Management of Decompensated Liver Disease

Assessment / monitoring

  • Bloods for FBC, coagulation screen, U&Es, LFTs, glucose
  • Signs of chronic liver disease
  • Arrange ultrasound scan of abdomen
  • Assess for alcohol withdrawal
  • Dietary assessment
  • Liver screen including AFP (alpha fetoprotein) if not previously performed
  • For patients with cirrhosis please follow BASL Decompensated Cirrhosis Care bundle - First 24 hours on the British Society of Gastroenterology website.
  • In encephalopathy (signs = mental slowness, confusion, drowsiness, liver flap), assess for the following precipitants and treat as appropriate:
    • Sepsis: culture blood and urine. Note guidance on aminoglycosides (further below)
    • Tap ascites if present for WCC, protein content and culture (see below)
    • Arrange chest x-ray
    • Bleeding
    • Renal failure, electrolyte abnormalities
    • Constipation
    • Medication (e.g. sedatives or over-diuresis)
  • In renal impairment:
    • Assess for potentially reversible factors – dehydration, diuretics, sepsis, intrinsic renal disease.
    • Renal tract ultrasound to exclude obstruction. Urine dipstick – if hepatorenal should be nothing abnormal detected. If blood and protein consider renal causes.
    • Assess for hydration.
  • If ascites is present
    • Consider other causes of ascites (e.g. malignancy, Budd-Chiari syndrome or cardiac failure).
    • Perform diagnostic ascitic tap. Aspirate 50ml of fluid (normally straw coloured) and send for:
      • Microbiology – WCC and culture in blood culture bottle (anaerobic and aerobic)
      • Biochemistry – total protein and albumin
      • Cytology – send if malignancy suspected or SAAG (serum-ascites albumin gradient) <11. Obtain >100ml of fluid to increase yield.
    • SAAG can differentiate ascites resulting from portal hypertension and from other causes. It is more useful than the protein based exudate / transudate concept. Calculate SAAG by:

      SAAG = (serum albumin) – (ascites albumin)

      Obtain both values on the same day. If SAAG >11g/L then ascites very likely the result of portal hypertension (97% accuracy). Table 1 below lists the major differential diagnoses based on the SAAG.

Table 1 – Differential diagnoses of ascites based on serum-ascites albumin gradient

SAAG ≥11g/L SAAG <11g/L
Cirrhosis Diffuse peritoneal metastases
Alcoholic hepatitis Tuberculous peritonitis
Cardiac ascites Pancreatic ascites
Massive liver metastases Nephrotic syndrome
  • Consider DVT prophylaxis (see here for guidance). In patients with liver disease LMWH can be considered as long as platelet count is ≥50x 109/L.

General management and treatment options

Diet

  • Aim for high protein, high calorie diet.
  • Reduce protein slowly if encephalopathic.
  • Restrict dietary salt if ascites is present.
  • Give vitamin K (Phytomenadione) 10mg slow IV injection over 3 - 5 minutes. Give further doses on day 2 and day 3.
    Note: This will not correct clotting unless there is a deficiency (can occur in obstructive liver disease or prolonged malnutrition) but will ensure patient's level is replete.
  • If history of alcohol abuse is suspected give Pabrinex® (contains thiamine) – see vitamin prophylaxis flowchart here.

Management of encephalopathy

  • Assess for precipitating factors (see above under ‘Assessment / monitoring’ section) and treat as appropriate. If sepsis suspected, treat with antibiotics. Remember typical signs of sepsis may be masked. Use broad-spectrum antibiotics (see here).
  • Stop sedatives
  • Give lactulose oral 20ml three times daily (titrate dose to give three soft motions per day).

Management of ascites

  • If ascites WCC >500/mm3 or neutrophil count >250/mm3, treat as for spontaneous bacterial peritonitis (SBP) (see below).
  • Low salt diet
  • Diuretics - initially use spironolactone oral 100–400mg each day. Seek senior advice if renal impairment, high potassium or hyponatraemia. Titrate dose / consider adding furosemide according to weight and renal function. Aim for weight reduction of no more than 1kg/day.
  • If ascites is causing respiratory compromise or is not responding to above measures consider large volume paracentesis. In contrast to patients with malignant ascites (see separate guideline here) drains should ideally be removed at 6 hours to reduce infection risk and 100ml of Human Albumin Solution 20% (20g albumin per 100ml) is recommended for every 2.5L drained.
  • Treat SBP once diagnosis confirmed with:
    • Suitable antimicrobial (see here for guidance).
    • Human Albumin Solution 20% (20g albumin per 100ml), IV infusion 1.5g/kg on day one over 6 hours, then 1g/kg on day 3 over 3 hours.
  • Prophylaxis of SBP in:
    • Patients with one episode proven SBP, either previously or currently (once current episode treated).
    • Patients with total ascitic protein < 10g/L.
    • Prescribe co-trimoxazole oral 960mg once daily (first line) or norfloxacin oral 400mg once daily (second line) for prophylaxis.

    Management of renal impairment

    • Catheterise (strict input / output chart)
    • Stop diuretics
    • Assess hydration status.
      • If clinically dehydrated give sodium chloride 0.9% IV Infusion (1–1.5L is reasonable).
      • If evidence of ascites and peripheral oedema give
        • Human Albumin Solution  
          Day 1: HAS 20% IV 100ml, 1g/kg (usually 2-5 bottles) or HAS 5% IV 500ml 1.5g/kg (usually 2-4 bottles) 
          Day 2-16: HAS 20% IV 100ml or HAS 5% 500ml 1-2 bottles per day and consider:
        • Terlipressin IV – initially 0.5-2mg every 4 hours. Titrate dose over 72 hours in discussion with the local gastroenterology team. Terlipressin is contraindicated in ischaemic heart disease / peripheral vascular disease and arrhythmias.

    If no improvement in urine output after the above measures within 24 hours, seek senior review and consider central venous pressure monitoring.

Aminoglycoside in decompensated liver disease

Gentamicin should be avoided in patients with decompensated liver disease (jaundice, ascites, encephalopathy, variceal bleeding or hepatorenal syndrome). See the infection management section or contact microbiology / infectious diseases unit for advice (Appendix 6 for contact details).

Other information

For further monitoring

  • Daily FBC, U&Es until improving
  • Coagulation screen and LFTs 2-3 times per week
  • Daily weight
  • Monitor daily for encephalopathy

Pre-discharge

  • Aim to stabilise weight, mental state and diuretics dose prior to discharge.
  • Counsel about alcohol. Liaise with alcohol support services.
  • Arrange clinic review.

 

Guideline reviewed and content updated June 2021




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