Management of decompensated cirrhosis

Abstract

: s60-s5 of hepatic decompensation through a careful history, examination and investigations so appropriate treatment can be given. Assessment of a patient with decompensated cirrhosisInitial assessment of a patient with decompensated cirrhosis in the acute setting can be performed using the ABC (airway, breathing, circulation) approach. AirwayThe airway can be compromised in patients with severe hepatic encephalopathy where their conscious level is reduced (grade 3 or 4) or in those who present with large volume haematemesis. In these circumstances, early intubation and ventilation must be considered. BreathingBreathing is commonly compromised in patients with cirrhosis. Common causes of impaired breathing in cirrhotic patients include pneumonia (including aspiration pneumonia), pulmonary oedema (due to alcohol-related, ischaemic or cirrhotic cardiomyopathy), hepatic hydrothorax and gross ascites causing splinting of the diaphragm. Breathlessness can also be due to pulmonary complications of portal hypertension, namely portopulmonary hypertension (defined as pulmonary artery pressure >25 mmHg in a patient with portal hypertension and no other cause) and hepatopulmonary syndrome (HPS; triad of liver dysfunction, intrapulmonary vasodilation and arterial oxygenation defect). HPS is characterised by platypnoea and orthodeoxia (dyspnoea and hypoxia worse in the upright position and improved by lying flat) and can be diagnosed on bubble echocardiography. Both portopulmonary hypertension and HPS improve following liver transplant.Breathing should be assessed by respiratory rate, oxygen saturations and auscultation of the chest. In the context of tense ascites, early paracentesis can improve respiratory function. CirculationHypotension and tachycardia can occur as a result of sepsis, hypovolaemia/overdiuresis and GI bleeding. Tachycardia may not be present in subjects with significant hypovolaemia who are on beta-blockers. While it is important to identify and ameliorate the cause, the initial focus should be on adequate resuscitation. Hypovolaemic or shocked patients should be fluid resuscitated in IntroductionDecompensated cirrhosis is a frequent reason for admission to the acute medical unit, and such patients typically have complex medical needs that can lead to a prolonged hospital stay and a significant risk of an in-hospital death (10-20%). It is therefore vital that these patients receive the appropriate investigations and treatment as early as possible in their patient journey. The aim of this review is to provide an overview of the management of decompensated cirrhosis for non-specialists.Decompensated cirrhosis is defined as an acute deterioration in liver function in a patient with cirrhosis and is characterised by jaundice, ascites, hepatic encephalopathy, hepatorenal syndrome or variceal haemorrhage. Common precipitants of hepatic decompensation include infections, gastrointestinal (GI) bleeding, high alcohol intake / alcohol-related hepatitis or drug-induced liver injury although no specific cause is fo...

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