GastroenterologyTier 2Topic

Management of chronic liver disease complications, such as ascites, coagulopathy, and encephalopathy

Complications and their drivers

Complications of cirrhosis flow from two things: portal hypertension and loss of hepatocyte function

Complication	Driven by
Varices / portal hypertensive bleeding	Portal HTN
Ascites, hydrothorax	Portal HTN + splanchnic vasodilatation + Na retention
SBP	Ascites + bacterial translocation
Hepatorenal syndrome	Extreme splanchnic vasodilatation -> renal vasoconstriction
Hepatic encephalopathy	Portosystemic shunting + loss of function
Coagulopathy	Loss of function (rebalanced, not one-way)
Hyponatraemia	Non-osmotic ADH release
HCC	Chronic injury + regeneration

First decompensation drops median survival from >12 years to ~2 years - the trigger for transplant referral
Recompensation (Baveno) is now a recognised endpoint: remove the aetiology + resolution of ascites/HE off drugs + stable improvement in liver function

Epidemiology

The haemodynamic cascade - one mechanism explains most of it

Hepatic encephalopathy - mechanism

Coagulopathy - rebalanced haemostasis

Ascites - paracentesis on every new or deteriorating ascites

SBP - diagnosis

Hepatic encephalopathy - clinical, by exclusion

Hepatorenal syndrome (HRS-AKI)

Variceal screening

1. Ascites

2. SBP

3. Hepatic encephalopathy

4. Hepatorenal syndrome

5. Varices and portal hypertensive bleeding

6. TIPS

7. Coagulopathy

Other complications

Prognosis

What changes the trajectory

Monitor

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