Quick tip: Identify whether your trust has a local decompensated care bundle/use the BSG care bundle (link below) and use this on admission to help guide the initial management of patients presenting with decompensated liver disease
This occurs when there is a deterioration in liver function in patients with underlying chronic liver disease. It usually presents with jaundice, encephalopathy, ascites or renal dysfunction. It is a common cause of medical admissions. It is important to try and identify the cause of decompensation. Common causes are:
For any patients presenting with decompensated liver disease the decompensated care bundle should be completed (see link at bottom of page). This document guides you though the initial management of patient with decompensated liver disease.
Ascites is a collection of fluid in the peritoneal cavity. It can be due to a number of causes, one of which is liver disease. New onset of ascites should be investigated to identify an underlying cause which will guide treatment.
The first time a sample is taken the ascitic fluid should be sent for:
Causes of ascites are:
A serum albumin ascites gradient (SAAG) should be calculated (subtract level of albumin in ascitic fluid from serum albumin). A value of >11g/l is likely to represent ascites secondary to portal hypertension.
Treatment of ascites depends on the underlying cause and should be discussed with the relevant speciality.
Hepatic encephalopathy (HE) is a complication of cirrhosis and carries a poor prognosis once it develops. It is defined as brain dysfunction caused by liver disease and /or portosystemic shunting. It can present with a variety of neuropsychiatric signs and symptoms.
HE can be graded using the Conn score (West Haven classification)
Other causes of neuropsychiatric symptoms should be excluded (stroke, central nervous system infection).
Precipitating causes should be identified:
Management needs to treat the precipitating cause.
Lactulose should be started and titrated to aim for two soft stools per day. It can be administered via an NG tube if the patient is unable to take orally. Enemas can be used if the patient is drowsy or unable to tolerate oral / NG lactulose.
Rifaxamin, a non-absorbable antibiotic and can be initiated when symptoms persist despite use of lactulose or intolerance to lactulose.
Given the poor prognosis associated with the development of hepatic encephalopathy, patients should be managed by a liver disease specialist and referral to a transplant centre should be considered if appropriate.
Jaundice has been covered in the section on abnormal liver function tests.
If patients with chronic liver disease become jaundiced the following should be considered:
Hepato-renal syndrome is a type of functional renal impairment seen in patients with cirrhosis. It is due to haemodynamic changes associated with cirrhosis that lead to a reduction in renal blood flow and subsequent rise in creatinine.
However, it is important to rule out other causes of renal impairment, which can also occur in those with cirrhosis
Hepato-renal syndrome carries a poor prognosis and should be managed by specialists. Treatment is with a combination of human albumin solution (HAS) and a vasoconstrictor such as terlipressin.
Upper GI bleeding is a common presentation to hospital and is a medical emergency.
The acute upper GI bleeding bundle (see link at bottom of page) should be completed within 24 hours. This details recognition, resuscitation, risk assessment, treatment, referral and review post-endoscopy.
If the patient is known to have cirrhosis or a variceal bleed is suspected: