Gastrointestinal & Hepatic · Topic 5 of 26

Cirrhosis & Decompensation

Gastrointestinal · liver

Cirrhosis & Decompensation

Stage it with Child-Pugh and MELD, watch for ascites, variceal bleeding and encephalopathy, and refer for transplant at MELD 15 or any decompensation.

Key numbers

Child-Pugh: A 5–6, B 7–9, C 10–15A 5–6 · B 7–9 · C 10–15

Refer for transplant at MELD 15MELD ≥ 15

Portal hypertension significant at HVPG 10 mmHgHVPG ≥ 10 mmHg

Acetaminophen up to 2 g/day; no NSAIDsAcetaminophen ≤ 2 g/day

AKI: stop diuretics, give albumin 1 g/kgAlbumin 1 g/kg × 48 h

01 · Defined byChild-Pugh: A 5–6, B 7–9, C 10–15

Child-Turcotte-Pugh scores bilirubin, albumin, INR, ascites and encephalopathy (1–3 points each): class A 5–6, B 7–9, C 10–15, stratifying prognosis and surgical risk.

02 · DoRefer for transplant at MELD 15

Refer to a transplant center when MELD is 15 or higher, at the first clinical decompensation, or with hepatocellular carcinoma meeting exception criteria — above MELD 15, transplant benefit outweighs its risk.

03 · What it isDecompensation: ascites, variceal bleeding, encephalopathy

Compensated cirrhosis can be silent for years; decompensation means ascites, variceal hemorrhage or hepatic encephalopathy, and once one event occurs, further decompensation is much more likely.

What it is

Core idea

Portal hypertension significant at HVPG 10 mmHgClinically significant portal hypertension is HVPG of 10 mmHg or more; varices, collaterals or any decompensation prove it, and liver stiffness of 25 kPa or more on elastography identifies it noninvasively.

ACLF: liver failure plus another organ failureACLF is rapid deterioration with liver failure (rising bilirubin and INR) plus at least one extrahepatic organ failure — brain, circulation, lungs or kidneys; ACLF scores, especially with lactate, predict mortality better than MELD.

Diagnosis & monitoring

Work-up

MELD 3.0 predicts 90-day mortalityMELD 3.0 (bilirubin, INR, creatinine, sodium, albumin and female sex) predicts 90-day mortality on objective data and sets US liver allocation; it replaced MELD-Na.

HCC surveillance: ultrasound ± AFP every 6 monthsScreen every patient with cirrhosis for hepatocellular carcinoma with abdominal ultrasound, with or without alpha-fetoprotein, every 6 months.

Do right now

In this order

First moves

Full infection work-up, including diagnostic paracentesis

→

AKI: stop diuretics, give albumin 1 g/kgAlbumin 1 g/kg × 48 h

→

Acetaminophen up to 2 g/day; no NSAIDsAcetaminophen ≤ 2 g/day

Why each step

Full infection work-up, including diagnostic paracentesisEvery admission for a cirrhosis complication gets an infection work-up — diagnostic paracentesis, blood and urine cultures, urinalysis and chest radiograph — repeated whenever ascites, encephalopathy, AKI or organ failure worsens.

AKI: stop diuretics, give albumin 1 g/kgFor AKI in cirrhosis, stop diuretics and nephrotoxins, treat precipitants such as infection, and give IV albumin 1 g/kg/day (maximum 100 g) for 48 hours; stage 2+ hepatorenal AKI gets terlipressin plus albumin.

Acetaminophen up to 2 g/day; no NSAIDsAcetaminophen, limited to 2 g/day, is the preferred analgesic; avoid NSAIDs in all patients with cirrhosis.

Management

Orders

Carvedilol for clinically significant portal hypertensionCarvedilol (6.25–12.5 mg/day) is the preferred nonselective beta-blocker: with clinically significant portal hypertension it prevents decompensation and makes screening endoscopy unnecessary. Avoid in asthma, advanced heart block or bradyarrhythmia.

Sedate with short-acting agentsFor intubated patients with cirrhosis, sedate and treat pain with short half-life drugs such as propofol or dexmedetomidine; reduce doses of drugs cleared by the liver.

Minimize PPIs and urinary cathetersTo prevent infection and acute-on-chronic liver failure in hospitalized patients with cirrhosis, minimize proton pump inhibitor use and Foley catheters.

Shock: MAP 65, norepinephrine then vasopressinIn shock, resuscitate judiciously with balanced crystalloid or albumin, target MAP 65 mmHg, start norepinephrine first and add vasopressin as the second agent.

Do not restrict proteinMalnutrition and sarcopenia are common and predict death: do not restrict protein; critically ill patients need 1.2–2.0 g/kg/day protein (ideal body weight), preferably by enteral feeding.

Stop alcohol; vaccinate for hepatitis A, BTreat the cause, stop all alcohol and hepatotoxic drugs, anticipate alcohol withdrawal in the hospital, and vaccinate against hepatitis A and B unless immune.

The rules

Know these

INR does not predict bleeding riskHemostasis in cirrhosis is rebalanced: the INR does not predict bleeding and should not guide plasma transfusion; therapeutic anticoagulation carries non-portal-hypertensive bleeding rates similar to the general population.

Compensated or decompensated cirrhosis?

Commonly confused

Defined by	No ascites, variceal bleeding or encephalopathy
Symptoms	Often none for years
Beta-blocker	Carvedilol if clinically significant portal hypertension, to prevent decompensation
Transplant referral	When MELD reaches 15

More detail

Reference

Show 5 reference facts

Approximate 1-year survival by Child-Pugh class: A 90–96%, B 73–78%, C 41–51%.

Noninvasive CSPH criteria: liver stiffness 25 kPa or more at any platelet count, 20–24.9 kPa with platelets below 150,000, or 15–19.9 kPa with platelets below 110,000.

Compensated patients not on a beta-blocker and without varices repeat endoscopy every 2 years with active liver injury or every 3 years once it is controlled.

In decompensated cirrhosis, high-risk varices are treated with a nonselective beta-blocker (preferred) or band ligation; reduce or stop the beta-blocker if systolic BP stays below 90 mmHg and then band.

Offer palliative care consultation to critically ill patients with cirrhosis or ACLF to clarify prognosis and goals; it does not preclude transplant evaluation.

Pearl

Any new decompensation — ascites, encephalopathy, AKI — starts with an infection work-up, including a diagnostic paracentesis.

Sources · Merck Manual Professional — Cirrhosis (updated 2026) · Kaplan DE et al. AASLD Practice Guidance on risk stratification and management of portal hypertension and varices in cirrhosis. Hepatology 2024;79:1180–1211 · Karvellas CJ et al. AASLD Practice Guidance on acute-on-chronic liver failure and the management of critically ill patients with cirrhosis. Hepatology 2024 · Kim WR et al. MELD 3.0: The Model for End-Stage Liver Disease Updated for the Modern Era. Gastroenterology 2021;161:1887–1895 · Rakoski M et al. Pain management in patients with cirrhosis. Clin Liver Dis (Hoboken) 2018 · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).