Jaundice- Decompensated liver disease

42M presents with a 3/7 history of gradual worsening lethargy and confusion. Lives with partner. No other known comorbidities, but the partner says that the patient drinks a bottle of whiskey daily.

On examination, he appears unwell. His observations are blood pressure 92/62, heart rate 102 beats per minute, temperature 38.2, RR 21/min, Sats 95% (air). He appears jaundiced with palmar erythema, numerous spider naevi across his chest and shoulders. On extension of his arms, he appears to have a flap. He has bilateral pitting pedal oedema to his shins. His abdomen is distended but soft with an everted umbilicus. There is shifting dullness on percussion. His bowel sounds are normal.

PR examination reveals a malaena. Chest and CVS: NAD. CNS: drowsy but responsive. Not oriented to time/place/person. No focal deficit.

His bloods are significant for a hemoglobin of 80 (baseline 110 checked 3/12 ago), urea of 30.6 (baseline around 4), Cr 132, GFR 30, Na 122, K 3.6, Albumin 29, AST 47, ALT 24, ALP 133, Bilirubin 70, WCC 12.2, Plts 78, INR 1.4, CRP 63.

Impression:

Decompensated ALD cirrhosis. Causes of decompensation – ongoing alcohol use, possible variceal bleed, possible infection (SBP).

Management:

1. Critically unwell patient needs A to E assessment. Particularly paying attention to airway – variceal bleeds frequently have haematemesis and may need consideration of intubation to protect their airway. Circulation – these patients are frequently haemodynamically unstable and need aggressive fluid resuscitation with crystalloid, blood, and blood products. Consider activation of the major haemorrhage protocol if patients actively bleeding and hypotensive. Avoid overtransfusion as this can raise portal pressures and precipitate worsening bleeding.
2. Definitive management with terlipressin 2mg stat, and then QDS.
3. High risk of bacterial infections. Broad-spectrum antibiotics for variceal bleed are recommended, based on local guidance.
4. Initiation of the decompensated cirrhosis bundle. Tap ascites, correct coagulopathy, and perform a full sepsis screen.
5. Once stabilized, consult endoscopist. These patients benefit from endoscopy sooner rather than later. Out of hours, this is done in theatres with airway protection, possibly requiring input from ITU/anaesthetics/theatres.
6. Catheterize and monitor urine output. If bleeding is controlled and patient is adequately pre-filled, renal function should improve. Consider imaging of the urinary tract. If no improvement, consider hepatorenal syndrome and treat with albumin and terlipressin (longer periods of time than for bleeds).
7. Stop aldosterone antagonists. This is due to bleeding and hyponatremia.
8. Beta blockers. These can be stopped on a case-by-case basis, particularly in severe bleeds.
9. For refractory bleeds, consider IR and salvage TIPSS.