Red Flags
- Variceal haemorrhage (haematemesis, melaena) — admit; antibiotic prophylaxis (ceftriaxone), terlipressin/octreotide, urgent endoscopic band ligation; transfuse to Hb 70–80 g/L[1]
- Hepatic encephalopathy (asterixis, confusion, coma) — identify precipitant (infection, GI bleed, sedative, electrolytes); lactulose, rifaximin; admit if severe[1]
- Spontaneous bacterial peritonitis (ascites + fever, abdominal pain, encephalopathy) — diagnostic paracentesis (PMN ≥250/mm³); IV cefotaxime; albumin 1.5 g/kg day 1, 1 g/kg day 3[1]
- Hepatocellular carcinoma on surveillance imaging — multiphasic CT/MRI; multidisciplinary HBC meeting; treatment per BCLC stage[1]
First-line treatment
Interventions
- Aetiology-targeted treatment[1]HBV: nucleos(t)ide analogue. HCV: DAA cure. Alcohol: cessation, structured support. MASH: weight loss, resmetirom, GLP-1 RA. Autoimmune hepatitis: corticosteroids ± azathioprine. PBC: ursodeoxycholic acid
- Variceal bleeding prevention[1]Small varices with high-risk features or any large varices: non-selective beta-blocker (carvedilol or propranolol) or endoscopic band ligation. Decompensated cirrhosis with high-risk varices: combine band ligation + carvedilol
- Ascites management[1]Sodium <2 g/day; spironolactone 100 mg ± furosemide 40 mg PO daily, titrate up to 400 mg + 160 mg max; large-volume paracentesis with albumin replacement (8 g/L removed) for tense or refractory ascites; TIPS for refractory in selected patients
- Hepatic encephalopathy prevention[1]Lactulose to 2–3 soft stools/day; rifaximin 550 mg BD as add-on for recurrent HE; identify and treat precipitants; avoid benzodiazepines and sedating antiemetics
- Nutrition and frailty[1]25–35 kcal/kg/day, 1.0–1.5 g/kg/day protein; late-evening snack; sarcopenia screening; consider BCAA in protein-energy malnutrition; physiotherapy
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Carvedilol or propranolol (variceal prophylaxis)[1] | Non-selective beta-blocker | Carvedilol 6.25 mg PO daily start, titrate to 12.5 mg/day; propranolol 20 mg PO BD start, titrate to maximum tolerated to HR 55–60 | — | Primary and secondary variceal prophylaxis; carvedilol preferred per AASLD 2024 — additional alpha-1 antagonism reduces portal pressure more; hold for SBP <90 or refractory ascites with hyponatraemia |
| Spironolactone ± furosemide (ascites)[1] | Mineralocorticoid receptor antagonist + loop diuretic | Spironolactone 100 mg PO daily start, titrate every 3–5 days to 400 mg max; combine with furosemide 40 mg PO daily, titrate to 160 mg max — keep 100:40 ratio | — | Standard combination; monitor sodium, potassium, creatinine; gynaecomastia from spironolactone — consider eplerenone or amiloride |
| Lactulose[1] | Non-absorbable disaccharide laxative | 30–45 mL PO TDS-QDS titrated to 2–3 soft stools/day | — | First-line for hepatic encephalopathy; reduces gut ammonia; hypokalaemia and dehydration with overdose; rectal route in obtunded patients (300 mL in 700 mL water) |
| Rifaximin[1] | Non-absorbable rifamycin antibiotic | 550 mg PO BD | — | Add-on to lactulose for recurrent HE; reduces hospital admission; minimal systemic absorption; expensive |
| Ceftriaxone (SBP / variceal bleed prophylaxis)[1] | Third-generation cephalosporin | 1–2 g IV daily × 5–7 days | — | Empirical for SBP and prophylactic in variceal bleed; switch to oral norfloxacin after stabilisation; SBP recurrence prevention with daily norfloxacin |
| Terlipressin (acute variceal bleed)[1] | Synthetic vasopressin analogue | 2 mg IV every 4 h × 24 h then 1 mg every 4 h × 2–5 days | — | Reduces splanchnic blood flow and portal pressure; alternative octreotide 50 µg IV bolus then 50 µg/h infusion; cardiac monitoring (myocardial ischaemia) |
Carvedilol or propranolol (variceal prophylaxis)[1]
Non-selective beta-blocker
- Adult
- Carvedilol 6.25 mg PO daily start, titrate to 12.5 mg/day; propranolol 20 mg PO BD start, titrate to maximum tolerated to HR 55–60
- Paediatric
- —
Primary and secondary variceal prophylaxis; carvedilol preferred per AASLD 2024 — additional alpha-1 antagonism reduces portal pressure more; hold for SBP <90 or refractory ascites with hyponatraemia
Spironolactone ± furosemide (ascites)[1]
Mineralocorticoid receptor antagonist + loop diuretic
- Adult
- Spironolactone 100 mg PO daily start, titrate every 3–5 days to 400 mg max; combine with furosemide 40 mg PO daily, titrate to 160 mg max — keep 100:40 ratio
- Paediatric
- —
Standard combination; monitor sodium, potassium, creatinine; gynaecomastia from spironolactone — consider eplerenone or amiloride
Lactulose[1]
Non-absorbable disaccharide laxative
- Adult
- 30–45 mL PO TDS-QDS titrated to 2–3 soft stools/day
- Paediatric
- —
First-line for hepatic encephalopathy; reduces gut ammonia; hypokalaemia and dehydration with overdose; rectal route in obtunded patients (300 mL in 700 mL water)
Rifaximin[1]
Non-absorbable rifamycin antibiotic
- Adult
- 550 mg PO BD
- Paediatric
- —
Add-on to lactulose for recurrent HE; reduces hospital admission; minimal systemic absorption; expensive
Ceftriaxone (SBP / variceal bleed prophylaxis)[1]
Third-generation cephalosporin
- Adult
- 1–2 g IV daily × 5–7 days
- Paediatric
- —
Empirical for SBP and prophylactic in variceal bleed; switch to oral norfloxacin after stabilisation; SBP recurrence prevention with daily norfloxacin
Terlipressin (acute variceal bleed)[1]
Synthetic vasopressin analogue
- Adult
- 2 mg IV every 4 h × 24 h then 1 mg every 4 h × 2–5 days
- Paediatric
- —
Reduces splanchnic blood flow and portal pressure; alternative octreotide 50 µg IV bolus then 50 µg/h infusion; cardiac monitoring (myocardial ischaemia)
Safety-net
- Avoid alcohol completely once diagnosed with cirrhosis — even small amounts accelerate decompensation[1]
- Vomiting blood, black stools, confusion, fever, sudden weight gain, increasing abdominal swelling, or yellowing eyes — same-day medical review (decompensation)[1]
- Avoid NSAIDs (ibuprofen, diclofenac), tramadol, and herbal preparations — they can precipitate kidney injury and encephalopathy[1]
Referral criteria
- Compensated cirrhosis with deteriorating function (rising MELD, new ascites, jaundice)Hepatology[1]
- Decompensated cirrhosis (ascites, encephalopathy, variceal bleed, jaundice)Hepatology and transplant centre — early transplant evaluation if eligible[1]
- Suspected hepatocellular carcinoma on imagingHepatobiliary multidisciplinary meeting[1]
- Acute-on-chronic liver failureTertiary hepatology / liver intensive care[1]
Clinical summary
Diagnosis, complications surveillance, and aetiology-driven management of compensated and decompensated liver cirrhosis in adults.