What are the signs and symptoms of decompensated liver cirrhosis?

Signs and Symptoms 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. 1, 2

Cardinal Clinical Manifestations

The transition from compensated to decompensated cirrhosis occurs when patients develop any of these four major complications:

Ascites

• Ascites is the most common first manifestation of decompensation, occurring in approximately 50% of patients within 10 years of cirrhosis diagnosis 2
• Presents as abdominal distension and fluid accumulation in the peritoneal cavity 2
• May progress to refractory ascites in advanced disease 2

Variceal Hemorrhage

• Presents as hematemesis (vomiting blood) or melena (black, tarry stools) 2
• Gastroesophageal varices are present in 30-40% of patients with compensated cirrhosis but increase to 85% in decompensated cirrhosis 2
• Represents portal-hypertensive hemorrhage from ruptured esophageal or gastric varices 3

Hepatic Encephalopathy

• Manifests as altered mental status ranging from subtle cognitive changes to coma 2
• Early signs include confusion, personality changes, sleep disturbances, and asterixis (flapping tremor) 2
• Can be precipitated by infections, gastrointestinal bleeding, or electrolyte disturbances 2

Jaundice

• Yellow discoloration of skin and sclera due to elevated bilirubin 2
• Indicates progressive liver failure and worsening synthetic function 2
• Represents inability of the liver to conjugate and excrete bilirubin 3

Additional Clinical Features and Complications

Renal Complications

• Hepatorenal syndrome presents with progressive oliguria (decreased urine output) and rising creatinine 2
• Hyponatremia (low sodium) indicates advanced disease with a mortality rate of 20% at 1 year 2

Infectious Complications

• Spontaneous bacterial peritonitis presents with fever, abdominal pain, and altered mental status 2
• Bacterial infections can occur at any stage but particularly accelerate disease progression in decompensated patients 2

Cardiovascular Complications

• Diastolic dysfunction may occur as an early sign of cirrhotic cardiomyopathy with normal systolic function 1
• Echocardiographic criteria include 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
• Hypoxia is defined by PaO₂ <80 mmHg or alveolar-arterial oxygen gradient ≥15 mmHg in ambient air, ≥20 mmHg in patients >65 years 1
• Hepatic hydrothorax (pleural effusion) can develop as a complication 1

Physical Examination Findings

• Liver surface nodularity may be palpable on examination 2
• Signs of portal hypertension including splenomegaly and caput medusae may be present 4

Important Clinical Caveats

• Patients may have multiple decompensating events simultaneously, which significantly worsens outcomes compared to isolated complications 1
• Decompensation can present through two distinct pathways: a non-acute pathway (slow development of ascites, mild hepatic encephalopathy, or jaundice not requiring hospitalization) or an acute pathway (requiring hospitalization) 5
• Median survival drops dramatically from >12 years in compensated cirrhosis to approximately 2 years after first decompensation 1, 2
• Obesity and ongoing alcohol use independently worsen prognosis regardless of cirrhosis etiology 1, 2
• The transition from compensated to decompensated cirrhosis occurs at a rate of 5-7% per year 1