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

Management of Decompensated Cirrhosis

Immediately treat the underlying cause of liver disease—this is the single most important intervention that decreases further decompensation and improves survival in patients with decompensated cirrhosis. 1, 2

Primary Treatment Strategy: Address the Etiology

The foundation of managing decompensated cirrhosis is eliminating or suppressing the causative factor:

• Alcohol cessation is mandatory and can lead to "re-compensation" with improved outcomes in alcoholic cirrhosis 3
• Antiviral therapy for hepatitis B should be initiated immediately with nucleos(t)ide analogues (NAs) if HBV DNA is detectable at any level, regardless of ALT; interferon is absolutely contraindicated as it can precipitate liver failure 1
• Direct-acting antivirals for hepatitis C improve liver function and portal hypertension in HCV-related decompensated cirrhosis 3

Complication-Specific Management

Ascites

Start spironolactone 100 mg daily (can range 25-200 mg) as the initial diuretic, administered in a hospital setting with slow titration. 2, 4

• Add furosemide if needed to achieve goal weight loss of 0.5 kg/day without peripheral edema or 1 kg/day with edema 2
• Perform therapeutic paracentesis for tense ascites with albumin infusion (1 g/kg body weight, maximum 100 g) 5
• Fluid restriction is unnecessary unless serum sodium drops below 120-125 mmol/L 2
• Critical pitfall: Spironolactone can cause sudden electrolyte shifts precipitating hepatic encephalopathy and coma in cirrhotic patients—hospitalization for initiation is mandatory 4

Hepatic Encephalopathy

Lactulose is first-line therapy and reduces both mortality and recurrent overt hepatic encephalopathy. 2, 6

• For acute overt hepatic encephalopathy, start lactulose immediately while identifying precipitating factors 6, 7
• For prevention of recurrence, use lactulose plus rifaximin combination therapy 6
• Screen for mild hepatic encephalopathy using the animal naming test (takes 60 seconds, requires no equipment) 1

Infection Prophylaxis

Administer norfloxacin 400 mg orally twice daily for spontaneous bacterial peritonitis prophylaxis in high-risk patients. 2

• In advanced cirrhosis, quinolone-resistant settings, or during variceal bleeding, use ceftriaxone 1 g IV every 24 hours for up to 7 days 2, 5
• Screen for infections promptly as they are present in over 50% of patients with acute decompensation 5

Variceal Bleeding Management

When acute variceal hemorrhage occurs:

• Start vasoactive drugs (terlipressin, somatostatin, or octreotide) immediately upon suspicion, before endoscopic confirmation 5
• Perform upper endoscopy within 12 hours once hemodynamically stable 5
• Use restrictive transfusion strategy with hemoglobin threshold of 7 g/dL and target range 7-9 g/dL to avoid increasing portal pressure 5, 3
• Discontinue diuretics, beta-blockers, and vasodilators during acute bleeding 5

Emerging Therapies Requiring Validation

While promising, these interventions need further study before routine recommendation:

• Statins show potential for reducing portal hypertension and improving survival through pleiotropic effects 1, 2
• Enoxaparin (12-month course) may prevent portal vein thrombosis and delay decompensation in patients with Child-Pugh scores 7-10 1, 3
• Rifaximin beyond hepatic encephalopathy may reduce hospitalizations, though evidence remains hypothesis-generating 8

Critical Monitoring and Avoidance Strategies

Avoid nephrotoxic drugs (NSAIDs, aminoglycosides) as they precipitate renal failure and convert diuretic-sensitive to refractory ascites. 2, 5

• Monitor renal function closely; discontinue nephrotoxic agents immediately if acute kidney injury develops 5
• For AKI stage >1A without obvious cause, administer 20% albumin solution (1 g/kg, maximum 100 g) for two consecutive days 5
• Use Child-Pugh score for initial severity stratification; MELD/MELD-Na for transplant prioritization 5, 3

Liver Transplantation Evaluation

Refer early for liver transplantation evaluation as decompensation significantly worsens prognosis. 2, 3

• Consider evaluation for all appropriate candidates with decompensated cirrhosis 5
• Mean pulmonary arterial pressure ≥45 mmHg is an absolute contraindication to transplantation 3

Special Considerations for Diabetes Management

In decompensated cirrhosis with diabetes:

• Insulin therapy is the only evidence-based treatment option 1
• Initiate insulin in hospital due to high glucose variability and hypoglycemia risk (which mimics hepatic encephalopathy) 1
• Avoid metformin (increases lactic acidosis risk), and avoid other oral agents as most are eliminated by liver or kidney 1
• Do not use HbA1c for diagnosis or monitoring glycemic control 1
• Target fasting blood glucose <10 mmol/L 1