What is the initial management for a patient with decompensated liver cirrhosis?

Initial Management of Decompensated Liver Cirrhosis

The initial management of a patient with decompensated liver cirrhosis should focus on identifying and treating the precipitating factors, managing complications, and preventing further deterioration of liver function. 1, 2

Initial Assessment and Stabilization

• Assess airway, breathing, and circulation immediately, with prompt volume replacement using crystalloids to restore hemodynamic stability in patients with active bleeding 3
• Implement a restrictive transfusion strategy with a hemoglobin threshold of 7 g/dL and target range of 7-9 g/dL to avoid increasing portal pressure 1, 3
• Discontinue diuretics, beta-blockers, vasodilators, and other hypotensive drugs during acute decompensation 1, 3
• Identify and treat precipitating factors such as infections, gastrointestinal bleeding, alcohol intake, or drug-induced liver injury 4, 5

Management of Specific Complications

Acute Variceal Hemorrhage

• Start vasoactive drugs (terlipressin, somatostatin, or octreotide) immediately upon suspicion of variceal bleeding, even before endoscopic confirmation 1, 6
• Perform upper endoscopy within 12 hours of admission once hemodynamic stability is achieved 1, 3
• Consider pre-endoscopy erythromycin (250 mg IV, 30-120 minutes before) to improve visibility 1, 3
• Perform endoscopic band ligation (EBL) for esophageal varices or cyanoacrylate injection for gastric varices 1
• Administer antibiotic prophylaxis with ceftriaxone 1g/day IV for up to seven days 1, 6

Ascites

• Perform therapeutic paracentesis with albumin infusion (1 g/kg body weight, maximum 100 g) in patients with tense ascites 1
• Initiate diuretic therapy with spironolactone starting at 100 mg daily (range 25-200 mg) in cirrhotic patients after stabilization 7
• Monitor for hepatic encephalopathy and renal function deterioration during ascites management 1, 2

Hepatic Encephalopathy

• Use lactulose or lactitol when encephalopathy develops 1, 3
• Consider oral non-absorbable disaccharides for prevention of hepatic encephalopathy 1
• Monitor for precipitating factors such as infections, GI bleeding, electrolyte disturbances, and medication effects 5

Acute Kidney Injury (AKI)

• Discontinue nephrotoxic drugs such as NSAIDs and aminoglycosides 1
• Administer 20% albumin solution (1 g/kg body weight, maximum 100 g) for two consecutive days in AKI stage >1A with no obvious cause 1
• Preserve renal function with adequate replacement of fluids and electrolytes 1, 2

Infections

• Screen for and treat infections promptly, as they are present in over 50% of patients with acute bleeding 1
• Use ceftriaxone (1 g/24 h) for antibiotic prophylaxis in advanced cirrhosis or settings with high quinolone resistance 1
• Consider oral quinolones (norfloxacin 400 mg b.i.d) in patients without advanced cirrhosis 1

Prognostic Assessment

• Use Child-Pugh score for initial stratification of cirrhosis severity (scores of 7-10 indicate decompensated disease) 2
• Consider MELD and MELD-Na scores for transplant prioritization 2, 8
• Use CLIF-C ACLF score for better prognostic accuracy in patients with acute-on-chronic liver failure 2

Prevention of Further Decompensation

• Screen for gastroesophageal varices with endoscopy if not previously diagnosed and treated 1
• Initiate secondary prophylaxis with non-selective beta-blockers and/or endoscopic band ligation once bleeding is controlled 1, 3
• Consider liver transplantation evaluation in appropriate candidates 2, 9
• Address underlying causes of cirrhosis (alcohol cessation, antiviral therapy for HBV/HCV) 1, 2

Monitoring and Follow-up

• Repeat endoscopy yearly in patients without varices if the etiological factor persists and/or decompensation continues 1
• Monitor for development of complications such as hepatorenal syndrome, spontaneous bacterial peritonitis, and hepatopulmonary syndrome 5, 8
• Perform surveillance for hepatocellular carcinoma with ultrasound every six months 8

Special Considerations

• Initiate spironolactone therapy in a hospital setting for cirrhotic patients and titrate slowly 7
• Use caution with beta-blockers in patients with severe or refractory ascites 3
• Consider early TIPS in high-risk patients with variceal bleeding 3
• Be vigilant for acute-on-chronic liver failure, characterized by rapid deterioration, liver failure, and at least one extrahepatic organ failure 2