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
- For patients with cirrhosis please follow BASL Decompensated Cirrhosis Care bundle - First 24 hours on the British Society of Gastroenterology website.
- 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 (further below)
- 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
- Consider other causes of ascites (e.g. malignancy, Budd-Chiari syndrome or cardiac failure).
- Perform diagnostic ascitic tap. Aspirate 50ml of fluid (normally straw coloured) and send for:
- Microbiology – WCC and culture in blood culture bottle (anaerobic and aerobic)
- Biochemistry – total protein and albumin
- Cytology – send if malignancy suspected or SAAG (serum-ascites albumin gradient) <11. 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
||Diffuse peritoneal metastases
|Massive liver metastases
- Consider DVT prophylaxis (see here for guidance). In patients with liver disease LMWH can be considered as long as platelet count is ≥50x 109/L.
General management and treatment options
- Aim for high protein, high calorie diet.
- Reduce protein slowly if encephalopathic.
- Restrict dietary salt if ascites is present.
- Give vitamin K (Phytomenadione) 10mg slow IV injection over 3 - 5 minutes. Give further doses on day 2 and day 3.
Note: This will not correct clotting unless there is a deficiency (can occur in obstructive liver disease or prolonged malnutrition) but will ensure patient's level is replete.
- If history of alcohol abuse is suspected give Pabrinex® (contains thiamine) – see vitamin prophylaxis flowchart here.
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
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).
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.
Guideline reviewed and content updated June 2021