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, 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
- If ascites WCC >500/mm3 or neutrophil count >250/mm3, treat as for spontaneous bacterial peritonitis (SBP) (see below).
- Low salt diet
- Diuretics - initially use spironolactone oral 100–400mg each day. Seek senior advice if renal impairment or high potassium. 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 6 hours 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 here for guidance).
- Human Albumin Solution 20% (20g albumin per 100ml), IV infusion 1.5g/kg on day one then 1g/kg on day 3.
- Prophylaxis of SBP in:
- Patients with one episode proven SBP, either previously or currently (once current episode treated).
- Patients with total ascitic protein < 10g/L.
- Prescribe co-trimoxazole oral 960mg once daily (first line) or norfloxacin oral 400mg once daily (second line) for prophylaxis.
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 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.
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.
Content last updated June 2019