Sr. Consultant, Liver Transplant, HPB & GI Surgery, Metro Heart Institute with Multispeciality, Faridabad
Part 5 of 10 in Diagnosis and Management of Liver Cirrhosis
Decompensated Cirrhosis: Ascites, Encephalopathy and Liver Failure
June 16, 2024
When a cirrhotic liver starts to fail, a defined set of complications emerges, and any one of them is a signal that a liver transplant should be considered.
Ascites, variceal bleeding and liver cancer
Fluid builds up in the abdomen (ascites) and the spleen enlarges. Bleeding varices in the food pipe can cause vomiting of blood or black stools. Patients with cirrhosis also carry a high risk of developing liver cancer. Around 5% of cirrhosis patients decompensate every year.
Encephalopathy and hepatorenal syndrome
Hepatic encephalopathy occurs when the failing liver can't clear toxins, which then affect the brain: the patient becomes confused, drowsy, talks nonsense, fails to recognise faces, or becomes irritable. Hepatorenal syndrome is when the kidneys are affected by the failing liver, seen as a rising serum creatinine. Refractory ascites, where fluid returns within days of being drained, has no long-term management besides transplant; in the interim, patients are managed with twice-weekly tapping and albumin.
This article is based on a Jivo Masterclass session conducted by Dr. Sandeep Jha, Consultant Liver Transplant, Manipal Hospital, New Delhi. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
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This guide is based on a live Jivo Masterclass: Dr. Sandeep Jha taught doctors across Africa on June 16, 2024.
FROM THE LIVE Q&A
Jivo Doctor Partner (name unclear from transcript)
How is the progression from fatty liver to cirrhosis diagnosed and managed?
Dr. Sandeep Jha
The first step is to determine whether cirrhosis has actually developed, using a fibroscan or, less often now, a liver biopsy. If the disease is only at the steatohepatitis stage (fatty liver inflammation with no fibrosis yet), controlling risk factors can make it fully resolve. If cirrhosis has already developed, the patient is kept under regular monitoring, since there is no way to predict when a cirrhotic liver will start to fail.
Frequently Asked Questions
What are the exam findings of cirrhosis, and when do they appear?▼
On examination, jaundice, ascites, leg oedema, spider angiomas, palmar erythema and gynaecomastia are the telltale signs of cirrhosis. Unfortunately, these are only seen in advanced cirrhosis. Since the goal is to catch cirrhosis before complications develop, an ultrasound or fibroscan done proactively is the better approach for early diagnosis.
What are the effective drugs for hepatitis B and C?▼
For hepatitis B, tenofovir and entecavir are very effective drugs with low resistance levels that can practically control the virus. For hepatitis C, directly-acting agents such as sofosbuvir and velpatasvir are very effective and can practically eliminate the virus from the body.
What is the donor's recovery timeline after living donor liver transplant?▼
The donor is admitted for about seven days. By the third or fourth day, the donor is walking around, eating, and relatively pain-free, and is discharged by day six or seven. A follow-up OPD visit happens on day 10; if doing fine, the donor can return to their home country and resume office and light household work, with the only restriction being on lifting heavy weights.
What is the recipient's recovery timeline after living donor liver transplant?▼
This depends on how sick the recipient was before surgery: a weaker, sicker patient takes longer to recover. The recipient typically stays in hospital for around 18 days, with discharges starting around day 12-13 and about 95% discharged by day 18. Complete recovery, meaning a return to normal muscle mass and full function, takes about two to three months. After 2-3 weeks of local follow-up near the hospital in India, the patient can return to their home country and continue follow-up from there.
What is the risk to the donor's life during liver donation?▼
The overall global success rate is 99.5%, meaning about 1 in 200 donors could lose their life during the liver donation process. This is a rare occurrence that donors must understand during counselling as part of a major surgery, though outcomes have become safer with growing surgical experience.
What are the major complications of decompensated cirrhosis?▼
Ascites, variceal bleeding, liver cancer, hepatic encephalopathy, and hepatorenal syndrome - any one of these signals the liver is failing and a transplant should be considered.
What is refractory ascites?▼
When fluid returns within days of being drained (tapped). It has no long-term management besides liver transplant; in the meantime, patients are managed with twice-weekly tapping and albumin.
In This Series: Diagnosis and Management of Liver Cirrhosis
- 1.Liver Cirrhosis
- 2.What Causes Liver Cirrhosis: Hepatitis, Alcohol and NAFLD
- 3.Diagnosing Cirrhosis Early: Fibroscan Before Symptoms Appear
- 4.MELD and Child-Pugh Scores: Grading Cirrhosis and Timing a Transplant
- 5.Decompensated Cirrhosis: Ascites, Encephalopathy and Liver Failure
- 6.Living Donor vs Deceased Donor Liver Transplant
- 7.Living Liver Donor Safety and Evaluation
- 8.Liver Transplant Recovery: Donor and Recipient Timelines
- 9.Hepatitis B and C: Treatment and Family Precautions
- 10.NAFLD and Metabolic Risk Factors: Diet and Lifestyle Management