Management of Decompensated Cirrhosis

Primary Treatment Strategy: Address the Etiology

The American Association for the Study of Liver Diseases recommends treating the underlying cause of liver disease as the single most important intervention to decrease further decompensation and improve survival in patients with decompensated cirrhosis 1, 2, 3
Alcohol cessation is mandatory and can lead to improved outcomes in alcoholic cirrhosis 4
Antiviral therapy for hepatitis B should be initiated immediately with nucleos(t)ide analogues if HBV DNA is detectable at any level, regardless of ALT 5
Direct-acting antivirals for hepatitis C improve liver function and portal hypertension in HCV-related decompensated cirrhosis 4

The European Association for the Study of the Liver recommends starting spironolactone 100 mg daily as the initial diuretic for ascites management 3
Add furosemide if needed to achieve goal weight loss of 0.5 kg/day without peripheral edema or 1 kg/day with edema 3
Perform therapeutic paracentesis for tense ascites with albumin infusion (1 g/kg body weight, maximum 100 g) 6

Lactulose is first-line therapy and reduces both mortality and recurrent overt hepatic encephalopathy 3
Screen for mild hepatic encephalopathy using the animal naming test (takes 60 seconds, requires no equipment) 7

Administer norfloxacin 400 mg orally twice daily for spontaneous bacterial peritonitis prophylaxis in high-risk patients 3
In advanced cirrhosis, quinolone-resistant settings, or during variceal bleeding, use ceftriaxone 1 g IV every 24 hours for up to 7 days 3, 6

Start vasoactive drugs (terlipressin, somatostatin, or octreotide) immediately upon suspicion of variceal hemorrhage, before endoscopic confirmation 6
Perform upper endoscopy within 12 hours once hemodynamically stable 6
Use restrictive transfusion strategy with hemoglobin threshold of 7 g/dL and target range 7-9 g/dL to avoid increasing portal pressure 6, 4

Statins show potential for reducing portal hypertension and improving survival through pleiotropic effects 1, 3
Enoxaparin (12-month course) may prevent portal vein thrombosis and delay decompensation in patients with Child-Pugh scores 7-10 1, 4

Avoid nephrotoxic drugs (NSAIDs, aminoglycosides) as they precipitate renal failure and convert diuretic-sensitive to refractory ascites 3, 6
Monitor renal function closely; discontinue nephrotoxic agents immediately if acute kidney injury develops 6

Refer early for liver transplantation evaluation as decompensation significantly worsens prognosis 3, 4
Consider evaluation for all appropriate candidates with decompensated cirrhosis 6

Insulin therapy is the only evidence-based treatment option for diabetes management in decompensated cirrhosis 7
Initiate insulin in hospital due to high glucose variability and hypoglycemia risk (which mimics hepatic encephalopathy) 7
Avoid metformin (increases lactic acidosis risk), and avoid other oral agents as most are eliminated by liver or kidney 7
Do not use HbA1c for diagnosis or monitoring glycemic control 7
Target fasting blood glucose <10 mmol/L 7