis: advanced fibrosis without cirrhosis, noncirrhotic portal hypertension (schistosomiasis, idiopathic), chronic hepatitis, infiltrative liver disease, hepatic amyloidosis.
• Complications: progression to decompensation, hepatocellular carcinoma (1 to 4 percent per year), portal hypertension and varices, portal vein thrombosis, infections, sarcopenia, hepatic osteodystrophy, coagulopathy.

Liver profile, INR, albumin, platelets (below 150 x 10^9/L suggests portal hypertension), full blood count.

• Transient elastography above 15 kPa (above 20 kPa with portal hypertension) rules in compensated advanced chronic liver disease; liver biopsy if uncertain.
• Ultrasound: nodular surface, caudate hypertrophy, splenomegaly, portal vein flow; alpha-fetoprotein.
• Upper endoscopy for varices when platelets are below 150 x 10^9/L or stiffness is above 20 kPa; aetiology work-up (viral serology, ferritin and transferrin saturation, ceruloplasmin, autoimmune markers, alpha-1 antitrypsin).

Supportive: abstain from alcohol; weight control; protein 1.2 to 1.5 g/kg/day and caloric intake 35 kcal/kg/day with a late evening snack; coffee; avoid raw shellfish, NSAIDs and herbal remedies; exercise; vaccination against hepatitis A and B, pneumococcus, influenza and COVID-19.

Pharmacological

• Treat the cause: antivirals for hepatitis B (tenofovir 300 mg daily or entecavir 0.5 mg daily) and hepatitis C (sofosbuvir plus velpatasvir 12 weeks), prednisolone with azathioprine for autoimmune hepatitis, ursodeoxycholic acid 13 to 15 mg/kg/day for primary biliary cholangitis, phlebotomy for haemochromatosis, zinc or trientine for Wilson disease.
• Clinically significant portal hypertension or medium to large varices: carvedilol 6.25 mg once daily increasing to 12.5 mg daily (alternatives propranolol 20 to 40 mg twice daily, nadolol 20 to 40 mg daily); stop if systolic pressure is below 90 mmHg, sodium is below 130 mmol/L, or creatinine rises.
• Statins in cirrhosis: simvastatin 20 mg or atorvastatin 20 mg daily (reduce the dose in moderate liver dysfunction, avoid in advanced disease); aspirin is not used for prevention without indication.
• Muscle cramps: baclofen 5 to 10 mg three times daily or taurine 2 g daily.
• Avoid benzodiazepines and opioids; paracetamol up to 2 g daily is safe.

Procedures

• Endoscopic band ligation for large varices if beta blockers are not tolerated; upper endoscopy every 2 years with small varices or 1 year if ongoing injury.
• Hepatocellular carcinoma surveillance: ultrasound with or without alpha-fetoprotein every 6 months.
• Liver transplantation referral at the first sign of decompensation or hepatocellular carcinoma.

Special groups: women (contraception advice; avoid oestrogen in advanced disease), pregnancy (specialist care, variceal screening in the second trimester), HIV coinfected (avoid hepatotoxic antiretrovirals), perioperative patients (risk assessment).

Red flags: new ascites, jaundice, confusion, gastrointestinal bleeding, rising alpha-fetoprotein, weight loss, platelets falling.

Follow-up: clinical review and liver tests every 3 to 6 months; elastography yearly; bone density every 2 to 3 years.