Decompensated Chronic Liver Disease (DCLD): Examination, Workup & Treatment

Definition and Staging

• Variceal hemorrhage
• Ascites (with or without SBP)
• Hepatic encephalopathy
• Jaundice (in the absence of another cause)

Clinical Examination

Symptoms (History)

• General: lethargy, weakness, fatigue, weight loss, muscle wasting
• GI: nausea, anorexia, right upper quadrant discomfort, abdominal distension
• Neurological: memory impairment, confusion, personality change, altered sleep, slurred speech (encephalopathy)
• Bleeding: easy bruising, hematemesis (melena from varices), dark stools
• Other: pruritus, decreased libido/impotence, amenorrhoea, tea-colored urine, acholic (pale) stools

Physical Signs (with approximate incidence from Mulholland & Greenfield's Table 59.6)

Workup / Investigations

Blood Tests

• Bilirubin (total, direct, indirect): elevated in hepatocellular and cholestatic disease
• AST, ALT, ALP, GGT: elevated; classic DCLD - AST:ALT ratio >2 (especially alcoholic); ALT rarely >300 IU/L in alcoholic disease
• Albumin: reduced (marker of synthetic dysfunction)
• PT/INR: prolonged (synthetic failure - loss of Factors II, VII, IX, X)

• FBC: thrombocytopenia (hypersplenism + reduced thrombopoietin), macrocytic anemia, leukocytosis (infection or alcoholic hepatitis)
• Reticulocyte count

• U&E: hyponatremia (dilutional), hypokalemia (diuretics), hypomagnesemia, hypophosphatemia, hypocalcemia
• Creatinine, eGFR: watch for hepatorenal syndrome (HRS)
• Blood glucose: hypoglycemia risk (impaired gluconeogenesis)

• MELD score (Model for End-Stage Liver Disease): uses bilirubin, INR, creatinine - best predictor of 90-day mortality; guides transplant listing
• Child-Pugh score: bilirubin, albumin, PT, ascites, encephalopathy
• Maddrey Discriminant Function (MDF): = 4.6 × (PT prolongation above control in seconds) + bilirubin (mg/dL); MDF ≥32 or MELD >20 = severe alcoholic hepatitis requiring steroids

• Viral serology: HBsAg, anti-HBc, anti-HCV, HCV RNA
• Autoimmune: ANA, ASMA, anti-LKM1, IgG (autoimmune hepatitis)
• Metabolic: serum ferritin + transferrin saturation (hemochromatosis), ceruloplasmin + 24h urinary copper (Wilson's), alpha-1 antitrypsin
• Thyroid function

• Serum AFP: HCC surveillance (every 6 months with liver US in all cirrhotic patients)
• Blood, urine cultures if infection suspected
• Ammonia level: non-specific/non-sensitive for HE grading but useful as a contributing factor assessment

Ascitic Fluid Analysis (Diagnostic Paracentesis)

• Cell count (neutrophils >250/mm³= SBP)
• Culture & sensitivity (send at bedside in blood culture bottles)
• Albumin (to calculate SAAG = serum albumin - ascites albumin; SAAG ≥1.1 = portal hypertension)
• Total protein, glucose, LDH, cytology (if malignancy suspected)

Imaging

Liver Biopsy

• Required for definitive diagnosis or when etiology is uncertain
• Percutaneous (or transjugular if coagulopathic)
• Minimum 11 portal tracts recommended
• Grading systems: Batts-Ludwig, Metavir (AASLD preferred)

Scoring Indices

• APRI >2 suggests cirrhosis
• Bonacini cirrhosis discriminant score ≥7 suggests cirrhosis
• Lok index <0.2 argues against cirrhosis

Treatment

1. Treat the Underlying Cause

• Alcohol: Complete abstinence - only intervention proven to reverse ALD. Treat alcohol use disorder concurrently.
• Viral hepatitis: DAA therapy (HCV - see below); antiviral therapy for HBV
• NAFLD/NASH: weight loss, control of metabolic risk factors (diabetes, dyslipidemia)
• Autoimmune hepatitis: corticosteroids ± azathioprine

2. Management of Ascites

• Sodium-restricted diet (≤2 g/day)
• Spironolactone 50-200 mg/day (mainstay - blocks aldosterone-driven sodium retention)
• Furosemide 20-40 mg/day (added for loop diuresis; use cautiously to avoid over-diuresis)
• Amiloride 5-10 mg/day (alternative to spironolactone)

• Large-volume paracentesis (LVP) - safe even with elevated INR unless overt DIC or fibrinolysis
• IV albumin 6-8 g/L of fluid removed for volumes >4 L - prevents post-paracentesis circulatory dysfunction

• TIPS (transjugular intrahepatic portosystemic shunt) - reduces portal pressure; consider in refractory ascites
• Liver transplantation

3. Management of Spontaneous Bacterial Peritonitis (SBP)

• SBP defined by ascitic PMN >250/mm³
• 1-year incidence in patients with ascites: 30%; recurrence up to 44%
• Classic presentation: fever + diffuse abdominal pain/tenderness (but may be absent - any new symptom in a cirrhotic with ascites warrants diagnostic tap)

• IV cefotaxime (first-line) - covers E. coli, Klebsiella, Streptococcus pneumoniae
• Oral quinolones (ciprofloxacin) for mild, uncomplicated cases with close follow-up
• IV albumin 1.5 g/kg at diagnosis + 1 g/kg on day 3 - reduces renal failure and hospital mortality
• Long-term prophylaxis after first episode: norfloxacin or trimethoprim-sulfamethoxazole

4. Management of Hepatic Encephalopathy (HE)

• Grade I: sleep reversal, mild confusion, irritability, asterixis
• Grade II: lethargy, disorientation, inappropriate behavior
• Grade III: somnolence, severe confusion, aggressive behavior
• Grade IV: coma

• GI bleeding, infection, electrolyte imbalances (hypokalemia), constipation, opioids/sedatives, high protein intake, diuretic over-treatment, TIPS dysfunction

• Lactulose 15-45 mL PO bid-qid (first-line): non-absorbable disaccharide - traps ammonia in gut by acidifying colon. Target 3-5 soft stools/day. Acute dosing: 30 mL every 1-2 hours until bowel movement, then titrate down. Lactulose enema (300 mL lactulose + 700 mL water) for patients unable to take orally.
• Rifaximin 550 mg PO bid (add-on therapy): non-absorbable oral antibiotic, reduces colonic bacterial ammonia production; significantly reduces risk of HE recurrence and time to first hospitalization
• Low-protein diet is NO longer recommended; maintain adequate nutrition

5. Management of Variceal Bleeding

• Resuscitation: IV access × 2, cautious fluid resuscitation, target Hb 7-8 g/dL (over-transfusion worsens portal pressure)
• Vasoconstrictors (start immediately): terlipressin (preferred), octreotide, or somatostatin - reduce splanchnic blood flow; continue for 2-5 days
• Antibiotics (at admission, regardless of signs of infection): IV ceftriaxone or oral norfloxacin - reduce bacterial translocation, SBP risk, and mortality
• Urgent endoscopy (within 12 hours): endoscopic band ligation (EBL) is first-line; N-butyl cyanoacrylate injection for gastric varices
• TIPS for refractory or recurrent variceal hemorrhage

• Non-selective beta-blockers (propranolol, nadolol, carvedilol) + endoscopic band ligation (EBL) - reduces re-bleeding risk
• Avoid NSAIDs, aspirin

• Non-selective beta-blockers for medium/large varices or red wale signs

6. Management of Coagulopathy

• Vitamin K 10 mg IV or PO if PT/INR elevated (particularly if cholestatic component)
• Fresh frozen plasma (FFP) - for active uncontrolled bleeding or pre-procedure
• Platelet transfusion for severe thrombocytopenia with active bleeding or pre-procedure
• Note: INR in cirrhosis is an unreliable guide to bleeding risk (does not reflect the balance of pro- and anti-coagulant factor deficiencies)

7. Hepatorenal Syndrome (HRS)

• Diagnosis of exclusion in patients with CLD and progressive oliguria/rising creatinine without other cause
• Type 1 HRS: rapid decline in renal function (creatinine doubles in <2 weeks) - precipitated by SBP, GI bleeding
• Type 2 HRS: slower progression, associated with refractory ascites

• Remove precipitants (hold diuretics, NSAIDs)
• Terlipressin + albumin (first-line; terlipressin 0.5-2 mg IV q4-6h)
• Norepinephrine + albumin (alternative where terlipressin unavailable)
• Renal replacement therapy (bridge to transplant)
• TIPS may improve HRS
• Liver transplantation is definitive

8. Nutrition

• Malnutrition is near-universal in DCLD; protein restriction is CONTRAINDICATED
• Target: 1.2-1.5 g/kg/day protein, 30-35 kcal/kg/day
• Branched-chain amino acids (BCAA) supplementation may help in HE
• Small frequent meals + late evening snack to minimize fasting gluconeogenesis

9. HCC Surveillance

• All cirrhotic patients: liver ultrasound + AFP every 6 months
• AFP alone is insufficient; imaging is mandatory

10. Liver Transplantation

• Definitive treatment for end-stage liver disease
• MELD score drives organ allocation (MELD ≥15 generally when benefit exceeds risk of surgery)
• King's College Criteria used in acute liver failure for transplant listing
• Screen all DCLD patients with worsening MELD, recurrent decompensation, or HCC for transplant evaluation

Summary Scoring Reference