Management of Decompensated Liver Cirrhosis

Initial Assessment and Stabilization

The European Association for the Study of the Liver recommends assessing airway, breathing, and circulation immediately, with prompt volume replacement using crystalloids to restore hemodynamic stability in patients with active bleeding 3
The American Association for the Study of Liver Diseases suggests implementing a restrictive transfusion strategy with a hemoglobin threshold of 7 g/dL and target range of 7-9 g/dL to avoid increasing portal pressure 1, 3
Discontinue diuretics, beta-blockers, vasodilators, and other hypotensive drugs during acute decompensation, as recommended by the European Association for the Study of the Liver 4, 3

The American College of Gastroenterology recommends starting vasoactive drugs (terlipressin, somatostatin, or octreotide) immediately upon suspicion of variceal bleeding, even before endoscopic confirmation 1, 5
Perform upper endoscopy within 12 hours of admission once hemodynamic stability is achieved, as suggested by the European Association for the Study of the Liver 1, 3
Consider pre-endoscopy erythromycin (250 mg IV, 30-120 minutes before) to improve visibility, as recommended by the American College of Gastroenterology 1, 3
Perform endoscopic band ligation (EBL) for esophageal varices or cyanoacrylate injection for gastric varices, as suggested by the European Association for the Study of the Liver 1, 6
Administer antibiotic prophylaxis with ceftriaxone 1g/day IV for up to seven days, as recommended by the American College of Gastroenterology 1, 5

Perform therapeutic paracentesis with albumin infusion (1 g/kg body weight, maximum 100 g) in patients with tense ascites, as suggested by the European Association for the Study of the Liver 4
Monitor for hepatic encephalopathy and renal function deterioration during ascites management, as recommended by the American Association for the Study of Liver Diseases 4, 2

Use lactulose or lactitol when encephalopathy develops, as suggested by the European Association for the Study of the Liver 1, 3
Consider oral non-absorbable disaccharides for prevention of hepatic encephalopathy, as recommended by the American College of Gastroenterology 1

Discontinue nephrotoxic drugs such as NSAIDs and aminoglycosides, as recommended by the European Association for the Study of the Liver 1, 4
Administer 20% albumin solution (1 g/kg body weight, maximum 100 g) for two consecutive days in AKI stage >1A with no obvious cause, as suggested by the European Association for the Study of the Liver 4
Preserve renal function with adequate replacement of fluids and electrolytes, as recommended by the American Association for the Study of Liver Diseases 1, 2

Screen for and treat infections promptly, as they are present in over 50% of patients with acute bleeding, as recommended by the European Association for the Study of the Liver 1
Use ceftriaxone (1 g/24 h) for antibiotic prophylaxis in advanced cirrhosis or settings with high quinolone resistance, as suggested by the American College of Gastroenterology 1
Consider oral quinolones (norfloxacin 400 mg b.i.d) in patients without advanced cirrhosis, as recommended by the European Association for the Study of the Liver 1

Use Child-Pugh score for initial stratification of cirrhosis severity (scores of 7-10 indicate decompensated disease), as suggested by the American Association for the Study of Liver Diseases 2
Consider MELD and MELD-Na scores for transplant prioritization, as recommended by the European Association for the Study of the Liver 2
Use CLIF-C ACLF score for better prognostic accuracy in patients with acute-on-chronic liver failure, as suggested by the American Association for the Study of Liver Diseases 2

Screen for gastroesophageal varices with endoscopy if not previously diagnosed and treated, as recommended by the European Association for the Study of the Liver 6
Initiate secondary prophylaxis with non-selective beta-blockers and/or endoscopic band ligation once bleeding is controlled, as suggested by the American College of Gastroenterology 6, 3
Consider liver transplantation evaluation in appropriate candidates, as recommended by the American Association for the Study of Liver Diseases 2
Address underlying causes of cirrhosis (alcohol cessation, antiviral therapy for HBV/HCV), as suggested by the European Association for the Study of the Liver 7, 2

Repeat endoscopy yearly in patients without varices if the etiological factor persists and/or decompensation continues, as recommended by the European Association for the Study of the Liver 6
Monitor for development of complications such as hepatorenal syndrome, spontaneous bacterial peritonitis, and hepatopulmonary syndrome, as suggested by the American Association for the Study of Liver Diseases

Use caution with beta-blockers in patients with severe or refractory ascites, as recommended by the American College of Gastroenterology 3
Consider early TIPS in high-risk patients with variceal bleeding, as suggested by the European Association for the Study of the Liver 3
Be vigilant for acute-on-chronic liver failure, characterized by rapid deterioration, liver failure, and at least one extrahepatic organ failure, as recommended by the American Association for the Study of Liver Diseases 2