Decompensated chronic liver disease

Manage now— do this, in order

• Airway first in grade 3 or 4 encephalopathy — the airway is not safe: nurse head-up at 30 degrees with suction available and arrange tracheal intubation. If agitation threatens the airway the answer is airway protection, not a benzodiazepine — never sedate the encephalopathic patient, and flumazenil is not a treatment for hepatic encephalopathy.Doctor / NurseNot available at your setup — Endotracheal intubation kit. If intubation is not available, nurse head-up at 30 degrees with continuous suction and arrange urgent transfer.
• Stop what is harming the patient: diuretics if creatinine or potassium is rising or sodium falling; non-selective beta-blockers in SBP, hypotension or AKI; all NSAIDs, aspirin and aminoglycosides; sedatives, opioids, antidepressants and antihistamines; and high-sodium or sodium-retaining preparations (antacids, alginates, effervescent tablets). An NSAID here causes renal failure and gastrointestinal bleeding.
• Correct hypoglycaemia, give thiamine before glucose, and resuscitate promptly but not over-vigorously: parenteral thiamine before any glucose-containing fluid in every patient with an alcohol history; then balanced crystalloid or 0.9% sodium chloride in 250–500 mL boluses in adults (10–20 mL/kg in children), reassessed after each, with 20% human albumin the preferred expander. Judge perfusion on capillary refill, mental state, lactate and urine output — a pressure of 100/60 may represent shock in someone whose baseline is 90/50. Over-rapid fluid removal or replacement is the commonest iatrogenic disaster in this disease.Doctor / Nurse
• Do a diagnostic paracentesis in every patient with new ascites, every admission with a complication of cirrhosis, and every patient with known ascites who deteriorates in any way: 10–20 mL through a 21 G needle in the left lower quadrant, lateral to the rectus sheath and clear of scars and visible collaterals. Inoculate blood culture bottles at the bedside for an 80–90% culture yield. Coagulopathy is not a contraindication — failing to tap is the error.DoctorNot available at your setup — Blood culture.
• Treat SBP immediately on an ascitic neutrophil count above 250 × 10⁶/L, without waiting for culture: cefotaxime 2 g IV every 8 hours (6-hourly if severe) for 5–7 days, or ceftriaxone 1–2 g IV once daily; piperacillin/tazobactam 4.5 g IV every 8 hours or meropenem 1 g IV every 8 hours where multidrug-resistant organisms are likely. Add albumin 1.5 g/kg on day 1 and 1.0 g/kg on day 3 where there is jaundice or renal impairment, and stop non-selective beta-blockers. Paediatric: cefotaxime 50 mg/kg IV 8-hourly (max 12 g/day); ceftriaxone 50–80 mg/kg IV daily (max 4 g).Doctor / Nurse
• Variceal haemorrhage — transfuse to a restrictive target of haemoglobin 80 g/L (children 10 mL/kg of packed red cells, then reassess), because over-transfusion raises portal pressure and provokes early rebleeding. Give ceftriaxone 1 g IV daily for 5–7 days to every cirrhotic who bleeds, infected or not. Start terlipressin 2 mg IV every 6 hours, reducing to 1 mg every 4 hours after 48 hours, for up to 5 days (alternatives somatostatin 250–500 micrograms/hour, or octreotide in children 1 microgram/kg IV then 1–5 micrograms/kg/hour). Add a proton pump inhibitor and vitamin K 10 mg IV once if the prothrombin time is prolonged (children 250–300 micrograms/kg, max 10 mg), keep nil by mouth and arrange endoscopic band ligation.Doctor / NurseNot available at your setup — Blood & blood products.
• Encephalopathy — treat the precipitant and empty the bowel: lactulose 30–60 mL orally every 2 hours until mental status improves or the first bowel movement, then 10–30 mL three times daily titrated to two or three soft stools per day and no more (children from about 0.5 mL/kg, up to 30 mL, two or three times daily). Add rifaximin 550 mg orally twice daily if it persists or recurs, or metronidazole 200 mg orally four times daily where rifaximin is unavailable. Never give oral lactulose to a drowsy patient with an unprotected airway — use a lactulose retention or phosphate enema. Never titrate to diarrhoea, and never restrict dietary protein.
• Ascites — reduce sodium in and increase sodium out, slowly: restrict sodium to ≤2 g (about 100 mmol) per day, give spironolactone 100 mg orally once daily increased stepwise to 400 mg daily (children 1–3 mg/kg/day in 1–2 divided doses, max 100–200 mg/day), adding furosemide 40 mg orally daily, range 40–160 mg/day (children 0.5–1 mg/kg/dose once or twice daily, max 2 mg/kg/day), keeping roughly a 100:40 ratio. Aim for no more than 0.5 kg weight loss per day without oedema and 1.0 kg/day with oedema — the maximum rate ascites can be mobilised is 500–700 mL in 24 hours. For tense or refractory ascites, large-volume paracentesis with albumin 6–8 g per litre removed (about 100 mL of 20% albumin per 2–3 litres drained), mandatory after ≥5 litres.Doctor / NurseNot available at your setup — Serum electrolytes, Renal function (creatinine/urea).
• Every rise in creatinine is an emergency: stop all diuretics, all beta-blockers and every nephrotoxic drug, catheterise and measure hourly urine output, tap the ascites to exclude SBP, and give intravenous albumin 1 g/kg/day (maximum 100 g) for 2 consecutive days. Only if there is no response is hepatorenal syndrome diagnosed, treated with terlipressin 1–2 mg IV every 4–6 hours with albumin. Feed the patient at least 35 kcal/kg/day with protein 1.2–1.5 g/kg/day and a late evening snack.Doctor / NurseNot available at your setup — Renal function (creatinine/urea), Serum electrolytes.