Management of Decompensated Liver Disease
Assessment / monitoring
- Bloods for FBC, coagulation screen, U&Es, LFTs, glucose
- Signs of chronic liver disease
- Arrange ultrasound scan of abdomen
- Assess for alcohol withdrawal
- Dietary assessment
- Liver screen including AFP (alpha fetoprotein) if not previously performed
- In encephalopathy (signs = mental slowness, confusion, drowsiness, liver flap), assess for the following precipitants and treat as appropriate:
- Culture blood and urine
- Tap ascites if present for WCC count, protein content and culture (see below)
- Arrange chest x-ray
- Renal failure, electrolyte abnormalities
- Medication (e.g. sedatives or over-diuresis)
- In renal impairment:
- Assess for potentially reversible factors – dehydration, diuretics, sepsis, intrinsic renal disease.
- Renal tract ultrasound to exclude obstruction. Urine dipstick – if hepatorenal should be nothing abnormal detected. If blood and protein consider renal causes.
- Assess for hydration.
- If ascites is present
Table 1 – Differential diagnoses of ascites based on serum-ascites albumin gradient
||Diffuse peritoneal metastases
|Massive liver metastases
General management and treatment options
Management of encephalopathy
- Assess for precipitating factors (see above under ‘Assessment / monitoring’ section) and treat as appropriate. If sepsis suspected, treat with antibiotics. Remember typical signs of sepsis may be masked. Use broad-spectrum antibiotics (see here).
- Stop sedatives
- Give lactulose oral 20ml three times daily (titrate dose to give three soft motions per day).
Management of ascites
Management of renal impairment
- Catheterise (strict input / output chart)
- Stop diuretics
- Assess hydration status.
- If clinically dehydrated give sodium chloride 0.9% IV Infusion (1–1.5L is reasonable).
- If evidence of ascites and peripheral oedema give salt poor albumin 20% IV, 2 x 100ml each day and consider terlipressin IV – initially 0.5mg 6 hourly. Titrate dose over 72 hours in discussion with the local gastroenterology team. Terlipressin is contraindicated in ischaemic heart disease / peripheral vascular disease and arrhythmias.
If no improvement in urine output after the above measures, seek senior review and consider central venous pressure monitoring.
Jaundiced patients who suffer from alcoholic liver disease should be discussed with the local gastroenterology team regarding eligibility for inclusion in the STOPAH (Steroids or Pentoxifylline for Alcoholic Hepatitis) trial.
Aminoglycoside in decompensated liver disease
Gentamicin should be avoided in patients with decompensated liver disease (jaundice, ascites, encephalopathy, variceal bleeding or hepatorenal syndrome). See the infection management section or contact microbiology / infections diseases unit for advice (Appendix 6 for contact details).
For further monitoring
- Daily FBC, U&Es until improving
- Coagulation screen and LFTs 2-3 times per week
- Daily weight
- Monitor daily for encephalopathy.
- Aim to stabilise weight, mental state and diuretics dose prior to discharge.
- Counsel about alcohol. Liaise with alcohol support services.
- Arrange clinic review.