Signs and Symptoms of Decompensated Cirrhosis
Decompensated cirrhosis is defined by the presence of clinically overt complications including ascites, variceal hemorrhage, hepatic encephalopathy, and jaundice—any one of these marks the transition from compensated to decompensated disease. 1
Cardinal Clinical Manifestations
The four primary signs that define decompensation are:
1. Ascites
- Most common first manifestation of decompensation, occurring in approximately 50% of patients within 10 years of cirrhosis diagnosis 2
- Presents as abdominal distension, increased abdominal girth, and fluid wave on examination 1
- Often accompanied by peripheral edema 3
- Associated with 1-year survival of 60% and 2-year survival of only 45% 2
2. Variceal Hemorrhage
- Presents as hematemesis (vomiting blood) or melena (black, tarry stools) 1, 3
- Gastroesophageal varices are present in 30-40% of patients with compensated cirrhosis but increase to 85% in decompensated cirrhosis 1, 2
- May present with signs of hypovolemic shock including hypotension and tachycardia 1
- Carries 20% 5-year mortality when isolated, but exceeds 80% when occurring with other complications 1
3. Hepatic Encephalopathy
- Manifests as altered mental status ranging from subtle cognitive changes to coma 1
- Early signs include confusion, personality changes, sleep disturbances, and asterixis (flapping tremor) 4, 3
- Can be precipitated by infections, bleeding, medications, or electrolyte disturbances 4
- Simple screening tests like animal naming can detect minimal hepatic encephalopathy 4
4. Jaundice
- Yellow discoloration of skin and sclera due to elevated bilirubin 1
- Indicates progressive liver failure and worsening synthetic function 3
- Often appears in later stages of decompensation 1
Additional Clinical Features and Complications
Signs of Portal Hypertension
- Splenomegaly (enlarged spleen) 5
- Caput medusae (dilated abdominal wall veins) 5
- Spider angiomata (spider-like blood vessels on skin) 5
- Palmar erythema (reddening of palms) 5
Renal Complications
- Hepatorenal syndrome presenting with progressive oliguria and rising creatinine 1, 4
- Acute kidney injury without other clear precipitants 1, 4
- Hyponatremia (low sodium) indicating advanced disease 1
Infectious Complications
- Spontaneous bacterial peritonitis presenting with fever, abdominal pain, and altered mental status 1, 4
- Increased susceptibility to bacterial infections that can accelerate disease progression 1
Cardiovascular Manifestations
- Hepatopulmonary syndrome with dyspnea and hypoxemia 1
- Portopulmonary hypertension 1
- Cirrhotic cardiomyopathy 1
Disease Progression Patterns
Decompensation occurs through two distinct pathways: 6
- Non-acute pathway: Slow development of ascites, mild hepatic encephalopathy (grade 1-2), or jaundice not requiring hospitalization—this is the most frequent pathway for first decompensation 6
- Acute pathway: Rapid onset requiring hospitalization, including acute-on-chronic liver failure with organ failures and high short-term mortality 7, 6
Important Clinical Context
Staging Implications
- Median survival drops from >12 years in compensated cirrhosis to approximately 2 years after first decompensation 1, 2
- Further decompensation (second event) carries significantly worse prognosis, with recurrent complications including refractory ascites, recurrent variceal hemorrhage, or recurrent hepatic encephalopathy 1
Common Pitfalls
- Do not wait for multiple complications to diagnose decompensation—a single qualifying event (ascites, bleeding, encephalopathy, or jaundice) is sufficient 1
- Recognize that bacterial infections can occur at any stage but particularly accelerate disease in decompensated patients 1
- Be aware that obesity and ongoing alcohol use independently worsen prognosis regardless of etiology 1