What is the initial management for a patient with acute decompensated liver cirrhosis?

Management of Acute Decompensated Liver Cirrhosis

Immediate Stabilization and Assessment

Begin with rapid assessment of airway, breathing, and circulation (ABC), followed by immediate volume resuscitation with crystalloids to restore hemodynamic stability. 1, 2

Initial Resuscitation

• Place at least two large-bore IV catheters capable of rapid volume expansion and initiate crystalloid resuscitation immediately 1
• Discontinue all diuretics, beta-blockers, vasodilators, NSAIDs, ACE inhibitors, and other hypotensive medications during acute decompensation 2, 3
• Implement 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
• Assess ACLF grade and volume status before initiating specific therapies, as ACLF Grade 3 carries significantly higher mortality risk 2, 4

Critical Early Interventions

• Initiate antibiotic prophylaxis immediately with ceftriaxone 1 g IV daily for up to 7 days in all patients with acute decompensation, as infections are present in over 50% of cases 1, 2
• Screen for precipitating factors including infections, gastrointestinal bleeding, alcohol intake, drug-induced liver injury, and electrolyte disturbances 5

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Management of Variceal Hemorrhage

If acute variceal hemorrhage is suspected based on clinical presentation, start vasoactive drug therapy immediately—even before endoscopic confirmation—as this is a medical emergency with high mortality. 1, 2

Immediate Pharmacologic Therapy

• Administer terlipressin 2 mg IV every 4 hours (given over 2 minutes as slow bolus) for the first 48 hours, then reduce to 1 mg every 4 hours 1
  • Alternative options: Somatostatin 250 µg/h continuous infusion (with 250 µg initial bolus) or octreotide 50 µg/h continuous infusion (with 50 µg initial bolus) 1
  • Continue vasoactive therapy for 5 days after bleeding confirmation to prevent early rebleeding 1

Critical Terlipressin Safety Considerations

• Obtain baseline oxygen saturation (SpO2) before initiating terlipressin and do not start if SpO2 <90% 4
• Monitor continuously with pulse oximetry during treatment and discontinue if SpO2 drops below 90% 4
• Avoid terlipressin in ACLF Grade 3 patients due to significantly increased risk of fatal respiratory failure (14% vs 5% with placebo) 4
• Contraindicated in patients with ongoing coronary, peripheral, or mesenteric ischemia 4
• Assess volume status carefully as fluid overload increases respiratory failure risk; manage by reducing albumin/fluids and judicious diuretic use 4

Endoscopic Management

• Administer erythromycin 250 mg IV 30-120 minutes before endoscopy to improve gastric emptying and visualization, unless QT prolongation present 1, 2
• Perform upper endoscopy within 12 hours of admission once hemodynamic stability achieved 1, 2
• Execute endoscopic band ligation (EBL) for esophageal varices during the same procedure when bleeding confirmed 1, 2
• Use cyanoacrylate injection for gastric (fundal) varices, as EBL only appropriate for small gastric varices that can be completely suctioned 1

Rescue Therapy

• Consider early TIPS in high-risk patients (Child-Pugh C with active bleeding or Child-Pugh B with active bleeding at endoscopy) 1, 2
• Use TIPS as rescue therapy for persistent bleeding or early rebleeding in approximately 15% of cases 1

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Management of Ascites

Grade 1 Ascites (Mild)

• Initiate sodium restriction to <5 g/day (avoid more severe restriction as it worsens malnutrition) 3
• Discontinue NSAIDs, ACE inhibitors, and angiotensin receptor blockers as these reduce urinary sodium excretion and can convert diuretic-sensitive to refractory ascites 3
• Address underlying etiology (alcohol cessation, antiviral therapy) 3

Grade 2 Ascites (Moderate)

• Start spironolactone 50-100 mg/day as first-line diuretic, with maximum dose 400 mg/day 3
• Add furosemide 20-40 mg/day if needed, with maximum dose 160 mg/day 3
• Continue sodium restriction and avoid nephrotoxic agents 3

Grade 3 Ascites (Tense)

• Perform therapeutic paracentesis immediately for symptomatic relief 1, 2, 3
• Administer albumin 1 g/kg body weight (maximum 100 g) during large-volume paracentesis to prevent post-paracentesis circulatory dysfunction 2
• Follow with sodium restriction and diuretic therapy after paracentesis 3

Refractory Ascites

• Consider serial large-volume paracentesis, TIPS, or liver transplantation evaluation 3
• Refer to palliative care if not a transplant candidate 3

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Management of Hepatic Encephalopathy

Initiate lactulose or lactitol immediately when encephalopathy develops, as these non-absorbable disaccharides are first-line therapy. 2, 3

• Administer lactulose to achieve 2-3 soft bowel movements daily 2
• Consider rifaximin as adjunctive therapy in patients with recurrent episodes 2
• Identify and treat precipitating factors including infections, GI bleeding, constipation, electrolyte disturbances, and medications 5

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Management of Acute Kidney Injury (AKI)

Discontinue all nephrotoxic drugs immediately, including NSAIDs, aminoglycosides, ACE inhibitors, and angiotensin receptor blockers. 2, 3

Volume Assessment and Treatment

• Administer 20% albumin solution 1 g/kg body weight (maximum 100 g) for two consecutive days in AKI stage >1A without obvious cause 2
• Assess for hepatorenal syndrome by excluding other causes of AKI (hypovolemia, shock, nephrotoxic drugs, structural kidney disease) 2
• Consider terlipressin plus albumin for hepatorenal syndrome in appropriate candidates without contraindications 4
  • Note: Patients with serum creatinine >5 mg/dL unlikely to benefit from terlipressin 4

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Infection Management and Prophylaxis

Maintain high index of suspicion for infections as they precipitate decompensation and are present in >50% of acute bleeding cases. 2

Antibiotic Prophylaxis

• Use ceftriaxone 1 g IV daily in advanced cirrhosis (Child-Pugh C), settings with high quinolone resistance, or patients with GI bleeding 1, 2
• Alternative: norfloxacin 400 mg PO twice daily in less advanced cirrhosis without quinolone resistance 1
• Continue prophylaxis for up to 7 days 2

Spontaneous Bacterial Peritonitis (SBP)

• Perform diagnostic paracentesis without delay in all cirrhotic patients with ascites on hospital admission 3
• Diagnose SBP when ascitic neutrophil count >250/mm³ 3
• Initiate empirical antibiotics immediately based on local resistance patterns, typically cefotaxime or ceftriaxone 3

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Prognostic Assessment

Calculate Child-Pugh score for initial severity stratification, with scores 7-10 indicating decompensated disease requiring intensive management. 2, 6

• Use MELD or MELD-Na scores for transplant prioritization 2, 6
• Apply CLIF-C ACLF score for better prognostic accuracy in patients with acute-on-chronic liver failure 2, 6
• Recognize ACLF as rapid deterioration with liver failure plus ≥1 extrahepatic organ failure, carrying significantly higher short-term mortality 2, 6, 7

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Treatment of Underlying Etiology

Address the underlying cause of cirrhosis aggressively, as this can lead to "re-compensation" and improved outcomes even in decompensated patients. 6, 3

Alcohol-Related Cirrhosis

• Mandate complete alcohol cessation as this can reverse decompensation in some patients 6, 3

Viral Hepatitis

• Initiate antiviral therapy for HBV with entecavir or tenofovir if HBV DNA ≥2,000 IU/mL, regardless of ALT levels 3
• Treat all decompensated HBV patients regardless of HBV DNA level 3
• Use direct-acting antivirals for HCV to improve liver function and reduce portal hypertension 6, 3
• Never use interferon-α in decompensated cirrhosis as it is absolutely contraindicated due to risk of infection and hepatic failure 3

Autoimmune Hepatitis

• Consider immunosuppressive therapy as it shows beneficial effects even in decompensated cirrhosis 3

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Common Pitfalls and Caveats

• Avoid excessive bed rest as it causes muscle atrophy; manage outpatients unless complicated by bleeding, encephalopathy, infection, or hypotension 3
• Do not use HbA1c for diabetes diagnosis or monitoring in decompensated cirrhosis 3
• Metformin is contraindicated due to lactic acidosis risk 3
• Insulin is the only evidence-based option for type 2 diabetes in decompensated cirrhosis 3
• Overuse of blood products worsens portal hypertension; adhere strictly to restrictive transfusion strategy 6
• Beta-blockers should be discontinued during acute decompensation with hypotension, bleeding, sepsis, or AKI 1
• Colloids offer no benefit over crystalloids for volume resuscitation 1
• For patients with MELD ≥35, carefully weigh risks versus benefits of terlipressin as adverse reactions may make them ineligible for transplantation 4

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Liver Transplantation Considerations

Refer appropriate candidates for liver transplantation evaluation early, as this is the definitive treatment for decompensated cirrhosis. 2, 3

• Mean pulmonary arterial pressure ≥45 mmHg is an absolute contraindication to transplantation 6
• Terlipressin-related complications (respiratory failure, ischemia) may render patients ineligible for transplantation 4