Preface

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David A. Sass, MD

Managing patients with cirrhosis and chronic liver failure can be a daunting task for the practicing clinician. Cirrhosis has become a very common disease as a result of the persistent high alcohol intake in many countries; the increased frequency of chronic hepatitis B and C infection; and the rising epidemic of obesity, the metabolic syndrome, and nonalcoholic steatohepatitis in the United States. Another factor emphasizing its importance as a disease entity is that cirrhosis and its complications are among the leading causes of death in many countries. In addition, the wide applicability and tremendous success of liver transplantation for hepatic failure has made this surgery a standard therapeutic procedure. For all of these reasons, it is timely to devote an issue of Medical Clinics of North America to “Care of the Cirrhotic Patient.”

This issue presents a collection of 10 original review articles that cover the complete spectrum of inpatient and outpatient management of cirrhosis and its attendant complications. I am extremely privileged to have secured the participation of clinicians from multiple disciplines who are well-known experts in their respective areas. These articles are clinically oriented and are designed to provide internists with the necessary up-to-date, evidence-based information for optimal management of this complex group of patients. The reviews also emphasize the multidisciplinary approach that is required to effectively treat patients with decompensated liver disease.

First, Dr. Lefton and coauthors introduce the topic of cirrhosis by describing its clinical presentation and other epidemiologic aspects. Next, Dr. Sanyal and his colleague discuss the management of ascites by emphasizing its pathophysiology and also cover treatment options for refractory cases by large volume paracentesis and transjugular intrahepatic portosystemic shunt. Following this, Dr. Shaikh and his coauthor delve into the neurologic manifestations of liver failure by providing a comprehensive review of the topic of hepatic encephalopathy. Next, Drs. Sass and Chopra provide an overview of the management of varices, including primary and secondary prophylactic strategies and treatment of the acutely bleeding patient. Renal failure occurring in a cirrhotic patient may portend a very poor prognosis, especially that due to type 1 hepatorenal syndrome. Dr. Ranganna and colleagues discuss the differential diagnosis of kidney disease occurring in patients with advanced liver failure and how such patients ought to be managed. Dr. Sager provides a comprehensive overview of an array of pulmonary manifestations of cirrhosis and the importance of screening for these complications, particularly during the liver transplant evaluation process. Dr. Reddy and coauthor next discuss the management options for cirrhotic patients who are diagnosed with hepatocellular carcinoma. They eloquently indicate the role of liver transplantation in such cases and highlight other locoregional therapies that may be used as a bridge to transplantation. The subsequent 2 articles review topics that are not frequently covered but are of particular relevance to the internist. Drs. Rothstein and Ahmad provide impressive reviews on preventative health issues and preoperative risk assessment in cirrhosis, respectively. Finally, to conclude this issue, Dr. Vargas and coauthor provide a comprehensive overview of liver transplantation and discuss the evolution of organ allocation from the Child-Pugh score to the MELD score.

I sincerely hope that this series of articles is informative and topical and provides useful tips to internists in managing this rather complex patient population. I truly appreciate all the effort put forth by the assembled panel of authors and their attention to detail in preparing their manuscripts for publication. I also thank Rachel Glover at Elsevier for her editorial assistance and guidance in the preparation of this issue.