From the Guidelines
Decompensated liver cirrhosis is diagnosed when a patient with cirrhosis develops one or more complications that indicate the liver can no longer function adequately, with key criteria including ascites, hepatic encephalopathy, variceal bleeding, jaundice, and coagulopathy, as defined by the European Association for the Study of the Liver (EASL) guidelines 1. The diagnosis of decompensated liver cirrhosis is based on the presence of overt clinical signs, such as:
- Ascites (fluid accumulation in the abdomen)
- Hepatic encephalopathy (brain dysfunction due to liver failure)
- Variceal bleeding (from enlarged veins in the esophagus or stomach)
- Jaundice (yellowing of skin and eyes)
- Coagulopathy (impaired blood clotting) Other criteria include hepatorenal syndrome (kidney dysfunction), spontaneous bacterial peritonitis, and hepatopulmonary syndrome, as outlined in the EASL guidelines 1 and supported by the American Association for the Study of Liver Diseases practice guidance 1. Laboratory findings typically show elevated bilirubin, prolonged prothrombin time, decreased albumin, and elevated creatinine, which are used to assess the severity of decompensation, with higher Child-Pugh and MELD scores indicating more severe disease 1. Patients with decompensated cirrhosis require immediate medical attention and often need evaluation for liver transplantation, as the condition carries a poor prognosis with a one-year mortality rate of approximately 20-50% without transplantation, emphasizing the need for prompt and effective management 1.
From the Research
Criteria for Decompensated Liver Cirrhosis
The criteria for decompensated liver cirrhosis include:
- Ascites
- Variceal hemorrhage
- Hepatic encephalopathy
- Jaundice 2, 3, 4, 5 These complications mark the transition from compensated to decompensated cirrhosis and are associated with a substantial worsening of patient prognosis.
Clinical Course of Decompensated Cirrhosis
Decompensated cirrhosis can occur through two distinct pathways:
- A non-acute pathway, characterized by a slow development of ascites or mild grade 1 or 2 hepatic encephalopathy, or jaundice, not requiring hospitalization
- An acute pathway, which includes acute-on-chronic liver failure 3 The clinical course of decompensated cirrhosis is complex and requires a comprehensive multistate model to assess the probabilities of multiple possible outcomes.
Management and Prognosis
Patients with decompensated cirrhosis require evaluation and medical care by a hepatologist and should be considered for liver transplantation evaluation 5 The prognosis is markedly worse in patients with decompensated compared to compensated cirrhosis, and novel disease-modifying strategies are urgently required to improve patient outcomes 6
Pathophysiology of Decompensated Cirrhosis
The pathomechanisms involved in decompensation and disease progression include:
- Portal hypertension
- Circulatory dysfunction
- Inflammation
- Metabolism and mitochondrial dysfunction 6 Understanding these mechanisms is crucial for identifying novel therapeutic targets and improving patient outcomes.