From the Guidelines
Decompensated cirrhosis is determined by the presence of clinical complications such as ascites, hepatic encephalopathy, variceal bleeding, and jaundice, which occur when the liver can no longer compensate for its decreased function. These complications are a result of the liver's inability to perform its normal functions, leading to a range of symptoms and signs that can be life-threatening if left untreated. Diagnosis of decompensated cirrhosis typically involves a combination of clinical assessment, laboratory tests (including liver function tests, complete blood count, and coagulation studies), imaging studies (ultrasound, CT, or MRI), and sometimes liver biopsy 1.
The Child-Pugh score and MELD (Model for End-Stage Liver Disease) score are commonly used to assess the severity of liver dysfunction and prognosis, incorporating laboratory values such as bilirubin, albumin, INR, creatinine, and clinical findings like ascites and encephalopathy 1. Early recognition of decompensation is crucial as it significantly worsens prognosis and may indicate the need for liver transplant evaluation. Management focuses on treating the specific complications and addressing the underlying cause of cirrhosis, such as alcohol cessation, antiviral therapy for hepatitis, or weight loss for fatty liver disease.
Some key points to consider in the diagnosis and management of decompensated cirrhosis include:
- The importance of endoscopic surveillance for varices, particularly in patients with a high risk of bleeding 1
- The use of noninvasive screening tests, such as liver stiffness measurement, to identify patients at low risk of varices who may not require endoscopic surveillance 1
- The need for careful management of complications such as ascites, hepatic encephalopathy, and variceal bleeding, which can significantly impact prognosis 1
- The importance of addressing the underlying cause of cirrhosis, such as alcohol cessation or antiviral therapy, to slow disease progression and improve outcomes.
Overall, the diagnosis and management of decompensated cirrhosis require a comprehensive approach that takes into account the patient's clinical presentation, laboratory results, and underlying cause of liver disease. By prioritizing early recognition and treatment of complications, and addressing the underlying cause of cirrhosis, healthcare providers can improve outcomes and reduce morbidity and mortality in patients with decompensated cirrhosis.
From the Research
Determining Decompensated Cirrhosis
To determine decompensated cirrhosis, the following factors are considered:
- Typical presenting clinical features include:
- Jaundice
- Ascites
- Hepatic encephalopathy
- Hepato-renal syndrome
- Variceal haemorrhage 2
- A careful history, examination, and investigations can help identify the precipitating cause, such as:
- Infections
- Gastrointestinal bleeding
- High alcohol intake or alcohol-related hepatitis
- Drug-induced liver injury 2
- Initial workup includes:
- Viral hepatitis serologies
- Ferritin
- Transferrin saturation
- Abdominal ultrasonography
- Complete blood count
- Liver function tests
- Prothrombin time/international normalized ratio 3
- Common serum and ultrasound-based screening tests to assess fibrosis include:
- Aspartate transaminase to platelet ratio index score
- Fibrosis 4 score
- FibroTest/FibroSure
- Nonalcoholic fatty liver fibrosis score
- Standard ultrasonography
- Transient elastography 3
- Physical findings are generally of low sensitivity for the diagnosis of cirrhosis, but signs with higher specificity represent decompensated disease 4
Diagnostic Accuracy
The diagnostic accuracy of physical examination for the detection of cirrhosis is limited, with:
- High specificity (range 75-98%) but low sensitivity (range 15-68%) for histologically-proven cirrhosis 4
- Most studies have been undertaken in highly selected populations 4
Management and Treatment
The management of decompensated cirrhosis includes: