Buku Medicine

General management

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: 

  • Variceal bleed 
  • Infections including spontaneous bacterial peritonitis (SBP) 
  • Electrolyte abnormalities 
  • Medication – particularly sedatives 
  • Cancer – including hepatocellular carcinoma 
  • Portal vein thrombosis 
  • Constipation 

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.  


  • Treat the underlying cause 
  • Patients with alcohol-related liver disease who are still drinking will require monitoring for alcohol withdrawal (e.g. CIWA-Ar) and vitamin replacement (e.g Pabrinex®) 

Link; https://www.bsg.org.uk/clinical-resource/bsg-basl-decompensated-cirrhosis-care-bundle-first-24-hours/



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.  


  • A detailed history and examination needs to be taken 
  • A full set of blood tests might provide a clue to underlying liver or renal disease as a cause of the ascites.  
  • An ultrasound scan will confirm presence of ascites and may provide additional information if there is evidence of cirrhosis or portal hypertension. Cross-sectional imaging may be required to investigate malignancy 
  • An echo should be performed if congestive cardiac failure or constrictive pericarditis is suspected 
  • An ascitic tap is a key test in determining the underlying cause of ascites 

The first time a sample is taken the ascitic fluid should be sent for: 

  • Biochemistry – albumin, protein, amylase, glucose and LDH 
  • Microbiology – cell count and culture (will need discussion with microbiology if TB suspected) 
  • Cytology 
  • If the fluid is cloudy / milky in appearance it should be sent for triglycerides to investigate chylous ascites. 

Causes of ascites are: 

  • Chronic liver disease with portal hypertension 
  • Renal dysfunction, particularly nephrotic syndrome 
  • Congestive cardiac failure or constrictive pericarditis 
  • Malignancy 
  • Infections – consider TB 

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.  



  • Aithal et al.  Guidelines on the management of ascites in cirrhosis.  Gut 2021; 70:9-29 


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) 

  • Grade 1: lack of awareness, euphoria or anxiety, shortened attention span, impaired performance of addition 
  • Grade 2: lethargy or apathy, minimal disorientation for time or place, subtle personality change, inappropriate behaviour, impaired performance of subtraction 
  • Grade 3: somnolence to semi-stupor but responsive to verbal stimuli, confusion, gross disorientation 
  • Grade 4: coma 

Other causes of neuropsychiatric symptoms should be excluded (stroke, central nervous system infection). 

Precipitating causes should be identified: 

  • Variceal bleed 
  • Infections including spontaneous bacterial peritonitis (SBP) 
  • Electrolyte abnormalities 
  • Medication – particularly sedatives 
  • Cancer – including hepatocellular carcinoma 
  • Portal vein thrombosis 
  • Constipation 

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: 

  • Problems related to the underlying liver disease 
  • Progression of the liver disease 
  • Decompensation (try to identify the precipitating cause) 
  • Alcoholic hepatitis on a background of chronic liver disease 
  • Co-existing liver disease 
  • Exclude viral hepatitis (A, B, C, E, CMV, EBV and HSV) ifs bloods are consistent with an acute hepatitis 
  • Obstructive jaundice – imaging should be requested on all patients presenting with jaundice. Ultrasound will usually be the first-line imaging modality. Cross-sectional imaging may be required.  
  • Haemolysis – see haematology section 

Hepato-renal syndrome

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 

  • Stop nephrotoxic medication 
  • Correct hypovolaemia  
  • Exclude urinary tract obstruction with an ultrasound scan 
  • Urine dipstick as blood or protein would be more suggestive of intrinsic renal disease 
  • Urinary sodium  

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

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: 

  • IV terlipressin 2mg QDS 
  • Antibiotics as per trust protocol 
  • Contact the endoscopist on call 

Link: BSGE acute upper GI bleeding bundle