What are the signs of decompensated liver cirrhosis?

Signs of Decompensated Liver Cirrhosis

Decompensated cirrhosis is defined by the presence of any one of four cardinal clinical manifestations: ascites, variceal hemorrhage, hepatic encephalopathy, or jaundice—the appearance of any single complication marks the critical transition from compensated to decompensated disease. 1, 2

Cardinal Clinical Manifestations

Ascites

• Ascites is the most common first sign of decompensation, occurring in approximately 50% of patients within 10 years of cirrhosis diagnosis 2
• Presents as abdominal distension, weight gain, and shifting dullness on physical examination 2
• May progress to refractory ascites (not responding to diuretics), indicating advanced decompensation 2

Variceal Hemorrhage

• Manifests as hematemesis (vomiting blood) or melena (black, tarry stools) from ruptured gastroesophageal varices 2
• Gastroesophageal varices are present in 30-40% of compensated cirrhosis patients but increase to 85% in decompensated cirrhosis 2
• Represents a life-threatening emergency with 20% five-year mortality when presenting as an isolated complication, but exceeds 80% when occurring with other complications 1

Hepatic Encephalopathy

• Presents as altered mental status ranging from subtle cognitive changes to coma 2
• Early signs include confusion, personality changes, sleep disturbances (particularly sleep-wake cycle reversal), and asterixis (flapping tremor) 2
• Progressive stages advance from mild confusion to stupor and eventually hepatic coma 2

Jaundice

• Yellow discoloration of skin and sclera due to elevated bilirubin levels 2
• Indicates progressive liver failure and worsening synthetic function 2
• Represents advanced hepatocellular dysfunction and portends poor prognosis 2

Additional Clinical Features and Complications

Renal Complications

• Hepatorenal syndrome presents with progressive oliguria (decreased urine output) and rising serum creatinine 2
• Develops particularly after infections such as spontaneous bacterial peritonitis, especially in patients with reduced cardiac output 1
• Represents a functional renal failure without intrinsic kidney disease 2

Electrolyte Abnormalities

• Hyponatremia (low serum sodium) indicates advanced disease with a 20% one-year mortality rate 2
• Results from impaired free water excretion and activation of neurohumoral systems 2

Infectious Complications

• Spontaneous bacterial peritonitis presents with fever, abdominal pain, and altered mental status 2
• Bacterial infections accelerate disease progression and can precipitate acute-on-chronic liver failure 2
• Patients with decompensated cirrhosis have cirrhosis-associated immune dysfunction affecting both innate and acquired immunity 1

Cardiovascular Manifestations

• Diastolic dysfunction may occur as an early sign of cirrhotic cardiomyopathy with normal systolic function 1
• Diagnosed using echocardiographic criteria: Average E/e' >14, tricuspid velocity >2.8 m/s, and left atrial volume index >34 ml/m² 1
• Prolonged QTc interval is common and indicates poor outcome 1

Pulmonary Complications

• Hepatopulmonary syndrome occurs in 15-23% of cirrhosis patients, presenting with respiratory symptoms and hypoxia 1
• Defined by hypoxia (PaO₂ <80 mmHg or alveolar-arterial oxygen gradient ≥15 mmHg in ambient air, ≥20 mmHg in patients >65 years) with pulmonary vascular defects 1
• Hepatic hydrothorax (pleural effusion) can develop as a complication 1
• Portopulmonary hypertension may occur in the setting of portal hypertension 1

Physical Examination Findings

• Liver surface nodularity may be palpable on abdominal examination 2
• Signs of portal hypertension including splenomegaly and caput medusae (dilated abdominal wall veins) 1

Prognostic Significance

• Median survival drops dramatically from >12 years in compensated cirrhosis to approximately 2 years after first decompensation 2, 1
• Further decompensation with recurrent complications (refractory ascites, recurrent variceal hemorrhage, recurrent hepatic encephalopathy) carries significantly worse prognosis with 5-year mortality exceeding 80% 2, 1
• The transition from compensated to decompensated cirrhosis occurs at a rate of 5-7% per year 1
• Once decompensation occurs, cirrhosis becomes a systemic disease with multi-organ dysfunction 1

Important Clinical Caveats

• Obesity and ongoing alcohol use independently worsen prognosis regardless of cirrhosis etiology 2
• Patients may have multiple decompensating events simultaneously, which significantly worsens outcomes compared to isolated complications 1
• Hepatic venous pressure gradient >20 mmHg is associated with poor outcomes and development of acute kidney injury after infections 1
• Decompensation represents a prognostic watershed—early recognition is critical for initiating appropriate management and liver transplant evaluation 1, 2