Download PDF
Der Klinikarzt 2015; 44(09): 392-397
DOI: 10.1055/s-0035-1564919
Schwerpunkt
© Georg Thieme Verlag Stuttgart · New York

Leberzirrhose – Wie lassen sich Komplikationen verhindern?

Liver cirrhosis – How to prevent complications?
Marcus Schuchmann
1   I. Medizinische Klinik, Klinikum Konstanz, Konstanz
› Author Affiliations
Further Information

Publication History

Publication Date:
28 October 2015 (online)

Also available at
    Permissions and Reprints

Für den Verlauf der Leberzirrhose bedeutet das Auftreten von Komplikationen einen entscheidenden Wendepunkt – Morbidität und Mortalität nehmen drastisch zu. Klinisch bedeutet das Auftreten einer Komplikation den Übergang von der kompensierten zur dekompensierten Leberzirrhose.

Wird bei einem Patienten eine Leberzirrhose diagnostiziert, müssen alle Anstrengungen dem Verhindern von Komplikationen dienen. Im besten Fall wird durch ein erfolgreiches Behandeln der Grunderkrankung eine Regression der Vernarbung erreicht und damit langfristig Zirrhose-assoziierte Komplikationen verhindert. Dies kann bei Patienten mit chronisch viraler Hepatitis gelingen oder durch vollständige Abstinenz eines Alkoholkranken dank Suchtbehandlung erreicht werden.

Der folgende Artikel fokussiert auf die Maßnahmen, die ein Fortschreiten vom kompensierten Status zur Dekompensation verhindern bzw. ein erneutes Auftreten unwahrscheinlicher machen. Während das Bewahren des kompensierten Status in erster Linie auf einer ambulanten Betreuung fußt, werden dekompensierte Patienten häufig stationär behandelt und die Einleitung einer geeigneten Sekundärprophylaxe erfolgt deshalb im Krankenhaus.

Cirrhosis is the end-stage of every chronic liver disease. Its natural history is characterized by an asymptomatic phase, termed 'compensated' cirrhosis followed by a rapidly progressive phase marked by the development of complications of portal hypertension and liver dysfunction, coined 'decompensated cirrhosis'. Taking care of cirrhotic patients asks for an anticipatory attitude to introduce prophylactic measures in order to avoid or at least to delay the occurrence of complications. While primary prophylactic interventions, such non-selective beta blocker therapy to prevent variceal bleeding, fall into the field of outpatient care, the introduction of secondary prophylaxis upon initial decompensation, such as lactulose and rifaximin for prevention of relapse of hepatic encephalopathy should be initiated immediately in the inpatient setting.

Key words

Complications of liver cirrhosis - prophylaxis - ascites - spontaneous bacterial peritonitis - esophageal variceal bleeding - hepatocellular carcinoma - encephalopathy
 

  • Literatur

  • 1 D'Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol 2006; 44: 217-231
    CrossrefPubMedGoogle Scholar
  • 2 Lee YA., Wallace MC, Friedman SL. Pathobiology of liver fibrosis: a translational success story. Gut 2015; 64: 830-841
    CrossrefPubMedGoogle Scholar
  • 3 Groszmann RJ, Garcia-Tsao G, Bosch J et al. Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis. N Engl J Med 2005; 353: 2254-2261
    CrossrefPubMedGoogle Scholar
  • 4 Cirera I, Bauer TM, Navasa M et al. Bacterial translocation of enteric organisms in patients with cirrhosis. J Hepatol 2001; 34: 32-37
    CrossrefPubMedGoogle Scholar
  • 5 Bonnel AR, Bunchorntavakul C, Reddy KR. Immune dysfunction and infections in patients with cirrhosis. Clin Gastroenterol Hepatol 2011; 9: 727-738
    CrossrefPubMedGoogle Scholar
  • 6 Appenrodt B, Grünhage F, Gentemann MG, Thyssen L, Sauerbruch T, Lammert F. Nucleotide-binding oligomerization domain containing 2 (NOD2) variants are genetic risk factors for death and spontaneous bacterial peritonitis in liver cirrhosis. Hepatology 2010; 51: 1327-1333
    CrossrefPubMedGoogle Scholar
  • 7 Jalan R, Fernandez J, Wiest R et al. Bacterial infections in cirrhosis: a position statement based on the EASL Special Conference 2013. J Hepatol. European Association for the Study of the Liver 2014; 60: 1310-1324
    PubMedGoogle Scholar
  • 8 Arvaniti V, D'Amico G, Fede G et al. Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis. Gastroenterology 2010; 139: 1246-1256
    CrossrefPubMedGoogle Scholar
  • 9 Pieri G, Agarwal B, Burroughs AK. C-reactive protein and bacterial infection in cirrhosis. Ann Gastroenterol Q Publ Hell Soc Gastroenterol 2014; 27: 113-120
    PubMedGoogle Scholar
  • 10 Fernández J, Acevedo J, Castro M et al. Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study. Hepatology 2012; 55: 1551-1561
    CrossrefPubMedGoogle Scholar
  • 11 Fernández J, Gustot T. Management of bacterial infections in cirrhosis. J Hepatol 2012; 56 (Suppl. 01) 1-12
    PubMedGoogle Scholar
  • 12 Merli M, Nicolini G, Angeloni S et al. Incidence and natural history of small esophageal varices in cirrhotic patients. J Hepatol 2003; 38: 266-272
    CrossrefPubMedGoogle Scholar
  • 13 Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology 2007; 46: 922-938
    CrossrefPubMedGoogle Scholar
  • 14 Kovalak M, Lake J, Mattek N et al. Endoscopic screening for varices in cirrhotic patients: data from a national endoscopic database. Gastrointest Endosc 2007; 65: 82-88
    CrossrefPubMedGoogle Scholar
  • 15 Tsochatzis EA, Triantos CK, Garcovich M, Burroughs AK. Primary prevention of variceal hemorrhage. Curr Gastroenterol Rep 2011; 13: 3-9
    CrossrefPubMedGoogle Scholar
  • 16 Reiberger T, Ulbrich G, Ferlitsch A et al. Carvedilol for primary prophylaxis of variceal bleeding in cirrhotic patients with haemodynamic non-response to propranolol. Gut 2013; 62: 1634-1641
    CrossrefPubMedGoogle Scholar
  • 17 Gluud LL, Krag A. Banding ligation versus beta-blockers for primary prevention in oesophageal varices in adults. Cochrane Database Syst Rev CD 004544 2012; 8
    PubMedGoogle Scholar
  • 18 Senzolo M, Cholongitas E, Burra P et al. beta-Blockers protect against spontaneous bacterial peritonitis in cirrhotic patients: a meta-analysis. Liver Int 2009; 29: 1189-1193
    CrossrefPubMedGoogle Scholar
  • 19 Thiele M, Albillos A, Abazi R. Non-selective beta-blockers may reduce risk of hepatocellular carcinoma: a meta-analysis of randomized trials. Liver Int 2015; 35: 2009-2016
    CrossrefPubMedGoogle Scholar
  • 20 Sersté T, Melot C, Francoz C et al. Deleterious effects of beta-blockers on survival in patients with cirrhosis and refractory ascites. Hepatology 2010; 52: 1017-1022
    CrossrefPubMedGoogle Scholar
  • 21 EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol 2012; 56: 908-943
    CrossrefPubMedGoogle Scholar
  • 22 Greten TF. Diagnostik und Therapie des Leitlinie. Z Gastroenterol 2013; 1-153
    PubMedGoogle Scholar
  • 23 Gerbes AL, Gülberg V, Sauerbruch T et al. German S 3-guideline “ascites, spontaneous bacterial peritonitis, hepatorenal syndrome”. Z Gastroenterol 2011; 49: 749-779
    Article in Thieme ConnectPubMedGoogle Scholar
  • 24 O'Leary JG, Reddy KR, Wong F et al. Long-Term Use of Antibiotics and Proton Pump Inhibitors Predict Development of Infections in Patients With Cirrhosis. Clin Gastroenterol Hepatol 2015; 13: 753-759
    CrossrefPubMedGoogle Scholar
  • 25 De Franchis R. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2010; 53: 762-768
    CrossrefPubMedGoogle Scholar
  • 26 García-Pagán JC, Caca K, Bureau C et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med 2010; 362: 2370-2379
    CrossrefPubMedGoogle Scholar
  • 27 Sauerbruch T, Mengel M, Dollinger M et al. Prevention of Rebleeding from Esophageal Varices in Patients with Cirrhosis Receiving Small-diameter Stents vs Hemodynamically Controlled Medical Therapy. Gastroenterology May 16 [Epub ahead of print] 2015;
    PubMedGoogle Scholar
  • 28 Jepsen P, Ott P, Andersen PK et al. Clinical course of alcoholic liver cirrhosis: A Danish population-based cohort study. Hepatology 2010; 51: 1675-1682
    CrossrefPubMedGoogle Scholar
  • 29 Bass NM, Mullen KD, Sanyal A et al. Rifaximin treatment in hepatic encephalopathy. New Engl J Med 2010; 362: 1071-1081
    CrossrefPubMedGoogle Scholar
  • 30 Kimer N, Krag A, Møller S et al. Systematic review with meta-analysis: the effects of rifaximin in hepatic encephalopathy. Aliment Pharmacol Ther 2014; 40: 123-132
    CrossrefPubMedGoogle Scholar
  • 31 American Association for the Study of Liver Diseases, European Association for the Study of the Liver. Hepatic Encephalopathy in Chronic Liver Disease: 2014 Practice Guideline by the European Association for the Study of Liver Diseases. J Hepatol 2014; 61: 642-659
    CrossrefPubMedGoogle Scholar