🩸 Cirrhotic patients may remain compensated for years, but an acute insult in the setting of advanced fibrosis and reduced hepatic reserve can trigger Acute on Chronic Liver Failure (ACLF).
⚠️ Short-term mortality can reach 50–90%.
| Category |
Examples |
Mechanism |
| Gastrointestinal Bleeding 💉 |
Oesophageal/gastric varices, peptic ulcer bleed |
Hypovolaemia + increased nitrogen load → encephalopathy + haemodynamic instability |
| Infection 🌡️ |
Spontaneous bacterial peritonitis (SBP), pneumonia, urinary tract infection, sepsis |
Systemic inflammation triggers multi-organ dysfunction; worsens encephalopathy |
| Alcohol 🍺 |
Binge drinking or continued excess intake |
Direct hepatotoxicity, inflammatory response, worsening portal hypertension |
| Drugs & Toxins 💊 |
NSAIDs, paracetamol overdose, antibiotics, herbal remedies |
Direct hepatic injury or renal impairment → precipitating decompensation |
| Metabolic / Electrolytes ⚡ |
Hypokalaemia, hyponatraemia, dehydration |
Triggers encephalopathy and renal dysfunction |
| Surgery / Trauma 🔪 |
Major abdominal surgery, trauma, anaesthesia |
Increased metabolic stress, bleeding risk, infection |
| Thrombosis 🩸 |
Portal vein thrombosis, hepatic vein thrombosis (Budd–Chiari) |
Worsens portal hypertension and liver congestion |
| Malignancy 🎗️ |
Hepatocellular carcinoma, metastatic disease |
Direct hepatic dysfunction and portal invasion |
Most patients with cirrhosis are compensated until an acute event tips them into decompensation.
Always actively search for a precipitanttransplant referral in patients with recurrent or severe decompensation.
| Problem | Management |
|---|
| Airway/Breathing | O₂, avoid hypoxaemia, consider ICU if low GCS |
| Circulation | IV access, fluids (avoid overload), monitor BP, treat sepsis early |
| Encephalopathy | Lactulose (30 ml TDS → 2–3 stools/day), phosphate enemas if unable to swallow |
| Sepsis | Blood/urine/ascitic cultures, start broad-spectrum IV antibiotics if suspected |
| SBP | Ascitic tap: if WBC >250/µL → Cefotaxime/Ceftriaxone; give albumin |
| Ascites | Salt restriction, spironolactone ± furosemide; paracentesis with IV albumin if tense |
| Electrolytes | Correct Na, K, Mg, PO₄; avoid overly rapid correction |
| Nutrition | High-calorie, high-protein diet unless encephalopathy severe; Pabrinex in alcoholics |
| Hepatorenal Syndrome | Albumin + Terlipressin if suitable, seek transplant opinion |
| Definitive | Liver transplant evaluation early in ACLF |
