From the Guidelines
Management of acute decompensated cirrhosis requires a comprehensive approach that includes prompt recognition and treatment of precipitating factors, supportive care, and consideration of liver transplant evaluation for eligible patients. The initial management includes identifying and addressing triggers such as infection, gastrointestinal bleeding, medications, or alcohol use. For ascites, sodium restriction (2g/day) and diuretic therapy with spironolactone (starting at 100mg daily) and furosemide (starting at 40mg daily) are recommended, with doses adjusted based on response, as suggested by the EASL clinical practice guidelines 1. Large-volume paracentesis may be needed for tense ascites, with albumin replacement (6-8g per liter removed) to prevent circulatory dysfunction.
Key Components of Management
- Identifying and addressing precipitating factors
- Supportive care, including sodium restriction and diuretic therapy for ascites
- Large-volume paracentesis with albumin replacement for tense ascites
- Lactulose for hepatic encephalopathy, with rifaximin added for recurrent episodes
- Immediate resuscitation, blood transfusion, and urgent endoscopic therapy for variceal bleeding
- Prophylactic antibiotics for spontaneous bacterial peritonitis
- Albumin and vasoconstrictors for hepatorenal syndrome
According to the KASL clinical practice guidelines for management of chronic hepatitis B 1, antiviral therapy can modify the natural history of decompensated cirrhosis, improve liver function, decrease the need for liver transplantation, and improve survival. However, even with antiviral therapy, some patients with severely impaired liver function may not recover, and liver transplantation should be considered for such cases. A care coordination programme, as suggested by the EASL guidelines 1, can improve survival and reduce emergent readmission to the hospital in patients with decompensated cirrhosis. Throughout management, it is essential to avoid nephrotoxic drugs, maintain euvolemia, and consider liver transplant evaluation for eligible patients, as it represents the definitive treatment for decompensated cirrhosis.
From the Research
Management of Acute Decompensated Cirrhosis
The management of acute decompensated cirrhosis involves a comprehensive approach to address the complex medical needs of patients with this condition. Key aspects of management include:
- Identifying the precipitating cause of decompensation, such as infections, gastrointestinal bleeding, high alcohol intake, or drug-induced liver injury 2
- Implementing a 'care bundle' to guide management for the first 24 hours, as endorsed by the British Society of Gastroenterology 2
- Rapid identification and treatment of the triggering event of decompensation, as well as specific measures for the treatment of concomitant extrahepatic organ dysfunctions 3
Complications and Organ Dysfunction
Patients with acute decompensated cirrhosis are at high risk of developing complications, including:
- Hepatic encephalopathy
- Hepatorenal syndrome
- Gastrointestinal bleeding
- Bacterial infections
- Extrahepatic organ dysfunction, such as cardiovascular, pulmonary, and renal complications 3, 4
Outpatient Management
After hospitalization for acute decompensation, outpatient management is crucial to:
- Prevent disease progression
- Reduce complications
- Improve quality of life
- Assess possible recompensation
- Evaluate for liver transplantation 5
Mortality Risk and Prognosis
Patients with acute decompensated cirrhosis have a high mortality risk, exceeding 50% in some cases 4. However, improvements in survival have been described when treated in specialized liver transplant centers 4. Early and appropriate management is essential to improve prognosis and prevent the development of acute-on-chronic liver failure (ACLF) 3.