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The most important complication of cirrhosis that this patient faces is upper gastrointestinal hemorrhage from his medium esophageal varices.  Patients with small varices that demonstrate bleeding risk factors or those with medium or large esophageal varices should receive primary prophylaxis to prevent bleeding.

Primary prophylaxis can be achieved either with endoscopic variceal ligation (EVL) or administration of a nonselective beta blocker such as propranolol or nadolol.  Nonselective beta blockers reduce portal venous pressure by blocking the adrenergic vasodilatory response of the mesenteric arterioles, which results in unopposed alpha-adrenergic tone, vasoconstriction, and reduced portal blood flow.  The choice of beta blocker or EVL depends on patient preference and the size of the varices (EVL is preferred for larger varices).

(Choice A)  Lactulose and rifaximin are treatments for hepatic encephalopathy, which commonly presents with confusion, neurologic impairment (eg, asterixis), or sleep disturbances.  However, unlike variceal bleeding, hepatic encephalopathy does not typically require primary prophylaxis.

(Choice B)  Furosemide and spironolactone are first-line therapy for ascites due to cirrhosis.  Large-volume therapeutic paracentesis is indicated in case of respiratory compromise or significant abdominal discomfort, which this patient does not have.

(Choice C)  ACE inhibitors such as lisinopril are mainstays in the management of hypertension, chronic kidney disease, and heart failure but do not have a role in the management of cirrhosis.

(Choice D)  Compensated cirrhosis without evidence of complications (eg, variceal hemorrhage, encephalopathy) is not a sufficient criterion for transplantation.  In general, abstinence from alcohol for ≥6 months is required.

(Choice F)  A transjugular intrahepatic portosystemic shunt is often used as salvage therapy in patients with refractory ascites or esophageal varices who have failed endoscopic or medical management.

Educational objective:
Nonselective beta blockers such as propranolol or nadolol and endoscopic variceal ligation are the mainstays of primary prophylaxis for esophageal variceal hemorrhage.