Diagnosis of Decompensated Liver Cirrhosis
Decompensated cirrhosis is diagnosed clinically by the presence of one or more major complications: ascites, hepatic encephalopathy, variceal bleeding, or jaundice, which mark the transition from compensated to decompensated disease and dramatically worsen prognosis. 1, 2
Clinical Diagnostic Criteria
The diagnosis is primarily clinical and does not require liver biopsy in most cases 1:
- Ascites (most common first decompensating event) 1, 3
- Hepatic encephalopathy (altered mental status, confusion, asterixis) 1
- Variceal hemorrhage (gastrointestinal bleeding from portal hypertension) 1
- Jaundice (hyperbilirubinemia from hepatic dysfunction) 1, 2
Two distinct pathways of decompensation exist: non-acute decompensation (slow development of ascites, mild grade 1-2 hepatic encephalopathy, or jaundice not requiring hospitalization) versus acute decompensation (rapid onset requiring hospitalization, potentially progressing to acute-on-chronic liver failure). 2
Essential Initial Workup
Laboratory Assessment
Upon presentation with suspected decompensation, obtain 1, 4:
- Complete metabolic panel (liver function tests, electrolytes, renal function)
- Complete blood count
- Coagulation studies (PT/INR)
- Serum albumin
- Do NOT routinely measure ammonia levels - they are not recommended for diagnosis of hepatic encephalopathy 5
Imaging Studies
Conventional ultrasound, CT, or MRI can confirm cirrhosis based on morphological features (nodular liver surface, caudate lobe hypertrophy, splenomegaly, varices, ascites), though imaging alone cannot definitively stage fibrosis severity. 1
For patients without obvious cirrhosis on imaging, MR elastography has superior accuracy over conventional morphological imaging for detecting and grading hepatic fibrosis. 1
Identify Precipitating Factors
Critical step: Always investigate what triggered decompensation 1, 5, 4:
- Infections (spontaneous bacterial peritonitis, pneumonia, urinary tract infection)
- Gastrointestinal bleeding
- High alcohol intake or alcohol-related hepatitis
- Drug-induced liver injury or hepatotoxic medications
- Electrolyte disorders (particularly hyponatremia, hypokalemia)
- Acute kidney injury
- Constipation
- Dehydration
- Inappropriate sedative use (especially benzodiazepines)
Severity Stratification
Child-Pugh Score
Calculate using five parameters (each scored 1-3 points) 6:
- Bilirubin
- Albumin
- INR
- Ascites (absent, mild, moderate)
- Encephalopathy (none, grade 1-2, grade 3-4)
Class A (5-6 points): Compensated Class B (7-9 points): Decompensated with moderate dysfunction Class C (10-15 points): Decompensated with severe dysfunction
MELD Score
Model for End-Stage Liver Disease score predicts 3-month mortality and guides transplant prioritization. 6
Calculate using: serum bilirubin, creatinine, and INR.
MELD ≥15 indicates need for liver transplantation evaluation. 6
Diagnostic Pitfalls to Avoid
Do not automatically attribute altered mental status to hepatic encephalopathy - it is a diagnosis of exclusion requiring investigation for alternative causes including substance withdrawal, drug toxicity, infections, electrolyte disorders, intracranial bleeding, seizures, and primary psychiatric disorders. 5
Routine brain imaging is indicated for first episode of encephalopathy, seizures, focal neurological signs, or inadequate response to therapy. 5
Serum creatinine and GFR estimates have poor accuracy in decompensated cirrhosis - measured GFR through clearance of exogenous markers is the reference standard, particularly important for transplant candidates (measured GFR <30 ml/min suggests need for combined liver-kidney transplant). 1
HbA1c should not be used for diabetes diagnosis or monitoring in decompensated cirrhosis due to altered red blood cell turnover. 1
Screening for Complications
Hepatocellular Carcinoma Surveillance
All patients with decompensated cirrhosis require HCC surveillance with ultrasound every 6 months, as they would benefit from early detection. 1
If ultrasound reveals a nodule or is inadequate, proceed to contrast-enhanced CT or MRI for definitive characterization. 1
Diabetes Screening
Screen all patients with decompensated cirrhosis for type 2 diabetes given 30% prevalence and bidirectional worsening effects between diabetes and cirrhosis. 1
Chronic Kidney Disease Assessment
CKD affects nearly half of patients with decompensated cirrhosis - assess renal function early, especially in transplant candidates. 1
Hepatic Encephalopathy Screening
Use bedside tools like the animal naming test (requires only 60 seconds, no equipment) to screen for mild/covert hepatic encephalopathy, which affects quality of life and predicts progression to overt encephalopathy. 1