Management of Decompensated Chronic Liver Disease (2012)
(Link consultant: Dr Daniel Forton)
Patients with chronic impaired liver function can remain stable (compensated) for many months but can also decompensate rapidly. The commonest causes of acute (rapid) decompensation are hypovolaemia (sometimes secondary to a GI bleed), alcohol, sepsis, drugs and renal impairment. Rapid ‘decompensation’ may also occur with the development of heptocellular carcinoma (HCC).
2. Clotting screen
3. Urea, electrolytes, creatinine
4. Liver function tests, gGT, albumin
5. Alpha feto-protein (HCC marker)
6. Arterial blood gases if patient has encephalopathy, renal impairment or sepsis
7. Viral screen/autoantibodies/transferrin saturation/copper studies as appropriate where they might help establish aetiology
8. Septic screen – blood cultures, urine cultures, sputum cultures and ascitic tap
2. Early abdominal ultrasound to: define the texture of the liver; visualise any liver tumours; define the biliary tree; establish spleen size; look for ascites; and establish the patency of the portal and hepatic veins and hepatic artery.
Ascites (remember, treatment may not be needed if the patient is asymptomatic, and if there is renal impairment, accept the presence of ascites).
1. Do diagnostic paracentesis (ask for urgent cell count to check for spontaneous bacterial peritonitis (SBP) defined as >250 neutrophils/mm3 or >300 lymphocytes/mm3. Send sample for culture/biochemistry/cytology)
2. If moderate volume ascites and if plasma Na+ >130mmol/L and renal function is normal, give spironolactone 100mg plus furosemide 40mg daily. Measure weight daily, target weight loss at ~500g/day. The dose of both diuretics can be inc-reased simultaneously every 3–4 days to achieve target weight loss; maintain a 100:40 ratio up to a maximum of 400mg spironolactone: 160mg furosemide. Do daily U&E; rapid changes can lead to encephalopathy. If hyponatraemic, restrict Na+ to 88mmol (2000mg)/day and fluid to 1.5litres/day (arrange with dietician).
3. If there is massive ascites – seek advice about total paracentesis from hepatology team (Dr Clark/Dr Forton). Note that paracentesis is not usually performed if the patient has SBP.
If patient’s temperature >37.5oC it is important to exclude infection, do:
1. Blood cultures
3. Sputum culture
4. Ascetic tap – if the WBC is >250/mL (neutrophils) or >300/mL (lymphocytes), the patient is likely to have SBP. While awaiting culture results (send ascites inoculated in inoculated in culture-medium bottles to increase diagnostic yield) start IV co-amoxiclav 1.2g bd or tds (ciprofloxacin 750mg bd PO only if penicillin allergic).
1. Exclude haemolysis, do conjugated bilirubin and blood film
2. Exclude biliary obstruction
1. Give vitamin K (menadiol sodium phosphate) 10mg PO daily for 3 days. If severe coagulopathy, Vit K (phytomenadione) can be given IV 10mg slowly and, if response is inadequate, repeated every 3 hours, up to a total dose of 40mg in 24 hours,
2. Do not give clotting products unless patient is bleeding
3. Note that moderate coagulopathy is not itself a contraindication to central line insertion or ascitic tap
1. Give lactulose 20mL tds (titrate dose to achieve at least 2 loose stools/day), via nasogastric tube if necessary
2. Give phosphate enemas bd/tds – especially if not taking oral medication
3. Stop diuretics if plasma Na+ <130mmol/L as this increases the risk of encephalopathy
4. Avoid sedatives
5. Consider IV antibiotics (broad spectrum): co-amoxiclav (or ciprofloxacin only if penicillin allergic.)
6. If grade 3 or 4 encephalopathy, consider intubating to protect the airway
7. Remember other causes of reduced Glasgow Coma Scale, eg. sepsis, Wernicke’s (give Pabrinex), intercranial bleed (consider CT head)
In the context of liver failure, this has a very poor prognosis if not corrected quickly. Hepatology team should be contacted early.
1. Stop diuretics
2. Stop NSAIDs; they are contraindicated in liver failure
3. Catheterise bladder
4. Check urine sodium
5. Insert central venous line (internal jugular) and use it as one indicator of volume control; remember that in massive ascites the CVP will read higher than the true clinical position. Give human albumin solution (HAS) if CVP suggests hypo-volaemia
6. If fluid replacement does not result in an adequate urine output (>0.5mL/kg/hr) consider giving bolus of furosemide (50-100mg)
7. If adequately fluid resuscitated and still oliguric, start terlipressin 1mg qds: reduce dose in patients with ischaemic heart disease or peripheral vascular disease
8. Give infusion of N-acetylcysteine (150mg/kg over 24 hrs) if patient having CT, to prevent contrast nephropathy
9. Patients in whom decompensated chronic liver disease is secondary to alcohol and renal impairment should be given pentoxyphylline 400mg tds orally
Portal hypertension (defined by the presence of varices on endoscopy)
1. Give propranolol 20mg bd. Aim to reduce resting pulse rate by 20% or aim for pulse rate of 60bpm. If a b-blocker is contraindicated give isosorbide mononitrate 20mg bd
2. Give antibiotic prophylaxis (co-amoxiclav) to patients who have cirrhosis plus bleeding varices
The commonest cause is a metabolic acidosis due to fluid depletion. This should be treated by fluid resuscitation as for renal failure.
In liver failure there is total body sodium excess, therefore avoid saline or sodium-containing colloids if possible, unless the patient requires urgent fluid resuscitation, as this will worsen ascites or oedema. If the patient is hyponatraemic (Na+ <125mmol/l) seek specialist advice.
Patients are often malnourished. Feeding should be enterally, if necessary with a nasogastric tube provided the airway can be protected. With dietician’s advice give:
1. High protein diet (unless known to worsen encephalopathy)
2. High calorie diet
3. No added salt diet
4. Thiamine replacement (Pabrinex 1&2 IV over 10 mins for 3 doses, then thiamine 100mg po bd for 2 weeks)
1. Paracetamol is safe in the conventional doses (NB NSAIDS are contra-indicated)
2. Opioids may be used, but may precipitate encephalopathy (less likely with dihydrocodeine than codeine phosphate). Remember that opioids may accumulate even when given at traditional doses
Referral to Hepatology team
All patients with decompensated liver disease should be referred to the hepatology team. They should also be referred if they have:
1. Organ failure in addition to liver disease
2. Hepatocellular carcinoma
3. Variceal haemorrhage
4. Massive ascites and are likely to need total paracentesis
5. Recent-onset encephalopathy (<12 weeks of onset of jaundice)
5. Incipient renal failure
6. Alcoholic hepatitis