What is the management approach for a patient with decompensated cirrhosis?

Management of Decompensated Cirrhosis

The management of decompensated cirrhosis requires a systematic approach addressing the underlying cause of liver disease and the specific complications that arise, with prompt treatment of acute complications and prevention of further decompensation being essential to improve morbidity, mortality, and quality of life. 1, 2

Initial Assessment and General Management

• Identify and treat the underlying cause of liver disease:

  • Complete alcohol abstinence for alcoholic cirrhosis
  • Antiviral therapy for viral hepatitis
  • Weight management and metabolic control for MASLD
  • Immunosuppressive therapy for autoimmune hepatitis 2

• Assess severity using:

  • Child-Pugh score
  • MELD score
  • Presence of complications 2

• Consider liver transplantation evaluation for all patients with decompensated cirrhosis, especially those with:

  • MELD score ≥15
  • Child-Pugh score ≥7
  • First major complication 2

Management of Specific Complications

1. Ascites

• Grade-based 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 (can increase to 400 mg/day)
  • Add furosemide 40 mg/day (can increase to 160 mg/day) if needed
  • Target weight loss: 0.5 kg/day without edema, 1 kg/day with edema 1

• Large volume paracentesis (LVP):

  • Indicated for tense ascites (Grade 3)
  • Must administer albumin (8g/L of ascites removed) when removing >5L to prevent post-paracentesis circulatory dysfunction 1, 3

• Diagnostic paracentesis:

  • Perform in all patients with new onset grade 2-3 ascites or worsening of ascites
  • Check neutrophil count and culture (bedside inoculation)
  • Measure total protein concentration
  • Calculate serum-ascites albumin gradient (SAAG) 1

2. Spontaneous Bacterial Peritonitis (SBP)

• Diagnosis: Ascitic fluid neutrophil count >250 cells/μL 1
• Treatment:
  • Third-generation cephalosporins (e.g., ceftriaxone 1g/24h) for 5-7 days
  • Albumin administration (1.5 g/kg at diagnosis and 1 g/kg on day 3) to prevent hepatorenal syndrome 1
• Prophylaxis:
  • Primary: Norfloxacin 400 mg/day for patients with ascitic protein <15 g/L
  • Secondary: Norfloxacin 400 mg/day indefinitely after an episode of SBP 1

3. Variceal Bleeding

• Acute management:

  • Start vasoactive drugs immediately (terlipressin, somatostatin, or octreotide) for 3-5 days
  • Perform endoscopy within 12 hours after admission
  • Perform endoscopic variceal ligation during the same procedure
  • Administer antibiotics (ceftriaxone 1g/24h for 7 days) 1

• Prevention of rebleeding:

  • Combination of non-selective beta-blockers and endoscopic variceal ligation
  • Consider TIPS for high-risk patients or treatment failures 1

4. Hepatic Encephalopathy (HE)

• Diagnosis:

  • Clinical assessment
  • Animal naming test for mild HE screening
  • Exclude other causes of altered mental status 1

• Treatment:

  • Identify and treat precipitating factors (infection, GI bleeding, electrolyte disturbances)
  • Lactulose (starting dose 25 mL every 12 hours, titrate to 2-3 soft bowel movements/day)
  • Add rifaximin 550 mg twice daily for recurrent HE 1

• Prevention:

  • Lactulose for secondary prophylaxis
  • Avoid sedatives and opioids 1

5. Hepatorenal Syndrome (HRS)

• Diagnosis: Based on International Club of Ascites criteria 1

• Management:

  • Discontinue diuretics and nephrotoxic drugs
  • Volume expansion with albumin (1 g/kg for two consecutive days)
  • For HRS-AKI: Terlipressin plus albumin (terlipressin 0.5-1 mg every 4-6 hours, increasing to 2 mg if needed; albumin 20-40 g/day) for up to 14 days 1

6. Diabetes Management in Cirrhosis

• Screening: Regular screening for diabetes (avoid HbA1c for diagnosis)
• Treatment: Insulin is the only recommended pharmacological therapy
  • Initiate in hospital setting due to risk of hypoglycemia
  • Target fasting blood glucose <10 mmol/L 1

Nutritional Support

• Provide adequate caloric intake (35-40 kcal/kg/day)
• Ensure sufficient protein intake (1.2-1.5 g/kg/day)
• Avoid prolonged fasting 2

Monitoring and Follow-up

• Clinical assessment every 3-6 months
• Laboratory tests and recalculation of CTP and MELD scores every 6 months
• Ultrasound for HCC surveillance every 6 months
• Upper endoscopy for variceal screening and surveillance 2

Common Pitfalls to Avoid

1. Delayed paracentesis in patients with new-onset ascites or clinical deterioration
2. Inadequate albumin replacement after large volume paracentesis
3. Excessive diuresis leading to renal dysfunction
4. Failure to screen for varices and hepatocellular carcinoma
5. Inappropriate use of NSAIDs, aminoglycosides, and other nephrotoxic drugs
6. Delayed recognition of hepatorenal syndrome and spontaneous bacterial peritonitis
7. Delayed referral for liver transplantation evaluation 1, 2

By following this structured approach to decompensated cirrhosis management, clinicians can significantly improve outcomes and quality of life for these complex patients while reducing mortality.