Symptom management in patients with cirrhosis

Common symptoms seen in patients with cirrhosis include pain, itch, nausea and vomiting, anorexia, anxiety and depression, muscle cramps and fatigue.

For patients with cirrhosis who are receiving palliative care, Therapeutic Guidelines: Palliative Care provides detailed information on management of symptoms at the end of life. See Principles of palliative care for patients with chronic liver disease and individual topics on specific symptoms.

This topic outlines some considerations about symptom management specifically for patients with cirrhosis.

For management of pain, see Principles of analgesic use in patients with cirrhosis.

For management of itch, see Cholestatic itch in patients with liver disease.

For general management of nausea and vomiting, see Assessment and causes of nausea and vomiting and Antiemetic drugs in adults. For management of nausea and vomiting in patients in a palliative care setting, see Nausea and vomiting in palliative care and Anorexia, weight loss and cachexia in palliative care. In addition, for patients with cirrhosis:

  • consider draining ascites if appropriate
  • look for reversible causes (eg pancreatitis in alcohol-related liver disease).

For management of anxiety and depression, see Psychological symptoms in palliative care for advice on nonpharmacological management. In addition, for patients with cirrhosis:

  • exclude uncontrolled hepatic encephalopathy
  • if drug therapy is required, carefully consider possible adverse effects when selecting a drug. If a benzodiazepine is used for anxiety, oxazepam is the preferred drug, starting with a low dose.

For management of muscle cramps in patients with cirrhosis:

  • stop or reduce diuretics when possible and correct electrolyte abnormalities
  • there is limited evidence for the use of taurine, zinc, magnesium, baclofenRogal 2022, branched-chained amino acids and vitamin E (vitamin E should not be used in decompensated cirrhosis).

For management of fatigue in patients with cirrhosis:

  • look for reversible causes such as poorly controlled encephalopathy, obstructive sleep apnoea and iron deficiency (this is common in portal hypertension but should nevertheless be investigated if present)
  • consider hepatocellular carcinoma (and ensure 6-monthly surveillance for hepatocellular carcinoma is performed)
  • if reversible causes are treated or excluded, see Fatigue in palliative care for further advice.