What are the immediate management steps for a patient diagnosed with decompensated cirrhosis?

Management of Decompensated Cirrhosis

Immediate Stabilization and Assessment

Upon presentation, immediately assess airway, breathing, and circulation, with prompt volume replacement using crystalloids to restore hemodynamic stability, particularly in patients with active bleeding. 1

Critical Initial Actions

• Discontinue all diuretics, beta-blockers, vasodilators, and other hypotensive drugs immediately during acute decompensation to prevent worsening hemodynamic instability 1
• Implement a restrictive transfusion strategy with hemoglobin threshold of 7 g/dL and target range of 7-9 g/dL to avoid increasing portal pressure 1, 2
• Perform diagnostic paracentesis in all patients with new-onset grade 2 or 3 ascites or those hospitalized for any cirrhosis complication 2
• Stop all nephrotoxic medications including NSAIDs and aminoglycosides immediately 1, 2

Screening for Precipitating Factors

• Screen for infections immediately, as they are present in over 50% of patients with acute decompensation 1
• Evaluate for gastrointestinal bleeding, high alcohol intake, alcohol-related hepatitis, or drug-induced liver injury as precipitating causes 3
• Assess for hepatic encephalopathy using simple screening tests like animal naming 2

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, 2

• Administer antibiotic prophylaxis with ceftriaxone 1g/day IV for up to seven days in patients with advanced cirrhosis 1, 4
• In patients without advanced cirrhosis, use oral norfloxacin 400 mg twice daily 1
• Give pre-endoscopy erythromycin 250 mg IV, 30-120 minutes before procedure to improve visibility 1
• Perform upper endoscopy within 12 hours of admission once hemodynamic stability is achieved 1, 2
• Use endoscopic band ligation for esophageal varices or cyanoacrylate injection for gastric varices 1

Ascites Management

• Perform therapeutic paracentesis with albumin infusion (1 g/kg body weight, maximum 100 g) in patients with tense ascites 1
• Implement moderate sodium restriction (80-120 mmol/day, equivalent to 4.6-6.9 g of salt) 2
• Monitor closely for hepatic encephalopathy and renal function deterioration during ascites management 1

Hepatic Encephalopathy

• Initiate lactulose or lactitol when encephalopathy develops 1, 2
• Identify and treat precipitating factors including infection, bleeding, and medications 2
• Consider oral non-absorbable disaccharides for prevention of recurrent episodes 1

Acute Kidney Injury

In AKI stage >1A with no obvious cause, administer 20% albumin solution (1 g/kg body weight, maximum 100 g) for two consecutive days. 1

• Discontinue all nephrotoxic drugs immediately 1
• Provide adequate replacement of fluids and electrolytes to preserve renal function 1
• Follow EASL guidelines' algorithm for suspected hepatorenal syndrome management 2

Infection Management

• Screen for and treat infections promptly with appropriate antibiotics 1
• Use ceftriaxone (1 g/24 h) for antibiotic prophylaxis in advanced cirrhosis or settings with high quinolone resistance 1
• Maintain surveillance for infections throughout hospitalization as they worsen both liver function and other complications 4

Etiology-Specific Treatment

Hepatitis B-Related Decompensation

Start antiviral therapy immediately regardless of ALT levels or HBV DNA levels in hepatitis B-related decompensated cirrhosis. 2

• Use entecavir 1 mg daily or tenofovir monotherapy as first-line agents due to potent antiviral efficacy and high genetic barrier to resistance 2
• Never use interferon-α in decompensated cirrhosis as it is absolutely contraindicated due to risk of precipitating liver failure and serious infections 2
• Do not delay antiviral therapy waiting for specific HBV DNA thresholds, as any detectable level requires immediate treatment 2

Hepatitis C-Related Decompensation

• Initiate direct-acting antivirals to improve liver function and portal hypertension 4

Alcohol-Related Decompensation

• Ensure complete cessation of alcohol consumption, which can lead to recompensation and improved outcomes in some patients 4

Prognostic Assessment

• Calculate Child-Pugh score for initial stratification (scores of 7-10 indicate decompensated disease) 1, 4
• Use MELD and MELD-Na scores for transplant prioritization 1, 4
• Apply CLIF-C ACLF score for better prognostic accuracy in patients with acute-on-chronic liver failure, as it outperforms MELD in this population 4
• Consider NACSELD ACLF score to incorporate advanced extrahepatic organ failure, age, MELD, WBC count, and serum albumin 4

Prevention of Further Decompensation

Secondary Prophylaxis

• Initiate non-selective beta-blockers and/or endoscopic band ligation once bleeding is controlled for secondary prophylaxis 1, 2
• Use beta-blockers with caution in patients with severe or refractory ascites 1, 2
• Screen for gastroesophageal varices with endoscopy if not previously diagnosed and treated 1
• Repeat endoscopy yearly in patients without varices if the etiological factor persists and/or decompensation continues 1

Disease-Modifying Strategies

• Consider enoxaparin to delay hepatic decompensation and improve survival in patients with Child-Pugh scores 7-10 by preventing portal vein thrombosis 4
• Use pentoxifylline to reduce liver-related complications (infections, renal failure, encephalopathy) by preventing intestinal bacterial translocation 4
• Administer propranolol to reduce portal hypertension and decrease risk of various complications in responders 4

Transplant Evaluation

Refer all patients with decompensated cirrhosis for liver transplantation evaluation immediately, as this is the definitive treatment. 2

• Patients with ascites should generally be considered for referral to a liver transplantation program 2
• Evaluate for transplantation in patients with MELD score of 15 or greater, complications of cirrhosis, or hepatocellular carcinoma 5
• Note that mean pulmonary arterial pressure ≥45 mmHg is an absolute contraindication to liver transplantation 4
• Antiviral therapy can stabilize patients and improve Child-Turcotte-Pugh scores, potentially delaying or avoiding need for transplantation 2

Monitoring and Follow-Up

• Manage patients with decompensated cirrhosis in institutions capable of handling complications 2
• Consider telemedicine and remote monitoring technologies for early detection of complications and reduction of hospital readmissions 4
• Use continuous heart rate variability monitoring to identify patients at high risk of decompensation 4
• Monitor for development of acute-on-chronic liver failure, characterized by rapid deterioration, liver failure, and at least one extrahepatic organ failure 1

Critical Pitfalls to Avoid

• Never continue beta-blockers, diuretics, or vasodilators during acute decompensation as they worsen hemodynamic instability 1
• Avoid large volume paracentesis without albumin replacement to prevent post-paracentesis circulatory dysfunction 4
• Do not overtransfuse blood products as this may worsen portal hypertension 4
• Never use interferon in decompensated patients under any circumstances due to risk of precipitating liver failure 2
• Avoid inappropriate use of nephrotoxic medications which can precipitate hepatorenal syndrome 4