Decompensated cirrhosis on the ward
Tap every patient with ascites on admission, find the trigger, protect the kidneys, and treat encephalopathy with lactulose.
A 52-year-old man with hepatitis C cirrhosis is admitted with a tense abdomen and mild confusion. Temperature 37.9 °C, BP 98/60. Creatinine 1.6 mg/dL (141 µmol/L), was 0.9 mg/dL (80 µmol/L) a month ago. Sodium 128 mmol/L.
What do you do in the first few hours?
- Diagnostic ascitic tap nowEvery admission with ascites, before antibiotics. Cell count, culture bottles, albumin.
- Look for the triggerInfection, GI bleed, constipation, drugs, alcohol, dehydration, missed lactulose.
- Protect the kidneysStop diuretics and NSAIDs if creatinine rising, give albumin per protocol.
- Grade the encephalopathyLactulose to 2–3 soft stools a day.
- BloodsCBC, INR, LFTs, creatinine, sodium, potassium, sugar, cultures.
- Sugar regularlyLow sugar is common in liver failure.
- Plan the long termHepatitis B or C treatment, alcohol, varices screen, transplant referral.
- GI bleeding (haematemesis, melaena)
- Grade 3–4 encephalopathy
- Creatinine rising despite albumin
- Low BP or sepsis
- INR rising with jaundice and confusion (acute liver failure)
- SBP (may have no pain or fever)
- Variceal bleed
- Hepatorenal syndrome
- Hypoglycaemia
- Alcohol withdrawal
- Subdural haematoma
- Hepatocellular carcinoma
| SBP | Ascitic neutrophils above 250 per mm³ (cells/µL) |
| Portal hypertension ascites | Serum minus ascitic albumin 1.1 g/dL (11 g/L) or more |
| AKI in cirrhosis | Creatinine up by 0.3 mg/dL (26.5 µmol/L) in 48 hours, or 50% in 7 days |
| Salt | About 5 g salt (2 g sodium) a day, no fluid restriction unless sodium below 125 |
| Large-volume paracentesis | Albumin with taps above 5 litres, per protocol |
| Lactulose target | 2–3 soft stools a day |
Check every dose against a current drug reference and your hospital protocol.
On this page
Why tap everyone?
Spontaneous bacterial peritonitis may cause only confusion, worsening kidneys or a mild fever, with no abdominal pain. Tap every patient with ascites who is admitted, and anyone who deteriorates.
- Consent, platelets and INR are not a reason to delayBleeding is rare. Avoid scars and visible veins.
- Left lower quadrantTwo finger-breadths medial and above the anterior superior iliac spine, or ultrasound-guided.
- SendCell count with differential, albumin, protein, Gram stain, and inoculate blood culture bottles at the bedside.
- Neutrophils above 250SBP: start antibiotics and albumin now.
Treating SBP
After SBP, long-term prophylaxis (for example ciprofloxacin or co-trimoxazole) is usually started; ask the senior.
Ascites
| Step | What |
|---|---|
| Salt | About 5 g salt a day. No added salt, avoid pickles and processed food |
| Diuretics | Spironolactone 100 mg daily, with furosemide 40 mg daily, increased together if needed |
| Monitor | Weight daily (aim for about 0.5 kg a day loss without leg oedema), sodium, potassium, creatinine |
| Stop diuretics if | Creatinine rising, sodium below 125, encephalopathy, potassium high |
| Tense ascites | Large-volume paracentesis with albumin per protocol |
Hepatic encephalopathy
| Grade | What you see |
|---|---|
| 1 | Short attention, sleep reversed, mild confusion |
| 2 | Drowsy, disoriented to time, asterixis (flap) |
| 3 | Very drowsy, confused, responds to voice |
| 4 | Coma |
- Find the trigger: infection (tap), GI bleed (rectal exam), constipation, dehydration, low potassium, sedatives.
- Grade 3–4: protect the airway, HDU or ICU.
- No sedatives if you can avoid them. If agitation is dangerous, discuss with the senior first.
Kidneys: AKI and hepatorenal syndrome
- StopDiuretics, NSAIDs, nephrotoxic drugs, blood pressure tablets.
- Give albumin1 g/kg IV for 2 days (maximum 100 g a day), per protocol.
- Look for causesInfection (tap), bleeding, obstruction (ultrasound), dehydration.
- Not improving after 48 hoursHepatorenal syndrome likely: senior and hepatology; terlipressin with albumin per protocol.
Variceal bleed
Treat as a medical emergency. See upper GI bleed: resuscitate, restrictive transfusion (target haemoglobin 7–8 g/dL), terlipressin, antibiotics (for example ceftriaxone 1 g daily), and endoscopy within 12 hours.
Things to avoid in cirrhosis
- NSAIDs (diclofenac, ibuprofen): kidney failure and bleeding.
- Sedatives and opioids: encephalopathy. If pain relief is needed, paracetamol up to 2–3 g a day is usually safe.
- Aminoglycosides.
- Large fluid boluses of saline.
Pakistan focus
- Hepatitis C and B are the main causes. Every cirrhotic patient should have hepatitis B and C tested and be linked to treatment.
- Screen for hepatocellular carcinoma with ultrasound (and AFP where used) every 6 months.
- Screen for varices by endoscopy.
Frequently asked questions
What is the treatment of decompensated liver cirrhosis?
Treat the trigger and each complication: diagnostic tap and antibiotics for SBP, salt restriction and diuretics or paracentesis for ascites, lactulose for encephalopathy, albumin for kidney injury, and urgent endoscopy for variceal bleeding. Long term: treat hepatitis B or C, stop alcohol and consider transplant referral.
What is spontaneous bacterial peritonitis?
Infection of ascitic fluid without a surgical cause, diagnosed by more than 250 neutrophils per mm³ on an ascitic tap. It can occur with no pain or fever.
How is hepatic encephalopathy treated?
Find and treat the trigger, and give lactulose to produce 2–3 soft stools a day. Rifaximin is added for recurrent episodes.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A cirrhotic patient with ascites is admitted with confusion. There is no abdominal pain or fever. What should be done?
Answer: Diagnostic ascitic tap. SBP can present with confusion alone. Tap every admission with ascites.
- CT head only: Not first.
- Lactulose only: Find the trigger too.
- Diuretics increased: Wrong.
- Paracentesis of 10 litres: Not first.
2. An ascitic tap shows 620 neutrophils per mm³. What is the treatment?
Answer: IV ceftriaxone and albumin. SBP (neutrophils above 250/mm³): antibiotics and albumin 1.5 g/kg on day 1 and 1 g/kg on day 3 to protect the kidneys.
- Repeat tap tomorrow: Treat now.
- Diuretics: Not the treatment.
- Oral ciprofloxacin only: Not enough for active SBP.
- Surgical laparotomy: Not surgical peritonitis.
3. A patient with cirrhosis on spironolactone and furosemide has creatinine rising from 0.9 to 1.6 mg/dL (80 to 141 µmol/L). What is the first step?
Answer: Stop diuretics and give IV albumin. AKI in cirrhosis: stop diuretics and nephrotoxins, albumin 1 g/kg for 2 days, look for infection and bleeding.
- Start ibuprofen for pain: Nephrotoxic.
- Start terlipressin immediately: Albumin and stopping diuretics come first.
- Large-volume paracentesis without albumin: Worsens kidneys.
- Increase furosemide: Worsens AKI.
4. A cirrhotic patient with tense ascites has creatinine rising from 90 to 230 µmol/L over a week, urine sodium < 10 mmol/L, bland sediment and no response to 2 days of albumin after stopping diuretics. What is the treatment?
Answer: Terlipressin + albumin. Hepatorenal syndrome–AKI is functional renal failure from splanchnic vasodilatation and renal vasoconstriction in advanced cirrhosis. Diagnosis requires no shock, no response to diuretic withdrawal and albumin (1 g/kg) for 48 hours, no nephrotoxins and no structural kidney disease. Treatment: vasoconstrictor (terlipressin, or noradrenaline in ICU) plus albumin; liver transplant is definitive. Prevent with albumin in SBP and after large-volume paracentesis.
- IV furosemide: Furosemide worsens renal perfusion.
- NSAIDs for pain: NSAIDs are nephrotoxic.
- High-volume saline: High-volume saline worsens ascites.
5. A cirrhotic patient becomes drowsy with a flapping tremor two days after an upper GI bleed. What is the first-line treatment?
Answer: Lactulose to 2–3 soft stools. Hepatic encephalopathy results from ammonia and other gut-derived toxins bypassing the liver. Precipitants: GI bleeding, infection (SBP), constipation, hypokalaemia/diuretics, sedatives, dehydration, high protein load. Treat the precipitant; lactulose (traps NH₄⁺, laxative) titrated to 2–3 soft stools daily; add rifaximin for recurrence. Avoid sedatives; protein restriction is no longer advised.
- Protein-free diet: Protein restriction causes malnutrition and is not advised.
- Diazepam for agitation: Benzodiazepines worsen encephalopathy.
- Oral neomycin first-line: Neomycin is toxic and not first-line.
6. A man with alcoholic cirrhosis vomits large amounts of blood from varices at the lower end of the oesophagus. Between which veins is the portosystemic anastomosis that forms these varices?
Answer: Left gastric and oesophageal veins. In portal hypertension, blood is diverted into portosystemic shunts. At the lower oesophagus, the left gastric (portal) vein connects with oesophageal veins draining to the azygos (systemic). These dilate into varices that can bleed massively. Other sites: rectum (superior with middle/inferior rectal) and umbilicus (caput medusae).
- Superior and middle rectal veins: Rectal varices, which rarely bleed heavily.
- Paraumbilical and epigastric veins: Caput medusae.
- Splenic and left renal veins: Retroperitoneal shunts.
- Inferior mesenteric and lumbar veins: Retroperitoneal shunts; do not cause haematemesis.
7. A newborn boy becomes lethargic and starts vomiting after starting feeds. Blood ammonia is very high and urine orotic acid is raised. Which enzyme is most likely deficient?
Answer: Ornithine transcarbamylase. Ornithine transcarbamylase deficiency is the most common urea cycle disorder and is X-linked. Carbamoyl phosphate builds up and spills into pyrimidine synthesis, raising orotic acid, while ammonia rises. CPS I deficiency causes hyperammonaemia without orotic aciduria. UMP synthase deficiency causes orotic aciduria with megaloblastic anaemia but normal ammonia.
- Carbamoyl phosphate synthetase I: No orotic aciduria.
- Phenylalanine hydroxylase: PKU; no hyperammonaemia.
- UMP synthase: Normal ammonia.
- Arginase: Rare; causes spasticity, mild hyperammonaemia.
References and dose sources
- EASL guidelines: decompensated cirrhosis (J Hepatol 2018)
- AASLD guidance: ascites, SBP and hepatorenal syndrome (Hepatology 2021)
- NICE CG141
- NICE NG50
- BSG/BASL — decompensated cirrhosis care bundle
- NICE CG100 — alcohol-use disorders: physical complications
- Ceftriaxone dosing: Drugs.com: Ceftriaxone dosage (see also our ceftriaxone dose page)
- Lactulose dosing: Drugs.com: Lactulose dosage (see also our lactulose dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.