Decompensated Cirrhosis

Decompensated cirrhosis is a common reason for admission under gastro and acute medicine in the NHS. These patients can deteriorate quickly and often require early senior input.

This guide focuses on practical clinical thinking for ward work and on-call, not textbook theory.

What is decompensated cirrhosis?

Cirrhosis becomes “decompensated” when complications of liver failure develop.

In simple terms:

The liver can no longer maintain normal physiological function.

How does it present?

Common features you will see on the ward:

  • Ascites
  • Jaundice
  • Hepatic encephalopathy
  • GI bleeding (often variceal)
  • Peripheral oedema
  • Confusion or drowsiness
  • Recurrent admissions with “generally unwell” picture

Red flags suggesting severe disease:

  • Reduced consciousness
  • Hypotension
  • Infection
  • AKI
  • Hyponatraemia
  • Rising bilirubin or INR

Common causes (think practically)

You don’t need every rare cause. Think of patterns you actually see:

Most common:

  • Alcohol-related liver disease
  • MASLD / NAFLD
  • Chronic viral hepatitis (B or C)

Also important:

  • Autoimmune hepatitis
  • PBC / PSC
  • Drug-induced liver injury
  • HCC in known cirrhosis

On the ward, always ask

What has triggered this decompensation?

Common triggers:

  • Infection (SBP, UTI, chest sepsis)
  • GI bleed
  • Alcohol binge
  • Non-adherence to diuretics
  • Constipation (precipitating encephalopathy)
  • Dehydration / over-diuresis
  • New medications (e.g. NSAIDs)

If you don’t look for a trigger, you’ll miss the real problem.

First priority = assess how sick they are

Before adjusting meds, assess severity:

Look at:

  • Conscious level
  • BP and perfusion
  • Oxygen
  • Urine output
  • NEWS score
  • Trend in bloods (bilirubin, INR, creatinine, sodium)

Patients with cirrhosis can look deceptively stable and then crash.

Immediate management on the ward (what juniors should actually do)

If called to review a decompensated cirrhosis patient:

Do early:

  • Full A–E assessment
  • Bloods: FBC, U&E, LFTs, INR, CRP
  • Blood cultures if infection suspected
  • Urinalysis
  • CXR if any respiratory symptoms
  • Ascitic tap if ascites present (don’t delay)

Practical steps:

  • Review medications (stop NSAIDs, review diuretics)
  • Avoid over-diuresis
  • Ensure adequate fluids if AKI suspected
  • Consider lactulose if encephalopathy
  • Early antibiotics if infection suspected

Key complications you must actively think about

These are the things that kill patients with cirrhosis:

  • Ascites and SBP
  • Hepatic encephalopathy
  • AKI / hepatorenal syndrome
  • Variceal bleeding
  • Sepsis
  • Hyponatraemia
  • Malnutrition

If you only treat “abnormal LFTs”, you miss the danger.

When to escalate

You should escalate early if there is:

  • New confusion or drowsiness
  • AKI
  • Rising bilirubin or INR
  • Hypotension
  • Sepsis
  • GI bleeding
  • Concern from nursing staff
  • NEWS ≥5

These patients often need:

  • Gastro registrar input
  • Sometimes HDU/ICU
  • Early consultant review

Do not manage sick cirrhosis patients alone overnight.

Common mistakes juniors make

  • Not doing an ascitic tap
  • Missing infection as the trigger
  • Over-diuresing and causing AKI
  • Ignoring hyponatraemia
  • Assuming confusion is “just their baseline”
  • Delayed escalation

Cirrhosis patients are fragile — small errors can have big consequences.

Take-home concept

Decompensated cirrhosis is not about chasing abnormal blood tests.
It is about identifying the trigger, recognising deterioration early, and escalating appropriately.