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Management of Decompensated Liver Disease

For patients with cirrhosis, please complete the GGC Decompensated Cirrhosis Care Bundle (link only active if connected to NHSGGC network).

For guidance on analgesic and antiemetic prescribing in patients with decompensated cirrhosis, see the following guideline. 

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
  • Refer for dietician assessment
  • Liver screen including AFP (alpha fetoprotein) if not previously performed; AFP should also be undertaken specifically if not done within 6 months.
  • In patients with acute decompensation and organ failures indicative of acute on chronic liver failure, urgent discussion with gastroenterology team is recommended, and critical care referral should be considered.  See the European Foundation for the Study of Chronic Liver Failure (EF-CLIF) calculators. 
  • In encephalopathy (signs = mental slowness, confusion, drowsiness, liver flap), assess for the following precipitants and treat as appropriate:
    • Sepsis: culture blood and urine. Note guidance on aminoglycosides below.
    • Tap ascites if present for WCC, protein content and culture (see below).
    • Arrange chest x-ray.
    • Bleeding
    • Renal failure, electrolyte abnormalities
    • Constipation
    • 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, there should be nothing abnormal detected. If blood and protein consider renal causes.
    • Assess for hydration.
  • If ascites is present:
    • Consider other causes of ascites (e.g. malignancy, cardiac failure or Budd-Chiari syndrome).
    • Perform diagnostic ascitic tap. In clinically moderate or large ascites, this should be performed within 6 hours of admission - prior USS or correction of coagulopathy is not required. Aspirate 50ml of fluid (normally straw coloured) and send for:
      • Haematology - Body Fluid Analysis: Send EDTA (purple top) for cell count. Cell count from the EDTA sample will be reported as units x109/L; Spontaneous Bacterial Peritonitis (SBP) is confirmed if polymorphs >0.25x109/L or total WCC >0.5x109/L.
      • Microbiology – Culture and Microscopy: At present, also send universal container (white top specimen pot) for cell count and culture. Out of hours, inform microbiology laboratory Biomedical Scientist on-call in order for assessment within 6hours of sample being taken. SPB is confirmed with WCC >500/mm3, neutrophils >250/mm3.
      • Microbiology - Culture Bottles: Culture in blood culture bottle (anaerobic and aerobic).
      • Biochemistry: Send white topped vacutainer tube to measure total protein and albumin.
      • Cytology: Send if malignancy suspected or SAAG (serum-ascites albumin gradient) <11g/L. Obtain >100ml of fluid to increase yield.

SAAG can differentiate ascites resulting from portal hypertension and from other causes. It is more useful than the protein based exudate / transudate concept. Calculate SAAG by:

SAAG = (serum albumin) – (ascites albumin)

Obtain both values on the same day. If SAAG >11g/L then ascites very likely the result of portal hypertension (97% accuracy). Table 1 below lists the major differential diagnoses based on the SAAG.

Table 1 – Differential diagnoses of ascites based on serum-ascites albumin gradient

SAAG ≥11g/L SAAG <11g/L
Cirrhosis Diffuse peritoneal metastases
Alcoholic hepatitis Tuberculous peritonitis
Cardiac ascites Pancreatic ascites
Massive liver metastases Nephrotic syndrome
  • Consider thromboprophylaxis (see here for guidance). In patients with liver disease LMWH can be considered as long as platelet count is ≥50x109/L and no active bleeding.

General management and treatment options

Diet

  • Prescribe Ensure Compact at 10pm as a bedtime snack to minimise starved state overnight.
  • Encourage high energy, high protein meals. 
  • Encourage carbohydrate / protein rich snacks between meal times.
  • Encourage full fat milk with meals and snacks. 
  • Aim for meal / snacks every 2-3hours during the day. 
  • No added salt diet if ascites present. 
  • Do not restrict protein if encephalopathic. 
  • Ask nurses to complete food record charts, screen on MUST and refer to dietician.
  • If history of alcohol abuse is suspected give Pabrinex® (contains thiamine) – see vitamin prophylaxis flowchart here.
  • Inpatient dietician assessment should take place for all patients with decompensated liver disease. 

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 four times daily (titrate dose to give three soft motions per day).

Management of ascites

  • If spontaneous bacterial peritonitis (SBP) is confirmed (see above), treat as per antibiotic guidance (see below).
  • No added salt diet
  • Diuretics - initially use spironolactone oral 100–400mg each day. Seek senior advice if renal impairment, high potassium or hyponatraemia. Titrate dose / consider adding furosemide according to weight and renal function. Aim for weight reduction of no more than 1kg/day.
  • If ascites is causing respiratory compromise or is not responding to above measures consider large volume paracentesis. In contrast to patients with malignant ascites (see separate guideline here) drains should ideally be removed at 6hours to reduce infection risk and 100ml of Human Albumin Solution 20% (20g albumin per 100ml) is recommended for every 2.5L drained.
  • Treat SBP once diagnosis confirmed with:
    • Suitable antimicrobial* (see the NHSGGC Infection Management Guideline poster).
    • If bilirubin >68mmol/L or creatinine >88mmol/L then give Human Albumin Solution 20% (20g albumin per 100ml), IV infusion 1.5g/kg on day one over 6hours, then 1g/kg on day 3 over 3hours.
  • Prophylaxis of SBP in:
    • Patients with one episode proven SBP, either previously or currently (once current episode treated).
    • Prescribe co-trimoxazole* oral 960mg once daily (first line) for prophylaxis. Discuss second line with GI consultant.  

*Co-trimoxazole should be used with caution - may increase potassium and decrease renal function. Monitor.

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
      • Human Albumin Solution (HAS)
        Day 1: HAS 20% IV 100ml, 1g/kg (usually 2-5 bottles) or HAS 5% IV 500ml 1.5g/kg (usually 2-4 bottles)
        Day 2-16: HAS 20% IV 100ml or HAS 5% 500ml 1-2 bottles per day and consider:
      • Terlipressin acetate IV – after 24 hours of fluid resuscitation and senior review. Initially 0.5-2mg every 4 hours or as a continuous infusion, if available (see HRS protocol). 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 within 24 hours, seek senior review and consider central venous pressure monitoring.

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 / infectious diseases unit for advice (Appendix 6 for contact details).

Other information

For further monitoring

  • Daily FBC, U&Es until improving.
  • Coagulation screen and LFTs 2-3 times per week.
  • Daily weight
  • Monitor daily for encephalopathy.
  • Should transfer to inpatient gastroenterology ward.

Pre-discharge

  • Aim to stabilise weight, mental state and diuretics dose prior to discharge.
  • Counsel about alcohol. Liaise with alcohol support services.
  • Document weight on immediate discharge letter (IDL).
  • Arrange clinic review.

 

Guideline reviewed: October 2024

Page last updated: November 2024