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Complications of cirrhosis: ascites, SBP, varices and encephalopathy
Almost every complication of cirrhosis comes from portal hypertension or loss of liver function, and each has one "must-do" step: a diagnostic tap for new ascites or on admission, antibiotics and albumin for SBP, vasoactive therapy and endoscopy for variceal bleeding, and lactulose for encephalopathy.
Why it matters in the exam
Cirrhosis questions are usually "next step" questions. In a cirrhotic patient admitted for any reason with ascites, a diagnostic tap is done: more than 250 neutrophils per mm³ = SBP, even without fever or abdominal pain. To find the source of ascites the SAAG is calculated: above 1.1 g/dL points to portal hypertension. In variceal bleeding the order is: resuscitation with restrictive transfusion (haemoglobin target 7–8 g/dL), octreotide or terlipressin to reduce portal pressure, ceftriaxone as prophylaxis and endoscopy with banding within 12 hours.
Further questions deal with the treatment of ascites (spironolactone and furosemide in a ratio of 100 to 40, sodium restriction, avoidance of NSAIDs), with albumin after a tap of more than 5 litres, and with encephalopathy — finding the trigger (infection, bleeding, constipation, hypokalaemia, sedatives) and giving lactulose, with rifaximin to prevent recurrence. Hepatorenal syndrome (HRS-AKI) is diagnosed when creatinine rises and does not improve after stopping diuretics and giving albumin, and is treated with terlipressin plus albumin. Every cirrhotic patient has surveillance for HCC with ultrasound every 6 months.
Key points
- Ascites: SAAG 1.1 g/dL or more = portal; spironolactone + furosemide in a 100 to 40 ratio.
- SBP: neutrophils 250 or more; ceftriaxone and albumin.
- Variceal bleeding: vasoactive drug, ceftriaxone, banding within 12 hours, Hb target 7–8 g/dL.
- Encephalopathy: trigger and lactulose; rifaximin for prevention.
- HRS-AKI: terlipressin and albumin; ultrasound for HCC every 6 months.
Summary table
| Complication | Diagnosis / threshold | Treatment | Exam note |
|---|---|---|---|
| Ascites | SAAG 1.1 g/dL or more = portal | Sodium restriction, spironolactone 100 mg + furosemide 40 mg | Tap above 5 litres → albumin 6–8 g per litre |
| SBP | Neutrophils 250 per mm³ or more in the fluid | Ceftriaxone or cefotaxime + albumin (1.5 g/kg first day, 1 g/kg third day) | Secondary prophylaxis with an antibiotic |
| Variceal bleeding | Haematemesis in a cirrhotic patient | Octreotide or terlipressin, ceftriaxone, banding within 12 hours | Restrictive transfusion: Hb target 7–8 g/dL |
| Preventing a first bleed | Large varices | Non-selective beta-blocker (carvedilol) or banding | Carvedilol preferred; per Baveno VII it also reduces decompensation |
| Encephalopathy | Confusion, asterixis | Trigger + lactulose; rifaximin for prevention | Ammonia is not needed for the diagnosis |
| HRS-AKI | Creatinine rising, no response to albumin 1 g/kg for two days | Terlipressin + albumin | Stop diuretics and nephrotoxic drugs |
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Sources
- AASLD Practice Guidance: Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome, 2021 — Ascites, SBP and HRS-AKI
- Baveno VII — Renewing consensus in portal hypertension, 2022 — Prevention and treatment of variceal bleeding
- Harrison's Principles of Internal Medicine, 21st edition (2022) — Cirrhosis and Its Complications
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.