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Decompensated Cirrhosis — Acute Management

Registrar quick reference · Baveno VII / EASL / AASLD aligned
Compiled Jun 2026
Verify doses locally
Always hunt the precipitant
Decision support only — not a substitute for Baveno VII, EASL/AASLD guidance, eTG, or your gastro/liver team. Decompensation usually means an event has tipped a compensated liver over: find and treat it (infection, bleed, constipation, drugs, AKI). Confirm antibiotic choice against local resistance/eTG and verify all doses.
1 The decompensating events — what's actually in front of you
Variceal bleedinghaematemesis / melaena
UGI bleed in known/suspected cirrhosis. ~15–20% six-week mortality.
Resuscitate + vasoactive drug + ceftriaxone now; endoscopy ≤12h. Restrictive transfusion. Don't wait for the scope to start drugs.
Ascites & SBPnew/worsening ascites, sepsis
Any admission with ascites → diagnostic tap. SBP = ascitic PMN ≥250/mm³.
Tap before antibiotics. If SBP: cefotaxime/ceftriaxone + albumin. LVP for tense ascites (+ albumin if >5L).
Encephalopathyconfusion, asterixis
Clinical diagnosis. A precipitant is present until proven otherwise.
Find the precipitant; lactulose to 2–3 stools/day; rifaximin add-on. Protect airway if grade 3–4. Don't protein-restrict.
HRS-AKIrising creatinine
AKI (ICA): SCr ↑≥26.5 µmol/L in 48h or ≥50% in 7d. Diagnosis of exclusion.
Stop diuretics/nephrotoxins, treat sepsis, albumin challenge. If true HRS-AKI: terlipressin + albumin.
ACLForgan failure(s)
Acute decompensation + extrahepatic organ failure(s); high short-term mortality (CLIF-C).
Early ICU + urgent transplant assessment. Aggressively treat the precipitant (often infection / alcohol hepatitis).
Several often coexist (a bleed precipitates HE and HRS; SBP precipitates everything). The single highest-yield habit: in any decompensation, septic-screen + diagnostic ascitic tap + medication review, every time.
2 Variceal bleeding — the time-critical one

Resuscitate

  • TransfuseRestrictive: target Hb 70–80 g/L. Over-transfusion raises portal pressure and rebleeding (Villanueva).
  • AirwayConsider intubation for massive bleed or grade 3–4 HE before endoscopy.
  • CoagDon't chase INR/platelets — INR doesn't reflect bleeding risk in cirrhosis (rebalanced haemostasis).

Drugs at presentation

  • VasoactiveTerlipressin 2 mg IV → 1 mg q4–6h (or 4–6 mg/24h infusion); or octreotide 50 µg bolus + 50 µg/h. 2–5 days.
  • AntibioticCeftriaxone 1 g IV daily up to 7d — all cirrhotics with AVB. Cuts infection, rebleeding, mortality.
  • Terli ECGBaseline ECG; watch hyponatraemia & ischaemia.

Endoscopy & rescue

  • Scope≤12h. EBL for oesophageal; cyanoacrylate for gastric varices.
  • RescueBalloon tamponade or oesophageal SEMS as a bridge if uncontrolled.
  • TIPSPre-emptive (≤72h) for high-risk: Child-Pugh C <14, or B with active bleeding at scope.
  • PPINot routine — Baveno VII discourages; no benefit, possible harm.
3 Ascites & spontaneous bacterial peritonitis

Tap, then treat

  • Dx tapEvery admission with ascites — cell count + culture (bedside bottles) + protein. SAAG ≥11 g/L = portal hypertensive.
  • SBPPMN ≥250/mm³ → cefotaxime or ceftriaxone (per local resistance), 5 days.
  • Albumin1.5 g/kg day 1 + 1 g/kg day 3 in SBP — reduces HRS and death.
  • 2° prophAfter SBP: norfloxacin/ciprofloxacin prophylaxis; refer for transplant.

Fluid, diuretics & two traps

  • LVPDrain tense ascites; give albumin 6–8 g per L removed if >5 L (prevents circulatory dysfunction).
  • DiureticsSpironolactone ± furosemide (≈100:40). Avoid NSAIDs, ACEi/ARB, aminoglycosides.
  • NSBBHold/reduce in refractory ascites if SBP <90, AKI, or hyponatraemia — the "NSBB window."
  • Albumin≠targetATTIRE: don't infuse albumin just to hit a level (>30 g/L) — no benefit, more pulmonary oedema. Use it for defined indications.
4 Encephalopathy, HRS-AKI & ACLF

Hepatic encephalopathy

  • PrecipitantInfection (incl SBP), GI bleed, constipation, dehydration/diuretics, electrolytes, sedatives/opioids, AKI. Hunt it.
  • LactuloseTitrate to 2–3 soft stools/day (NG or enema if needed).
  • Rifaximin550 mg BD add-on — cuts recurrence/admissions.
  • AmmoniaDon't use to diagnose or grade HE; nutrition continues, no protein restriction.

HRS-AKI

  • FirstStop diuretics/nephrotoxins, treat infection, volume-expand: albumin 1 g/kg/day ×2 (max 100 g).
  • If HRSNo response, no shock/nephrotoxins/structural cause → terlipressin + albumin (CONFIRM). Noradrenaline (ICU) or midodrine+octreotide if terli unavailable.
  • CautionTerlipressin: respiratory-failure warning, ischaemia/skin necrosis; avoid in high-grade ACLF / volume overload.

ACLF

  • RecogniseAcute decompensation + organ failure(s); grade by CLIF-C. Mortality tracks organ-failure count.
  • ActEarly ICU, treat precipitant hard, daily reassessment.
  • TransplantUrgent assessment — outcomes without it are poor. Baveno VII: all decompensated should be considered for LT.
5 Scoring, prophylaxis & the bigger picture

Stratify & refer

  • Child-PughBilirubin, albumin, INR, ascites, encephalopathy → A/B/C.
  • MELDMELD 3.0 (2021) for prognosis/transplant allocation; drives urgency.
  • Baveno VIIcACLD + CSPH drive decompensation risk; "recompensation" is now a real endpoint with etiological control.

Prevent the next event

  • CarvedilolPreferred NSBB — 6.25 → 12.5 mg/day — to prevent first decompensation in cACLD with CSPH, and for bleeding prophylaxis.
  • AetiologyThe foundation: alcohol abstinence, HBV/HCV antivirals — this is what actually changes the trajectory.
  • AvoidNSAIDs, nephrotoxins, sedatives, unnecessary PPIs. Vaccinate; screen HCC (6-monthly US).
Sources. Baveno VII — de Franchis et al, J Hepatol 2022 (portal hypertension, carvedilol, pre-emptive TIPS, recompensation). EASL CPG on decompensated cirrhosis 2018 & ACLF 2023. AASLD ascites/portal hypertension guidance. ESGE 2022 (variceal haemorrhage, ceftriaxone, restrictive transfusion). ICA-AKI criteria. eTG (antibiotic selection) for Australian practice.   Key trials: Villanueva 2013 (restrictive transfusion); CONFIRM (terlipressin in HRS-AKI); ATTIRE (albumin targeting — negative); ANSWER (long-term albumin — contested).   Caveats: antibiotic choice is resistance-dependent — confirm against local/eTG. Terlipressin carries a respiratory-failure boxed warning and ischaemic risk; patient selection matters. Doses are standard regimens — verify before prescribing. Decompensated cirrhosis without a reversible cause warrants early transplant-centre discussion.