Decompensated Cirrhosis

Cirrhosis with new ascites, variceal bleed, hepatic encephalopathy, jaundice, AKI/HRS, or infection.

Symptoms / Associated Sx

  • Abdominal distension/girth, ascites, early satiety, bloating, weight gain

  • Abdominal pain/tenderness ± fever/chills → SBP

  • Dyspnea → tense ascites/hepatic hydrothorax

  • BLE edema, jaundice/scleral icterus, pruritus

  • Confusion, sleep-wake reversal, asterixis → HE

  • Hematemesis/melena → variceal bleed

  • Poor PO intake, sarcopenia/muscle wasting

Denies

  • Hematemesis/melena — rules out active GI/variceal bleed

  • Fever/abdominal pain — lowers SBP likelihood but still needs paracentesis if hospitalized with ascites

  • Dysuria/cough — rules out UTI/PNA as precipitant

  • NSAID/aminoglycoside/contrast use — rules out iatrogenic AKI

  • Severe rebound/rigidity — if present, think secondary peritonitis/perforation

Social History (SHx)

Alcohol use/relapse, IV drug use, HBV/HCV risk, NASH/MASLD risk, known cirrhosis date/etiology, prior decompensations, prior SBP, variceal bleed, HE, med adherence, transplant/hepatology follow-up.

Main Etiology

  • Alcohol-related cirrhosis

  • MASLD/NASH

  • Chronic HBV/HCV

  • Autoimmune hepatitis, PBC, PSC

  • Hemochromatosis, Wilson disease, alpha-1 antitrypsin deficiency

Main Precipitants

  • Infection/SBP

  • GI bleed

  • Alcohol relapse

  • Medication noncompliance

  • AKI/HRS

  • Constipation

  • Electrolyte abnormalities

  • Portal vein thrombosis

  • Sedatives/opioids/benzos

Most Common DDx

  • Cardiac ascites/congestive hepatopathy — JVD, BNP ↑, SAAG ≥1.1 + ascitic protein >2.5

  • Malignant ascites — weight loss, SAAG <1.1, cytology positive

  • Budd-Chiari — painful hepatomegaly, ascites, Doppler hepatic vein thrombosis

  • Acute liver failure — INR >1.5 + HE without known cirrhosis

  • Alcoholic hepatitis — acute jaundice, AST >2:1

  • Secondary peritonitis — polymicrobial, glucose <50, LDH high, severe peritoneal signs

DATA

  • CBC — leukocytosis/SBP, anemia/GI bleed, thrombocytopenia/portal HTN

  • CMP/BMP — Cr/AKI/HRS, Na/hyponatremia, K/Mg, AST/ALT, ALP, bilirubin

  • PT/INR — synthetic function/coagulopathy

  • Albumin — synthetic function + SAAG calculation

  • MELD-Na + Child-Pugh score

  • Ammonia if AMS — supportive only, not diagnostic

  • Lactate if sepsis concern

  • Blood cultures ×2 if febrile/SBP/sepsis concern

  • UA/urine culture if urinary symptoms or infection concern

  • Diagnostic paracentesis: cell count + diff/PMN, culture in blood culture bottles, albumin, total protein

  • Add-ons if indicated: glucose/LDH, cytology, amylase, AFB/ADA

  • Serum albumin for SAAG

  • RUQ ultrasound + Doppler — ascites, cirrhosis morphology, portal/hepatic vein thrombosis

  • CXR — PNA, hepatic hydrothorax

  • CT abdomen/pelvis if unclear diagnosis, malignancy, secondary peritonitis, complication

  • AFP + HCC surveillance status

  • EGD status for variceal screening

Home Meds

  • Spironolactone/furosemide — assess dose/adherence; hold if AKI, severe hypoNa, hypotension

  • Lactulose/rifaximin — assess adherence

  • Nonselective beta blocker — hold if SBP <90, MAP low, AKI, active SBP/sepsis

  • SBP prophylaxis — ciprofloxacin/TMP-SMX/norfloxacin

  • Antivirals for HBV/HCV — usually continue

  • NSAIDs — stop

  • Opioids/benzos — avoid/hold if HE

  • ACEi/ARB/metformin — hold if AKI/hypotension/lactic acidosis concern

Assessment

  • Decompensated cirrhosis with ascites ± SBP/HE/AKI.

  • Need to identify precipitant: infection, GI bleed, medication noncompliance, AKI/HRS, alcohol relapse, constipation, electrolyte abnormality, PVT.

  • Calculate MELD-Na and Child-Pugh.

  • Diagnostic paracentesis required in all hospitalized patients with ascites.

Plan

  • F/U ordered labs, cultures, paracentesis studies, RUQ US/Doppler, CXR/CT if ordered

  • Diagnostic paracentesis ASAP in all hospitalized patients with ascites; do not delay for INR/thrombocytopenia

  • Send ascitic: cell count/diff, culture in blood culture bottles, albumin, total protein

  • Add glucose/LDH if secondary peritonitis concern; cytology if malignancy concern; amylase if pancreatic; AFB/ADA if TB concern

  • SAAG = serum albumin − ascitic albumin

  • SAAG ≥1.1 → portal HTN

  • SAAG <1.1 → malignancy/TB/pancreatic/nephrotic

  • SAAG ≥1.1 + protein <2.5 → cirrhosis

  • SAAG ≥1.1 + protein >2.5 → cardiac ascites/Budd-Chiari

Ascites

  • Sodium restriction <2 g/day

  • Fluid restriction only if severe hyponatremia, usually Na <125–130

  • Start/continue diuretics if renal function stable:

    • Spironolactone 100 mg PO daily

    • Furosemide 40 mg PO daily

    • Keep 100:40 ratio

    • Max spironolactone 400 mg/day + furosemide 160 mg/day

  • Goal weight loss:

    • ≤0.5 kg/day if no edema

    • ≤1 kg/day if edema present

  • Hold diuretics if:

    • Cr rises >50% or significant AKI

    • Na <130 or severe hypoNa

    • hypotension/sepsis/SBP

  • Daily weight, strict I/O, abdominal girth

  • Trend BMP/Mg daily and replete electrolytes

Large Volume Paracentesis

  • Perform LVP if tense ascites, dyspnea, pain, poor PO, or respiratory compromise

  • If >5 L removed:

    • Albumin 25% 6–8 g per liter removed

  • Example: 8 L removed → give 48–64 g albumin

  • Consider TIPS if refractory ascites requiring repeated LVP despite optimized diuretics

  • Refer hepatology/transplant if recurrent decompensation or refractory ascites

SBP

  • Diagnose SBP if ascitic PMN ≥250/mm³

  • Treat immediately; do not wait for culture

  • Community-acquired SBP:

    • Ceftriaxone 2 g IV daily × 5 days

    • OR Cefotaxime 2 g IV q8h × 5 days

  • If healthcare-associated, prior quinolone prophylaxis, septic shock, MDR/ESBL risk:

    • Piperacillin-tazobactam 3.375–4.5 g IV q6–8h

    • Consider meropenem if ESBL/MDR risk or worsening

  • Albumin for SBP:

    • 1.5 g/kg IV day 1

    • 1 g/kg IV day 3

  • Especially important if Cr >1, BUN >30, or bilirubin >4

  • Repeat paracentesis at 48 hr if severe illness, persistent fever, bacteremia, worsening status, or resistant organism concern

  • PMN should decrease by ≥25%; if not, broaden antibiotics and evaluate secondary peritonitis

  • Secondary SBP prophylaxis after any SBP episode:

    • Ciprofloxacin 500 mg PO daily

    • OR TMP-SMX DS 1 tab PO daily

    • Continue indefinitely until transplant or ascites resolves

Hepatic Encephalopathy

  • Identify/treat precipitant: SBP, GI bleed, constipation, AKI, hypokalemia, infection, sedatives, alcohol relapse

  • Lactulose:

    • 20–30 g PO/NG q1–2 hr until 2–3 soft BMs

    • Then titrate to 2–3 BM/day

    • If unable PO: lactulose enema 300 mL + 700 mL water PR

  • Rifaximin:

    • 550 mg PO BID if recurrent HE or inadequate response

  • Avoid benzos/opioids

  • If severe agitation: low-dose haloperidol 0.5–1 mg PO/IV cautiously

  • Protein restriction is outdated; goal protein 1.2–1.5 g/kg/day

  • Aspiration precautions, HOB elevated

  • ICU/intubation if grade III–IV HE, coma, or unable to protect airway

AKI / HRS Concern

  • Hold diuretics, NSAIDs, ACEi/ARB, nephrotoxins

  • Rule out infection/SBP, hypovolemia, obstruction, ATN

  • Albumin challenge if HRS concern

  • If HRS suspected:

    • Albumin + vasoconstrictor therapy

    • ICU norepinephrine if shock/ICU

    • Midodrine + octreotide if floor and terlipressin unavailable

    • Nephrology + hepatology consult

    • Transplant evaluation

Variceal Bleed Concern

  • If hematemesis/melena or acute Hgb drop:

    • NPO

    • 2 large-bore IVs

    • Type/screen

    • Ceftriaxone 1 g IV daily × 7 days

    • Octreotide 50 mcg IV bolus then 50 mcg/hr infusion

    • IV PPI until EGD clarifies source

    • GI consult for EGD within 12 hr if active bleed

    • Transfuse goal Hgb ~7 unless massive bleed/ischemia

    • Consider TIPS if uncontrolled/recurrent bleed

General Cirrhosis Care

  • Avoid NSAIDs

  • Acetaminophen okay up to 2 g/day if no active heavy alcohol use

  • Avoid opioids/benzos when possible

  • Nutrition consult; high-protein diet 1.2–1.5 g/kg/day

  • Alcohol cessation counseling; addiction medicine if needed

  • Vaccines: HAV, HBV, pneumococcal, influenza

  • HCC surveillance: RUQ US ± AFP q6 months

  • EGD for variceal screening/surveillance if not up to date

  • Hepatology consult if not established

  • Transplant referral if MELD-Na ≥15, recurrent decompensation, SBP, refractory ascites, HRS, or variceal bleed

  • PT/OT eval and treat

  • Trend daily CBC, CMP, INR, Cr, electrolytes, fever curve

  • Follow up pending cultures, paracentesis results, imaging

Discharge Recommendations

  • Sodium restriction <2 g/day

  • Daily weights; return if rapid weight gain, worsening distension, fever, abdominal pain, confusion, melena/hematemesis, decreased urine output

  • Continue/titrate diuretics if renal function stable

  • Lactulose titrated to 2–3 soft BMs/day ± rifaximin 550 mg BID

  • Lifelong SBP prophylaxis if prior SBP

  • Avoid NSAIDs, alcohol, benzos/opioids unless absolutely necessary

  • Hepatology follow-up within 1–2 weeks

  • Ensure HCC screening q6 months and EGD surveillance

  • Recheck CMP/BMP/INR within 1 week if diuretics adjusted or recent AKI/SBP

Red Flags

  • PMN ≥250 → SBP → antibiotics + albumin immediately

  • Rising Cr despite albumin/holding diuretics → HRS concern

  • Severe abdominal pain/rebound/rigidity → secondary peritonitis → CT + surgery

  • Hematemesis/melena → variceal bleed pathway

  • Grade III–IV HE/coma → ICU/airway

  • MELD-Na >20–21 → high mortality; urgent hepatology/transplant discussion

  • Triple decompensation: GI bleed + HE + AKI → ICU/high mortality

Senior IM Resident Pearls

  • VIBES = decompensations:

    • V = Variceal bleed

    • I = Infection/SBP

    • B = Brain/HE

    • E = Edema/ascites

    • S = Synthetic dysfunction

  • Diagnostic paracentesis is mandatory for hospitalized cirrhotics with ascites.

  • PMN ≥250 = SBP; culture can be negative.

  • Culture ascitic fluid in blood culture bottles at bedside.

  • SAAG ≥1.1 = portal HTN.

  • SAAG ≥1.1 + protein <2.5 = cirrhosis.

  • SAAG ≥1.1 + protein >2.5 = cardiac/Budd-Chiari.

  • Albumin after LVP >5 L prevents post-paracentesis circulatory dysfunction.

  • Albumin in SBP prevents HRS and improves survival.

  • Do not restrict protein in HE; it worsens sarcopenia.

  • Ammonia does not track HE severity well; treat the patient, not the number.

  • Hold BB only when hypotension, AKI, active SBP/sepsis, or shock—not automatically in every decompensated patient.

  • Avoid NSAIDs always in cirrhosis; use acetaminophen ≤2 g/day.

  • Every SBP episode should trigger transplant/hepatology discussion.

Scores

MELD-Na

  • Uses bilirubin, INR, creatinine, sodium

  • Drives transplant priority

  • MELD-Na ≥15 → transplant referral

  • MELD-Na >20–21 → high inpatient mortality risk

  • MELD-Na >30 → very high short-term mortality

Child-Pugh

  • Uses bilirubin, albumin, INR, ascites, encephalopathy

  • Class A = 5–6

  • Class B = 7–9

  • Class C = 10–15

  • Predicts prognosis and surgical risk

West Haven HE Grade

  • Grade 0: none/minimal

  • Grade 1: sleep changes, mild confusion

  • Grade 2: lethargy, disorientation, asterixis

  • Grade 3: somnolent but arousable

  • Grade 4: coma

ORDERS

Labs

Admission Labs

  • CBC with diff

  • CMP

  • BMP

  • PT/INR

  • PTT

  • Albumin

  • Lactate

  • Magnesium

  • Phosphorus

  • Blood cultures ×2

  • Type & Screen (if concern for bleed)

  • Ammonia (if AMS/HE)

  • MELD-Na calculation

  • Child-Pugh calculation

Additional Labs

  • AFP

  • HBV/HCV panel if etiology unclear

  • Ethanol level

  • Urinalysis

  • Urine culture

  • Ascitic fluid studies:

    • Cell count + differential

    • Culture (in blood culture bottles)

    • Albumin

    • Total protein

    • Glucose

    • LDH

    • Cytology

    • Amylase

    • AFB/ADA (if indicated)

Trending Labs

  • CBC daily

  • CMP daily

  • BMP daily

  • PT/INR daily

  • Cr daily

  • Mg/Phos daily

  • Daily MELD-Na

  • Daily weights

Imaging

Initial Imaging

RUQ Ultrasound + Doppler

  • Ascites

  • Portal vein thrombosis

  • Hepatic vein thrombosis

  • Cirrhotic morphology

CXR

  • Pneumonia

  • Hepatic hydrothorax

Additional Imaging

CT Abdomen/Pelvis

If:

  • Secondary peritonitis

  • Malignancy

  • Unclear diagnosis

  • Severe abdominal pain

Procedures

Mandatory

Diagnostic Paracentesis

(All hospitalized cirrhotics with ascites)

Send:

  • Cell count

  • Differential

  • Culture

  • Albumin

  • Total protein

Therapeutic

Large Volume Paracentesis (LVP)

Indications:

  • Tense ascites

  • Dyspnea

  • Poor PO intake

  • Abdominal pain

  • Respiratory compromise

If >5 L Removed

Albumin

  • Albumin 25%

  • 6–8 g per L removed

Example:

  • 8 L removed

  • Give 48–64 g albumin

Medications

Ascites Management

Sodium Restriction

  • <2 g/day

Fluid Restriction

Only if:

  • Na <125–130

Diuretics

Standard Starting Ratio

  • Spironolactone 100 mg PO daily

  • Furosemide 40 mg PO daily

Maximum

  • Spironolactone 400 mg/day

  • Furosemide 160 mg/day

Hold Diuretics If

  • AKI

  • Cr rise >50%

  • Na <130

  • Hypotension

  • SBP

  • Sepsis

SBP Treatment

PMN ≥250 = SBP

Treat immediately.

First-Line

Ceftriaxone

  • 2 g IV daily x5 days

OR

Cefotaxime

  • 2 g IV q8h x5 days

Healthcare Associated / MDR Risk

Piperacillin-Tazobactam

  • 4.5 g IV q6–8h

ESBL Risk

Meropenem

  • 1 g IV q8h

Albumin for SBP

Day 1

  • 1.5 g/kg IV

Day 3

  • 1 g/kg IV

Especially if:

  • Cr >1

  • BUN >30

  • Bilirubin >4

SBP Prophylaxis

Ciprofloxacin

  • 500 mg PO daily

OR

TMP-SMX DS

  • 1 tab PO daily

Continue indefinitely.

Hepatic Encephalopathy

Lactulose

Acute

  • 20–30 g PO/NG q1–2 hr until BM

Maintenance

  • Titrate to 2–3 soft BM/day

If Cannot Take PO

  • Lactulose enema

  • 300 mL lactulose + 700 mL water PR

Rifaximin

  • 550 mg PO BID

Agitation

  • Haloperidol 0.5–1 mg PO/IV PRN

Avoid

  • Benzos

  • Opioids

AKI / HRS

Hold

  • Diuretics

  • NSAIDs

  • ACEi

  • ARBs

  • Nephrotoxins

Albumin Challenge

If HRS suspected

Vasoconstrictors

ICU

  • Norepinephrine infusion

Floor

  • Midodrine + Octreotide

Consult

  • Nephrology

  • Hepatology

If Variceal Bleed Suspected

NPO

Two large-bore IVs

Type & Screen

Octreotide

  • 50 mcg IV bolus

  • Then 50 mcg/hr infusion

Ceftriaxone

  • 1 g IV daily x7 days

Pantoprazole

  • 40 mg IV BID until EGD

EGD

  • Within 12 hr

Transfusion Goal

  • Hgb ~7

Hold Medications

Hold

  • NSAIDs

  • ACEi

  • ARBs

  • Aminoglycosides

  • Metformin (AKI/lactic acidosis concern)

  • Opioids

  • Benzodiazepines

Hold NSBB If

  • SBP <90

  • MAP low

  • AKI

  • Active SBP

  • Sepsis

  • Shock

Consults

Hepatology

(All decompensated cirrhosis)

Gastroenterology

  • Varices

  • GI bleed

  • EGD needs

Interventional Radiology

  • TIPS

  • Refractory ascites

Nephrology

  • AKI

  • HRS

Transplant Team

If:

  • MELD-Na ≥15

  • Recurrent decompensation

  • SBP

  • HRS

  • Variceal bleed

Nutrition

  • Sarcopenia

  • Malnutrition

Addiction Medicine

  • Alcohol use disorder

PT/OT

  • Deconditioning

Nursing Orders

Monitoring

  • Strict I&O

  • Daily weights

  • Daily abdominal girth

  • Fall precautions

  • Aspiration precautions (HE)

Diet

  • Sodium restriction <2 g/day

  • Protein 1.2–1.5 g/kg/day

  • No protein restriction

Notify Physician

  • Fever

  • AMS

  • GI bleeding

  • Oliguria

  • Worsening abdominal pain

  • Rapid abdominal distension

Decompensation Hx: (VIBES)
-- Volume/Ascites: prior LVP, frequency, salt restriction on lasix/spironolactone
-- Infection/SBP: prior infections, h/o low protein ascites, on ppx
-- Bleeding/EV: last EGD, prior bleeds, banding, on nadolol/PPI
-- Encephalopathy/HE: prior decompensation, on lactulose/rifaximin, BM/day
-- Screening/HCC: last screen, AFP; if nodule >1cm get multiphase CT or MRI