EASL Guidelines for Management of Decompensated Cirrhosis
The European Association for the Study of the Liver (EASL) recommends a comprehensive approach to decompensated cirrhosis management that focuses on both treating the underlying cause of liver disease and addressing key pathogenic mechanisms of decompensation, as there is currently no treatment that can fully restore liver architecture. 1
Definition and Pathophysiology
Decompensated cirrhosis is characterized by the presence of one or more of the following complications:
- Ascites
- Hepatic encephalopathy
- Variceal hemorrhage
- Jaundice
The transition from compensated to decompensated cirrhosis represents a critical turning point, with median survival dropping from 10-12 years to only 1-2 years 2.
Key Management Strategies
1. Suppression of Etiological Factors
- Alcohol cessation: Complete abstinence is essential in alcoholic cirrhosis, though response varies among patients 1
- Antiviral therapy:
- Autoimmune hepatitis: Immunosuppressive therapy 1
Note: While removing etiological factors is effective in compensated cirrhosis, results are less predictable in decompensated disease and depend on disease severity at treatment initiation 1.
2. Management of Specific Complications
Ascites Management
| Grade | Description | Treatment |
|---|---|---|
| Grade 1 (mild) | Only detectable by ultrasound | Sodium restriction |
| Grade 2 (moderate) | Moderate abdominal distension | Sodium restriction + Diuretics |
| Grade 3 (large) | Marked abdominal distension | Sodium restriction + Diuretics + Paracentesis |
Diuretic therapy:
- Start with spironolactone (100 mg/day, up to 400 mg/day)
- Add furosemide (40-160 mg/day) when spironolactone alone is insufficient 3
Large volume paracentesis:
- Required for tense ascites (Grade 3)
- Must include albumin replacement (8g/L of ascites removed) for volumes >5L 3
Portal Vein Thrombosis (PVT) Prevention
- Prophylactic enoxaparin may delay hepatic decompensation and improve survival in patients with Child-Pugh scores of 7-10 1
Targeting Bacterial Translocation
- Pentoxifylline has been shown to reduce liver-related complications by preventing intestinal bacterial translocation 1
Portal Hypertension Management
- Non-selective beta-blockers (e.g., propranolol) can decrease the risk of various complications including ascites, hepatorenal syndrome, spontaneous bacterial peritonitis, and hepatic encephalopathy 1
- Most effective in patients who show marked decreases in portal pressure 1
3. Ongoing Monitoring and Care
- Clinical assessment every 3-6 months
- Laboratory tests and calculation of Child-Pugh and MELD scores every 6 months
- Ultrasound for hepatocellular carcinoma surveillance every 6 months 3
- Upper endoscopy for screening of esophageal varices 3
- Monitor for hepatic encephalopathy using ammonia levels and cognitive assessments 3
4. Nutritional Support
- Provide adequate caloric intake: 35-40 kcal/kg/day
- Ensure sufficient protein intake: 1.2-1.5 g/kg/day 3
Precipitating Factors of Decompensation
The most common precipitating events for acute decompensation include:
- Proven bacterial infections
- Severe alcoholic hepatitis
- Gastrointestinal bleeding with shock
- Toxic encephalopathy 4
Important: Adequate first-line antibiotic treatment of proven bacterial infections is associated with lower rates of acute-on-chronic liver failure development and reduced 90-day mortality 4.
Liver Transplantation Referral
Consider liver transplantation evaluation for patients with:
- MELD score ≥15
- Child-Pugh score ≥7
- First major complication 3
Pitfalls and Caveats
- Fluid restriction alone is not recommended as primary therapy unless severe hyponatremia is present (sodium <120-125 mmol/L)
- Weight loss should not exceed 0.5 kg/day in patients without edema to avoid complications like renal impairment 3
- Continue hepatological follow-up despite successful treatment of the underlying cause, as patients with advanced fibrosis/cirrhosis remain at risk for complications 3
- Multiple precipitating factors significantly increase 90-day mortality risk 4
The EASL guidelines emphasize that management should focus on both treating the underlying cause of liver disease and addressing the pathophysiological mechanisms driving decompensation, as there is currently no definitive treatment that can fully restore normal liver architecture 1.