Decision support only. Resuscitate and treat suspected sepsis or variceal bleeding without waiting for confirmatory tests. Discuss early with gastroenterology/liver; verify product-specific terlipressin dosing, antimicrobial choice and ICU thresholds locally.
1 First 6 hours — run the bundle in parallel
Decompensation is a syndrome, not a final diagnosis. Bleeding, infection, AKI and encephalopathy commonly travel together; dealing with them one after another wastes time.
0–15 minstabilise
ABCDE, mental state, glucose, continuous observations. Two large-bore IVs; group and crossmatch. Intubate before endoscopy if actively vomiting blood or unable to protect the airway.
Escalate early for shock, hypoxaemia, grade 3–4 HE, active haematemesis, lactate rise or organ failure. Aim perfusion rather than litres; a practical initial MAP floor is 65 mmHg.
Within 1 hfind the trigger
FBC; EUC/Cr; LFT/albumin; INR, APTT, fibrinogen; CRP; VBG/ABG + lactate; cultures; urinalysis/culture; CXR. Review alcohol, medicines and recent baseline creatinine.
Treat suspected infection immediately. Use local sepsis/MDRO guidance. Common precipitants: SBP/UTI/pneumonia, GI bleed, alcohol-associated hepatitis or withdrawal, constipation, dehydration/over-diuresis, sedatives/opioids, PVT and HCC.
Within 6 hdo not omit the tap
If ascites is present: diagnostic paracentesis for cell count/differential, bedside blood-culture bottles, albumin and total protein. INR or thrombocytopenia alone is not a reason to defer.
Tap promptly, but never delay sepsis antibiotics to achieve “tap before antibiotics”. Add liver/portal Doppler or CT when biliary obstruction, PVT, HCC, secondary peritonitis or another abdominal source is plausible. GESA bundle
Medication resetprotect kidney + brain
Stop NSAIDs, ACEi/ARB and avoid nephrotoxins. Hold diuretics during AKI/hypovolaemia. Minimise benzodiazepines, opioids and other sedatives; renally adjust antimicrobials.
Reduce/withhold NSBB if SBP <90, MAP <65, AKI; GESA also advises withholding if Na <130. Baveno VIII specifies persistent SBP <90 or MAP <65, or HRS-AKI, with restart after recovery. GESA 2026 · Baveno VIII comparison
Alcohol exposure: give thiamine and manage withdrawal using the local pathway; withdrawal scoring is unreliable in overt HE. Reassess the whole bundle at 6 hours, not just the presenting complaint.
2 Suspected acute variceal bleeding
Before endoscopy
- PRBCTransfuse at about Hb <70 g/L. Australian GESA target: 70–90 g/L. Baveno VIII target: 70–80 g/L. Individualise ongoing massive loss, cardiovascular disease, age and haemodynamics. GESA bundle · Baveno VIII
- Vasoactiveterlipressin 1.7 mg IV q4h per GESA bundle; product units vary. Alternative: local octreotide protocol. GESA: cease 2–5 d after successful haemostasis. Baveno VIII: continue 2–5 d or until TIPS; a course as short as 24 h may be considered after successful endoscopic haemostasis only if NSBB is then initiated.
- AntibioticGESA bundle: ceftriaxone 1 g IV daily for 3–5 d, modified for allergy, exposure and local resistance. Baveno VIII: prophylaxis at presentation, generally a third-generation cephalosporin; duration may be individualised, with shorter or no therapy considered in selected Child A patients. International comparison; local policy governs
Scope ≤12 h after resuscitation
- OesophagealEndoscopic variceal ligation.
- GOV1Usually EVL, with or without gastric injection.
- FundalGOV2/IGV1: cyanoacrylate, thrombin or EUS-guided coiling according to expertise; obtain portal-venous phase imaging after haemostasis. GESA 2026
- Baveno VIII preparationIf no QT contraindication, consider erythromycin 250 mg IV 30–90 min pre-scope. Give lactulose PO or rectally to accelerate blood clearance and prevent/treat overt HE. Begin oral nutrition early once safe.
- Imaging comparisonGESA targets portal-venous imaging particularly after gastric-variceal haemostasis. Baveno VIII recommends contrast CT or MRI after all AVB to exclude PVT/HCC and map collaterals.
- PPIReasonable while the bleed is undifferentiated; stop when a variceal source is confirmed unless another indication exists.
Failure or high-risk bleed
- BridgeGESA: Danis oesophageal stent or balloon tamponade, then urgent transfer for definitive therapy; Danis has practical advantages. Baveno VIII goes further and prefers a dedicated covered SEMS over balloon tamponade as bridge to TIPS/transplant.
- Salvage TIPSFailure of endoscopic/medical haemostasis or early rebleeding. Baveno VIII advises case-by-case discussion for any refractory variceal bleed rather than exclusion by age, Child–Pugh or MELD alone.
- Pre-emptive TIPSDiscuss immediately after haemostasis if Child C 10–13 or Child B >7 with active bleeding; Baveno VIII also includes HVPG ≥20 mmHg. Aim within 72 h, ideally 24 h. GESA-aligned criteria · Baveno VIII addition
- Missed windowBaveno VIII: possible benefit remains within 2 weeks for Child C10–13 or 1 week for Child B>7 with active bleeding. ACLF, overt HE, hyperbilirubinaemia, MELD or severe alcohol-related hepatitis are not automatic contraindications. Weak timing evidence; specialist decision
Do not “correct the INR”. PT/INR does not describe net haemostasis in cirrhosis. Avoid routine FFP in acute variceal bleeding: it adds volume and portal pressure without reliably correcting bleeding. Platelet/fibrinogen replacement is case-by-case for uncontrolled bleeding or a procedure; tranexamic acid and recombinant factor VIIa are not routine. GESA 2026 · Baveno VIII
3 Ascites, SBP and hydrothorax
SBP: diagnose and treat
- ThresholdAscitic PMN ≥250 ×10⁶/L is SBP until an alternative intra-abdominal source is found.
- Empiricceftriaxone 2 g IV daily is the GESA bundle community regimen. Broaden for healthcare exposure, septic shock or MDRO risk; de-escalate to culture.
- Albumin20–25% albumin 1.5 g/kg day 1 then 1.0 g/kg day 3. Dose to estimated dry weight; monitor pulmonary oedema.
- Not improvingRepeat tap at ~48 h; a PMN fall <25%, polymicrobial culture or persistent sepsis should trigger broader cover and a search for secondary peritonitis.
Tense or recurrent ascites
- LVPTherapeutic paracentesis for tense ascites. If >5 L removed, give 20 g albumin per 2 L above 5 L. GESA 2026
- DietNo-added-salt pattern, sodium ≤2300 mg/day. Do not make food so unpalatable that intake collapses.
- WaterNo routine restriction for ascites alone.
- DiureticsOnce stable, usual paired starting regimen is spironolactone/furosemide with close weight, Na, K and Cr monitoring; specialist maxima are 400/160 mg daily.
Prevention and procedures
- After SBPSecondary prophylaxis: norfloxacin 400 mg daily or TMP–SMX 800/160 mg daily, adjusted to local ecology and renal function.
- Primary prophylaxisDo not import older rules automatically. GESA 2026 no longer recommends routine primary SBP prophylaxis because efficacy is uncertain and MDRO harm matters; seek hepatology advice if considering it.
- RefractoryAssess for TIPS and transplant. Avoid permanent abdominal or intercostal drains except a deliberate palliative plan; never leave a chest tube for uncomplicated hepatic hydrothorax.
4 Hepatic encephalopathy
| Problem | What to do now | What not to do |
|---|
| Diagnosis | Clinical diagnosis. Look for infection, bleeding, constipation, dehydration/AKI, hypoglycaemia, electrolyte disturbance, sedatives/opioids, alcohol withdrawal and PVT. | Routine ammonia does not establish severity or guide treatment. A normal value should make you reconsider the diagnosis; a high value proves little. GESA 2026 |
| Airway / imaging | Grade 3–4: ICU and airway protection. CT brain for trauma, focal signs, anticoagulation, atypical course or failure to improve; evaluate other causes of delirium. | Do not assume every confused patient with cirrhosis has HE. |
| Lactulose | 25–30 mL PO/NG q1–2 h until bowel action/clinical improvement, then titrate to 2–3 soft stools/day; use rectal administration if enteral delivery is unsafe. Verify local protocol. | Avoid dehydration, hypernatraemia and aspiration from aggressive dosing. |
| Recurrence | Add rifaximin 550 mg BD after a further episode despite lactulose or when lactulose is not tolerated. Persistent/recurrent HE warrants imaging for a large spontaneous portosystemic shunt and transplant discussion. | Do not protein-restrict. Target 1.2–1.5 g/kg ideal body weight/day once feeding is safe. GESA 2026 |
5 AKI, HRS-AKI and hyponatraemia
AKI first: phenotype it
- DefinitionSCr rise ≥26.5 µmol/L in 48 h, ≥50% within 7 d, and/or urine output ≤0.5 mL/kg/h for ≥6 h. Use the lowest stable SCr from the previous 3 months where available.
- LookBleeding, sepsis/SBP, true volume loss, over-diuresis, nephrotoxins/contrast, ATN, glomerular disease and obstruction. Urine microscopy/protein, renal ultrasound and haemodynamics are more useful than a reflex label of HRS.
- VolumeCorrect clear depletion. If equivocal, a monitored 250–500 mL crystalloid or 20–25% albumin 1–1.5 g/kg challenge is reasonable, then reassess within 24 h.
HRS-AKI: treat once criteria met
- CriteriaCirrhosis + ascites + AKI, no strong alternative primary cause, and no improvement within 24 h after adequate volume correction when fluids were indicated. ADQI–ICA 2024
- TerlipressinGESA: 0.85 mg IV q6h or 1.7–3.4 mg/day infusion + individually dosed 20–25% albumin; escalate at 48–72 h if needed, maximum 14 d. Baveno VIII prefers continuous IV infusion, starting approximately 2–3 mg/24 h, to reduce adverse events. Verify product units locally
- SafetyMonitor SpO₂, respiratory status, fluid balance, Na and ischaemia. Stop albumin if pulmonary oedema/overload; terlipressin requires specialist review in hypoxia, ischaemia or severe ACLF. Noradrenaline is the ICU alternative when terlipressin is unsuitable.
- EndpointThis is a bridge, not definitive therapy. Discuss transplant early; RRT is mainly a bridge to recovery/transplant or for conventional life-threatening indications.
The automatic 48-hour albumin challenge is obsolete. ADQI–ICA 2024 recommends against systematic albumin for 48 hours merely to diagnose HRS-AKI. In a euvolaemic or overloaded patient it can delay vasoconstrictor therapy and cause pulmonary oedema. Use clinical volume assessment and a 24-hour response window when resuscitation is actually indicated.
| Hyponatraemia | Practical approach |
|---|
| Hypovolaemic | Stop diuretics/laxative excess, treat GI loss or bleeding, and restore effective volume cautiously. |
| Hypervolaemic | Stop/reduce diuretics if severe or AKI. Fluid restriction is mainly for severe/symptomatic dilutional hyponatraemia, often Na <125, rather than routine ascites care. Avoid vaptans outside specialist use. |
| Correction | Aim slow correction, usually ≤8 mmol/L per 24 h and often less in alcohol use, malnutrition or very low Na; active symptoms require ICU-level hypertonic-saline management. |
6 ACLF, ward safeguards and where the admission goes
Suspect ACLF
- PatternAcute decompensation plus one or more organ failures. Infection and active alcohol-associated hepatitis are common triggers.
- ActEarly ICU, prompt source control/antimicrobials, organ support and urgent transplant-centre discussion. Calculate MELD-Na and CLIF-C ACLF to support, not replace, clinical judgement. EASL 2023
Do the ordinary things properly
- VTECirrhosis is not auto-anticoagulation. Use pharmacological prophylaxis unless active clinically significant bleeding or another patient-specific contraindication.
- NutritionFeed early when safe; 1.2–1.5 g/kg ideal body weight/day protein, frequent meals and a late carbohydrate/protein snack. Avoid prolonged fasting.
- DailyWeight, fluid balance, mental state, Na/K/Cr, infection response; review every line, sedative and nephrotoxin.
Before discharge
- After AVBIf no TIPS: NSBB before discharge when haemodynamically safe + EVL every 1–3 months until eradicated; then scope at 6 months and annually. GESA 2026
- After SBP/HESecondary SBP prophylaxis; lactulose plan and rifaximin where indicated. Give written red flags and driving advice after overt HE.
- TrajectoryFirst decompensation, refractory ascites/hydrothorax, HRS, ACLF or HCC should trigger liver/transplant assessment if appropriate. Close the loop on aetiology treatment, HCC surveillance, nutrition and alcohol care.
Baveno VIII informational staging: “further decompensation” includes, after a first ascites event, ≥3 large-volume paracenteses in one year, SBP, HRS-AKI or another decompensating event; after AVB, portal-hypertensive rebleeding or another event; after overt HE, recurrent overt HE or another event. This is a trigger to revisit aetiological control and transplant suitability, not a substitute for bedside severity assessment.