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Cirrhosis & Complications

End-stage hepatic fibrosis with portal hypertension and synthetic dysfunction causing ascites, SBP, variceal bleeding, hepatic encephalopathy, and hepatorenal syndrome

Review date
reviewed 2026-05-04
Reading time
10 min read
Author
Dr Kola Tytler MBBS CertHE MBA MSt MRCGP
Gastroenterology & Hepatologycommonlong-term-condition
On this page
Condition details
Gastroenterology & Hepatology
common
10 min read
reviewed 2026-05-04
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About This Page

This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.

Key points

  • Cirrhosis causes portal hypertension and impaired synthetic function
  • Decompensation events: ascites, variceal hemorrhage, encephalopathy, jaundice, SBP, HRS
  • New ascites requires diagnostic paracentesis; SBP = ascitic PMN >=250 cells/mm3
  • Variceal bleeding: octreotide + ceftriaxone + urgent endoscopic band ligation
  • Encephalopathy: lactulose first-line, add rifaximin for recurrence

Overview

Cirrhosis is the final common pathway of chronic liver injury from alcohol, viral hepatitis, MASLD/MASH, autoimmune, cholestatic, metabolic, or vascular disease. Portal hypertension causes varices, splenomegaly, thrombocytopenia, ascites, and hepatorenal physiology.

Epidemiology

Major US etiologies include MASLD/MASH, alcohol-associated liver disease, chronic HCV, chronic HBV, and autoimmune/cholestatic disease. Ascites is the most common first decompensating event. Decompensation should trigger transplant evaluation unless contraindicated.

Clinical Features

Symptoms
Fatigue, anorexia, pruritus
Increasing abdominal girth and early satiety
Hematemesis or melena from variceal bleeding
Confusion, sleep-wake reversal, asterixis
Fever or abdominal pain in ascites suggests SBP
Oliguria or rising creatinine suggests HRS
Signs
Jaundice, spider angiomas, palmar erythema, gynecomastia
Ascites with shifting dullness
Splenomegaly and thrombocytopenia
Asterixis or altered mental status
Hypotension, renal dysfunction, or sepsis signs

Investigations

First-line
CBC, CMP, INR, albumin, bilirubin, creatinine, sodiumAssess synthetic function and MELD-Na
Diagnostic paracentesisAll new ascites and any hospitalized cirrhotic with ascites
Ultrasound with DopplerNodular liver, ascites, portal vein thrombosis, hepatic mass screen
Second-line
EGDScreen for esophageal/gastric varices at diagnosis
SAAG>=1.1 suggests portal hypertension
AmmoniaNot required to diagnose encephalopathy
Specialist
HCC surveillanceUltrasound with or without AFP every 6 months
Transplant evaluationDecompensated cirrhosis, elevated MELD-Na, recurrent complications

Management

AASLD Guidance for Ascites, SBP, and Cirrhosis Complications
1
Ascites
  • Sodium restriction, spironolactone plus furosemide
  • Large-volume paracentesis for tense ascites; give albumin when >5 L removed
  • Avoid NSAIDs and nephrotoxins; consider TIPS for refractory ascites
2
SBP
  • Treat PMN >=250 with IV cefotaxime or ceftriaxone
  • Give albumin in high-risk SBP to reduce renal failure
  • Secondary prophylaxis after SBP
3
Varices/encephalopathy/HRS
  • Primary variceal prophylaxis with nonselective beta-blocker or band ligation
  • Acute variceal bleed: octreotide, ceftriaxone, restrictive transfusion, band ligation
  • Lactulose to 2-3 soft stools/day; add rifaximin for recurrence
  • HRS-AKI: stop nephrotoxins, albumin, vasoconstrictor therapy, transplant evaluation

Complications

  • Ascites and SBP: Common decompensating events.
  • Variceal hemorrhage: Life-threatening portal hypertension complication.
  • Hepatic encephalopathy: Triggered by infection, GI bleed, constipation, sedatives, dehydration.
  • Hepatorenal syndrome: Functional renal failure with poor prognosis.
  • HCC: Requires surveillance every 6 months.
USMLE Step 2 CK Exam Tips
  • 1New ascites = diagnostic paracentesis
  • 2SBP diagnosis is PMN >=250 even if culture negative
  • 3Cirrhosis + GI bleed = ceftriaxone prophylaxis
  • 4Encephalopathy triggers: infection, GI bleed, constipation, dehydration, sedatives, hypokalemia
  • 5Lactulose target is 2-3 soft stools/day
  • 6Nonselective beta-blockers prevent variceal bleeding
  • 7Do not correct INR in stable cirrhosis just because INR is elevated

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Verified Sources & References

AASLD Guidance: Ascites, SBP, and Hepatorenal Syndrome
AASLD Practice Guidance: HCC 2023
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