Cirrhosis · House

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.

References

1.AASLD Practice Guidance on Cirrhosis (2024); JSGE Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis (2020) (2024)