Ascites
Diagnostic paracentesis on every new ascites. Calculate the serum–ascites albumin gradient:
- SAAG ≥ 11 g/L → portal hypertension (cirrhosis, heart failure, Budd–Chiari)
- SAAG < 11 g/L → not portal hypertension (peritoneal malignancy, tuberculosis, pancreatic, nephrotic)
Management: sodium restriction (about 2 g/day) plus spironolactone with furosemide, conventionally in a 100:40 ratio. Fluid restriction only for sodium below about 125 mmol/L. Large-volume paracentesis for tense ascites, with albumin replacement when more than 5 L is removed.
Spontaneous bacterial peritonitis
Ascitic neutrophil count ≥ 250 cells/mm³. You do not wait for the culture.
- Cefotaxime or ceftriaxone
- IV albumin on day 1 and day 3 — this reduces hepatorenal syndrome and mortality, and is the step candidates omit
- Secondary prophylaxis afterwards with norfloxacin or co-trimoxazole, lifelong or until transplant
- Avoid beta-blockers during an episode
Suspect it in any decompensation without an obvious cause: new encephalopathy, worsening renal function, or simply feeling unwell.
Hepatic encephalopathy
A clinical diagnosis. Ammonia levels do not correlate well and are not needed to diagnose or to follow it.
- Lactulose — titrated to 2–3 soft stools a day
- Rifaximin added for recurrence
- Find the precipitant: GI bleeding, infection, constipation, dehydration, electrolyte disturbance, sedatives, non-adherence, TIPS
Varices
- Screening endoscopy at diagnosis of cirrhosis
- Primary prophylaxis for medium/large varices: non-selective beta-blocker (propranolol, nadolol, or carvedilol) or band ligation — not both
- Secondary prophylaxis after a bleed: beta-blocker and band ligation
Hepatorenal syndrome
Functional renal failure in advanced liver disease, diagnosed after excluding everything else: no shock, no nephrotoxins, no improvement after withdrawing diuretics and giving albumin 1 g/kg for 2 days, and a bland urinary sediment with very low urinary sodium.
Treatment is terlipressin (or octreotide plus midodrine) with albumin, and liver transplantation is the only definitive answer.
Surveillance and the bigger picture
- Hepatocellular carcinoma: ultrasound every 6 months, with or without AFP
- Vaccinate against hepatitis A and B, influenza and pneumococcus
- Avoid NSAIDs entirely — they precipitate renal failure and bleeding
- Refer for transplant assessment early; MELD-Na drives allocation
- Alcohol cessation changes the trajectory at any stage