Decompensated Liver Disease: Junior Doctor Guide & Clerking Template

Q: What are the red flags for decompensated cirrhosis?

Haematemesis / melaena — think variceal bleed; Fever, abdominal pain, worsening ascites — think spontaneous bacterial peritonitis; Confusion, flap — think hepatic encephalopathy; Rising creatinine — think hepatorenal syndrome-AKI; Jaundice, fever, heavy drinking — think alcohol-related hepatitis; Tremor, sweating, agitation, seizures — think alcohol withdrawal; Hypoglycaemia — think liver failure — check glucose often

Q: What is the initial management of decompensated cirrhosis?

Diagnostic ascitic tap (neutrophil count, culture (in blood culture bottles)); IV thiamine (Pabrinex) (before glucose, if alcohol use or malnourished); Bloods (FBC, U&E, LFT, clotting, glucose, cultures, alcohol level); Stop nephrotoxics (diuretics, NSAIDs, ACEi if AKI); Withdrawal assessment (CIWA-guided chlordiazepoxide if alcohol-dependent); Gastro / hepatology (early, especially if bleeding or encephalopathic)

Q: What diagnoses must you not miss in decompensated cirrhosis?

Variceal bleed (haematemesis); Spontaneous bacterial peritonitis (often silent); Hepatorenal syndrome-AKI (rising creatinine); Grade 3–4 encephalopathy (GCS falling); Acute liver failure (non-cirrhotic) (new jaundice + coagulopathy + confusion)

Q: What investigations should a junior doctor order for decompensated cirrhosis?

Bloods: FBC, U&E, LFT, INR, glucose, CRP, Mg, phosphate.; Ascitic tap: Neutrophil count, culture (inoculate bottles at bedside), protein, albumin (SAAG).; Imaging: Portal vein thrombosis, HCC, ascites.; Scores: Prognosis.

Q: Admit or discharge: how is the plan decided for decompensated cirrhosis?

Gastro / hepatology ward: Most decompensated patients. Bundle completed, trigger treated, alcohol support, nutrition.; Hdu / itu: Variceal bleeding, grade 3–4 encephalopathy, HRS-AKI, sepsis, acute liver failure.

Settle them, and check the basics

the care bundle

Red flags — what each should make you think

Haematemesis / melaenavariceal bleed Fever, abdominal pain, worsening ascitesspontaneous bacterial peritonitis Confusion, flaphepatic encephalopathy Rising creatininehepatorenal syndrome-AKI Jaundice, fever, heavy drinkingalcohol-related hepatitis Tremor, sweating, agitation, seizuresalcohol withdrawal Hypoglycaemialiver failure — check glucose often

🩺

Pearl

Every decompensated patient with ascites needs a diagnostic tap on admission, even if they look well. SBP is often silent, and missing it is a common cause of death in cirrhosis. A neutrophil count above 250 cells/mm³ in the fluid means SBP.

Admission actions (BSG/BASL bundle)

💉Diagnostic ascitic tap
B1IV thiamine (Pabrinex)
🩸Bloods
✕Stop nephrotoxics
🍺Withdrawal assessment
☎Gastro / hepatology

Understand the patient — the four decompensations

find the trigger

Ascites

Diagnostic tap in every admission with ascites
SBP: neutrophils above 250/mm³ → IV antibiotics + IV albumin (protects the kidneys)
Large-volume paracentesis for tense ascites with albumin replacement (8 g per litre removed, usually as 20% albumin)
Salt restriction, diuretics (spironolactone ± furosemide) once stable and kidneys allow

Encephalopathy

Confusion, drowsiness, asterixis, constructional apraxia
Find the trigger: infection, GI bleed, constipation, dehydration, electrolytes (low K/Na), drugs (sedatives, opioids), AKI
Lactulose titrated to 2–3 soft stools a day; phosphate enemas if needed; rifaximin for recurrence
Protect the airway if GCS falling

Kidneys & alcohol

AKI — stop diuretics and nephrotoxics, give IV albumin (1 g/kg/day for 2 days, max 100 g/day); terlipressin for hepatorenal syndrome-AKI under specialist care
Alcohol withdrawal — CIWA-guided benzodiazepines; Pabrinex for Wernicke's risk
Alcohol-related hepatitis — jaundice, fever, tender liver; calculate Maddrey DF/GAHS; steroids only after specialist assessment

Work A–E — assess and act as you go

AAirway. GCS low (encephalopathy) or haematemesis → airway risk.anaesthetics

BBreathing. Hepatic hydrothorax, aspiration.oxygen

CCirculation. Often low BP at baseline; bleeding.cannulas, blood if bleeding

DDisability. GCS, flap, glucose (hypoglycaemia).lactulose, thiamine, glucose

EExposure. Jaundice, ascites, oedema, bruising, PR (melaena), infection source.tap

The diagnoses you must not miss

tap to open each

What points toward it, what would rule it in, and how to manage it.

points toward it

Large-volume haematemesis/melaena, shock.

rule in

Endoscopy.

manage it

Resuscitate, terlipressin, IV antibiotics, urgent endoscopy for banding. See the upper GI bleed page.

Source: Upper GI bleed page · NICE CG141

points toward it

Fever, abdominal pain, worsening encephalopathy, AKI — or nothing at all.

rule in

Ascitic neutrophils above 250/mm³.

manage it

IV antibiotics per local policy plus IV albumin; prophylaxis after recovery.

Source: NICE NG50 · BSG ascites guideline

points toward it

AKI in cirrhosis with ascites, no shock, no response to stopping diuretics and giving albumin.

rule in

Diagnosis of exclusion; urine sodium low.

manage it

Albumin, terlipressin under hepatology/ITU; treat the trigger.

Source: BSG/BASL

points toward it

Stupor or coma.

rule in

Clinical; exclude hypoglycaemia, intracranial bleed (CT), sepsis.

manage it

Airway protection (ITU), lactulose via NG/enemas, treat trigger.

Source: BSG/BASL

points toward it

No prior liver disease; paracetamol overdose, viral hepatitis, drugs.

rule in

INR, LFT, glucose, lactate, paracetamol level.

manage it

Discuss early with a liver transplant centre (King's College criteria); acetylcysteine for paracetamol.

Source: Overdose page

Investigate — what to order, when, and what it tells you

test with a question in mind

Bloods

Routine

FBC, U&E, LFT, INR, glucose, CRP, Mg, phosphate.

Cultures

Blood, urine, ascites.

Ascitic tap

Send

Neutrophil count, culture (inoculate bottles at bedside), protein, albumin (SAAG).

Imaging

USS with Doppler

Portal vein thrombosis, HCC, ascites.

CT head

If GCS low with focal signs or falls.

Scores

Child-Pugh, MELD

Prognosis.

Maddrey DF / GAHS

Alcohol-related hepatitis.

How the plan comes together

disposition · handover

gastro / hepatology ward

Most decompensated patients. Bundle completed, trigger treated, alcohol support, nutrition.

HDU / ITU

Variceal bleeding, grade 3–4 encephalopathy, HRS-AKI, sepsis, acute liver failure.

Hand over: trigger, tap results, encephalopathy grade, renal function, alcohol withdrawal score, ceiling of care.

🩺

Pearl

Tap every ascitic patient, give Pabrinex before glucose, and always ask what triggered this: bleeding, infection, constipation, drugs or alcohol. Nicely done getting here.

✎

Clerking template

copy or download

Decompensated liver disease — documentation structure

A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.

DECOMPENSATED LIVER DISEASE — CLERKING TEMPLATE PRESENTING COMPLAINT: HISTORY OF PRESENTING COMPLAINT Known liver disease (cause / Child-Pugh / previous decompensation): Alcohol — units / last drink / withdrawal history / seizures: Confusion / sleep reversal: Abdominal swelling / pain / fever: GI bleeding / melaena: Constipation / new drugs: RED FLAGS ASKED (record present or absent) [ ] Haematemesis / melaena -> variceal bleed [ ] Fever, abdominal pain, worsening ascites -> spontaneous bacterial peritonitis [ ] Confusion, flap -> hepatic encephalopathy [ ] Rising creatinine -> hepatorenal syndrome-AKI [ ] Jaundice, fever, heavy drinking -> alcohol-related hepatitis [ ] Tremor, sweating, agitation, seizures -> alcohol withdrawal [ ] Hypoglycaemia -> liver failure — check glucose often SCORES / KEY CHECKS Ascitic tap done: Y / N Neutrophils: Encephalopathy grade: CIWA score: Pabrinex given: Y / N Child-Pugh: MELD: Maddrey DF / GAHS (if alcohol hepatitis): PAST MEDICAL HISTORY: DRUG HISTORY: ALLERGIES: SOCIAL HISTORY (smoking / alcohol / function / who's at home): FAMILY HISTORY: OBSERVATIONS: RR SpO2 ( % O2) HR BP Temp GCS NEWS2 EXAMINATION A - B - C - D - (GCS pupils glucose ) E - INVESTIGATIONS ORDERED: IMPRESSION: DIFFERENTIALS CONSIDERED: [ ] Variceal bleed [ ] Spontaneous bacterial peritonitis [ ] Hepatorenal syndrome-AKI [ ] Grade 3–4 encephalopathy [ ] Acute liver failure (non-cirrhotic) [ ] Alcohol-related hepatitis [ ] Portal vein thrombosis [ ] Hepatocellular carcinoma [ ] Wernicke's encephalopathy PLAN: 1. 2. 3. ESCALATION / SENIOR DISCUSSION: Discussed with: Time: Advice: SAFETY NET / IF DETERIORATES: Documented by: Grade: Date/Time:

Test yourself

active recall

Cover the answer, say it out loud, then reveal. Retrieval beats re-reading.

0 / 12 known

Red flag

Haematemesis / melaena — what should it make you think?

variceal bleed

Red flag

Fever, abdominal pain, worsening ascites — what should it make you think?

spontaneous bacterial peritonitis

Red flag

Confusion, flap — what should it make you think?

hepatic encephalopathy

Red flag

Rising creatinine — what should it make you think?

hepatorenal syndrome-AKI

Red flag

Jaundice, fever, heavy drinking — what should it make you think?

alcohol-related hepatitis

Red flag

Tremor, sweating, agitation, seizures — what should it make you think?

alcohol withdrawal

Red flag

Hypoglycaemia — what should it make you think?

liver failure — check glucose often

Must not miss

How do you rule in variceal bleed?

Endoscopy.

Must not miss

How do you rule in spontaneous bacterial peritonitis?

Ascitic neutrophils above 250/mm³.

Must not miss

How do you rule in hepatorenal syndrome-AKI?

Diagnosis of exclusion; urine sodium low.

Must not miss

How do you rule in grade 3–4 encephalopathy?

Clinical; exclude hypoglycaemia, intracranial bleed (CT), sepsis.

Must not miss

How do you rule in acute liver failure (non-cirrhotic)?

INR, LFT, glucose, lactate, paracetamol level.

Frequently asked questions

quick answers

What are the red flags for decompensated cirrhosis?

Haematemesis / melaena — think variceal bleed
Fever, abdominal pain, worsening ascites — think spontaneous bacterial peritonitis
Confusion, flap — think hepatic encephalopathy
Rising creatinine — think hepatorenal syndrome-AKI
Jaundice, fever, heavy drinking — think alcohol-related hepatitis
Tremor, sweating, agitation, seizures — think alcohol withdrawal
Hypoglycaemia — think liver failure — check glucose often

What is the initial management of decompensated cirrhosis?

Diagnostic ascitic tap — neutrophil count, culture (in blood culture bottles)
IV thiamine (Pabrinex) — before glucose, if alcohol use or malnourished
Bloods — FBC, U&E, LFT, clotting, glucose, cultures, alcohol level
Stop nephrotoxics — diuretics, NSAIDs, ACEi if AKI
Withdrawal assessment — CIWA-guided chlordiazepoxide if alcohol-dependent
Gastro / hepatology — early, especially if bleeding or encephalopathic

Always alongside senior support and your local guideline.

What diagnoses must you not miss in decompensated cirrhosis?

Variceal bleed — haematemesis
Spontaneous bacterial peritonitis — often silent
Hepatorenal syndrome-AKI — rising creatinine
Grade 3–4 encephalopathy — GCS falling
Acute liver failure (non-cirrhotic) — new jaundice + coagulopathy + confusion

Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.

What investigations should a junior doctor order for decompensated cirrhosis?

Bloods — FBC, U&E, LFT, INR, glucose, CRP, Mg, phosphate.
Ascitic tap — Neutrophil count, culture (inoculate bottles at bedside), protein, albumin (SAAG).
Imaging — Portal vein thrombosis, HCC, ascites.
Scores — Prognosis.

Admit or discharge: how is the plan decided for decompensated cirrhosis?

Gastro / hepatology ward — Most decompensated patients. Bundle completed, trigger treated, alcohol support, nutrition.
Hdu / itu — Variceal bleeding, grade 3–4 encephalopathy, HRS-AKI, sepsis, acute liver failure.

Is there a clerking template for decompensated cirrhosis?

Yes — there is a free clerking template for decompensated cirrhosis on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.

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