The paradigm shift in cirrhosis management.
| Clinical challenge | Outdated practice | Contemporary evidence-based paradigm | Clinical evidence | Key references |
|---|---|---|---|---|
| Nutritional support | Protein restriction to reduce NH3 load. | High-protein diet (1.2–1.5 g/kg/day) and late-night snacks. | Restriction exacerbates sarcopenia; skeletal muscle is vital for compensatory NH3 detoxification. | [11–13] |
| Neuroimaging in AMS | Routine head CT for all cirrhotic patients with AMS. | Deferred neuroimaging unless focal deficits or trauma are present. | Diagnostic yield is extremely low (0.3%) and does not correlate with the severity of coagulopathy. | [9, 10, 14] |
| Coagulation status | “Auto-anticoagulation” myth based on elevated PT/INR. | Precarious rebalanced hemostasis; risk for both ICH and ischemic stroke. | Standard tests fail to reflect the parallel decline of pro- and anticoagulant factors. | [15–17] |
| Muscle cramps | Use of quinidine derivatives. | Pickle juice, Baclofen, or Taurine. | Quinine is no longer recommended due to cardiac toxicity; pickle juice triggers inhibitory oropharyngeal neural reflexes. | [18–21] |
| Sleep management | Standard hypnotics (Benzodiazepines or Z-drugs). | Bright light therapy or hydroxyzine. | Benzodiazepines precipitate HE; Z-drugs are associated with high exposure/toxicity in cirrhosis. | [22–24] |
AMS: altered mental status; CT: computed tomography; ICH: intracranial hemorrhage; INR: international normalized ratio; PT: prothrombin time.
LEFG: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Supervision, Validation, Visualization, Writing—review & editing. VAFG: Data curation, Investigation, Software, Validation, Visualization, Writing—original draft. LAGT: Conceptualization, Data curation, Investigation, Methodology, Validation, Writing—original draft. AAPG: Data curation, Investigation, Software, Visualization, Writing—original draft. SBH: Data curation, Investigation, Software, Visualization, Writing—original draft. HCM: Data curation, Investigation, Software, Visualization, Writing—original draft. IEB: Data curation, Formal analysis, Visualization, Validation, Writing—review & editing. CACH: Data curation, Formal analysis, Visualization, Validation, Writing—review & editing. RPNQ: Data curation, Investigation, Software, Visualization, Writing—original draft. ANR: Data curation, Investigation, Software, Visualization, Writing—original draft. All authors read and approved the submitted version.
The authors declare that they have no conflicts of interest.
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