Decompensated cirrhosis (ascites, SBP, hepatic encephalopathy): workup and management
Admission with decompensated cirrhosis: new or worsening ascites, hepatic encephalopathy, variceal bleeding or jaundice. Every admitted patient with ascites needs a diagnostic paracentesis to look for SBP. Find and treat the precipitant (infection, bleeding, drugs, alcohol, dehydration, constipation) and watch for AKI and hepatorenal syndrome.
Working diagnosis
Adult · US guidelines
Draft · awaiting physician review
01Orient
What's new in the evidence
- AGA 2025 clinical practice update: diagnostic paracentesis in every hospitalized patient with ascites, ideally within 12–24 hours; refer all patients with ascites for transplant evaluation
- AGA 2024 and AASLD 2024: terlipressin is the vasoactive drug of choice for HRS-AKI; avoid in ACLF grade 3, hypoxia or major cardiopulmonary disease (respiratory failure warning)
- AASLD 2024: albumin challenge 1 g/kg/day (max 100 g) for 48 hours in AKI; reassess albumin need by volume status
- ATTIRE (2021): albumin infused to a target serum level did not help and caused more pulmonary edema
- Routine ammonia testing is not recommended for hepatic encephalopathy
Differential diagnoses
- Spontaneous bacterial peritonitis (can't miss)
- Variceal or other GI bleeding (can't miss)
- Hepatic encephalopathy precipitated by infection, bleeding, constipation, sedatives, hypokalemia
- AKI: prerenal, ATN or hepatorenal syndrome (HRS-AKI)
- Alcohol-associated hepatitis
- Portal vein thrombosis or hepatocellular carcinoma
- Secondary peritonitis from perforation (can't miss)
02Assess
Risk scores and decision tools
- MELD 3.0 and Child-Pugh
- ICA-AKI staging for AKI in cirrhosis
- West Haven grade for hepatic encephalopathy
- CLIF-C ACLF score in organ failure
Key history questions
- Cause of cirrhosis, prior decompensations, transplant listing
- Alcohol use and last drink
- Abdominal pain, fever, confusion, sleep reversal
- Melena or hematemesis
- Diuretics, lactulose and rifaximin adherence; bowel movements
- Sedatives, opioids, NSAIDs, new drugs
Examination findings
- Ascites, abdominal tenderness, fever
- Asterixis, disorientation (West Haven grade)
- Jaundice, spider angiomata, palmar erythema
- Volume status, signs of GI bleeding
03Investigate
Initial investigations
- Diagnostic paracentesis: cell count with differential, albumin (SAAG), total protein, culture in blood culture bottles
- CBC, BMP, LFTs, INR, MELD 3.0
- Blood and urine cultures, chest X-ray
- Abdominal ultrasound with Doppler (portal vein, HCC)
Advanced investigations
- Ammonia is not needed to diagnose or monitor hepatic encephalopathy
- Urine sodium and microscopy for AKI
- Ascitic glucose, LDH, Gram stain if secondary peritonitis is possible
- CT abdomen if perforation or HCC suspected
04Treat
Immediate management
- SBP (ascitic PMN ≥250/mm³): ceftriaxone 2 g IV daily (or per local resistance) for 5–7 days
- SBP with creatinine >1 mg/dL, BUN >30 mg/dL or bilirubin >4 mg/dL: albumin 1.5 g/kg on day 1 and 1 g/kg on day 3
- Hepatic encephalopathy: lactulose titrated to 2–3 soft stools a day, and treat the precipitant
- Suspected variceal bleed: see the upper GI bleed workup (octreotide, ceftriaxone, endoscopy within 12 hours)
First-line treatment
- Ascites: 2 g/day sodium restriction, spironolactone with or without furosemide (100:40 ratio)
- Large-volume paracentesis >5 L: albumin 6–8 g per liter removed
- Add rifaximin 550 mg twice daily for recurrent hepatic encephalopathy
- AKI: stop diuretics, nephrotoxins and beta-blockers if hypotensive; albumin 1 g/kg/day (max 100 g) for 2 days
Second-line treatment
- HRS-AKI stage ≥2 not responding to albumin: terlipressin (per label, 0.85 mg IV every 6 hours, titrated, or continuous infusion) with albumin; norepinephrine in ICU if terlipressin is unsuitable or in shock
- Refractory ascites: serial paracentesis or TIPS evaluation
- SBP prophylaxis after an episode (e.g., ciprofloxacin or TMP-SMX)
Specialist referrals
- Hepatology; transplant evaluation for MELD ≥15 or any decompensation
- ICU for grade 3–4 encephalopathy, shock or active bleeding
- Palliative care for goals of care when not a transplant candidate
05Disposition
Admission criteria
- SBP, GI bleeding, grade ≥2 encephalopathy or AKI
- New ascites needing evaluation in an unwell patient
- Unable to manage at home
Safe discharge criteria
- Precipitant treated, encephalopathy resolved
- Stable creatinine and electrolytes on diuretics
- Hepatology follow-up within 1–2 weeks
Follow-up timing
- Hepatology within 1–2 weeks; labs within 1 week of diuretic changes
Patient instructions
- Take lactulose to keep 2–3 soft stools a day
- Avoid NSAIDs, alcohol and sedatives
- Daily weights; return for fever, confusion, abdominal pain or bleeding
Monitoring
- Daily weight, creatinine and sodium
- Mental status each shift
Clinical pearls and pitfalls
- Paracentesis is safe despite a high INR or low platelets; routine FFP or platelets are not needed
- Repeat paracentesis at 48 hours if SBP is not improving
- Cirrhosis with ascites admitted to hospital carries high short-term mortality: discuss goals of care early
RefGuidelines and landmark evidence
- GuidelineAASLD – Practice Guidance: Ascites, SBP and Hepatorenal Syndrome (2021)PubMed
- GuidelineAASLD/EASL – Hepatic Encephalopathy in Chronic Liver Disease (2014)PubMed
- TrialAlbumin in SBP reduces renal failure and mortality (Sort et al., 1999)PubMed
- TrialCONFIRM: terlipressin plus albumin for hepatorenal syndrome (2021)PubMed
- GuidelineAGA – Clinical Practice Update: Vasoactive Drugs and IV Albumin in Cirrhosis (2024)PubMed
- GuidelineAASLD – Practice Guidance on ACLF and the Critically Ill Patient With Cirrhosis (2024)PubMed
- TrialATTIRE: targeted albumin infusions in hospitalized cirrhosis (2021)PubMed
- GuidelineAGA – Clinical Practice Update: Ascites, Volume Overload and Hyponatremia in Cirrhosis (2025)PubMed
For education only. Typical adult starting points; confirm doses against renal function, allergies, interactions and your institution's protocols. Not a substitute for clinical judgment or senior review.