What is the difference between decompensated cirrhosis and acute liver failure?

Decompensated cirrhosis is jaundice, ascites, encephalopathy or variceal bleeding in someone with established chronic liver disease. Acute liver failure, per EASL, is coagulopathy with an INR usually above 1.5 and hepatic encephalopathy in a patient without pre-existing liver disease, classified as hyperacute, acute or subacute by the interval from jaundice to encephalopathy.

What defines spontaneous bacterial peritonitis?

An ascitic fluid neutrophil count above 250 cells per cubic millimetre, or above 0.25 x 10^9/L. The bundle treats it with antibiotics per local guidelines and 1.5 g/kg of 20% human albumin solution.

What is the terlipressin regimen for a variceal bleed?

2 mg intravenously stat followed by 2 mg four times daily, if there are no contraindications such as a creatinine of 442 micromol/L or above, septic shock, pregnancy or acute respiratory distress. Octreotide 50 micrograms then 25 to 50 micrograms per hour is the alternative, and beta-blockers are suspended.

What haemoglobin do you aim for in a variceal bleed?

70 to 80 g/L, rising to above 80 g/L only in massive bleeding. Routine correction of INR or APTT with blood products is not recommended unless the patient is on anticoagulants.

How is hepatic encephalopathy treated in the first hours?

Lactulose 20 to 30 mL four times daily or a phosphate enema, a search for the precipitant such as infection, bleeding or constipation, and a CT head if there is any clinical concern about a subdural haematoma.

When does acute liver failure go to a transplant unit?

EASL advises transfer to a specialised unit early if INR is above 1.5 with the onset of encephalopathy or other poor prognostic features, and early discussion with a transplant unit even if transfer is not yet needed. Its referral criteria include arterial pH below 7.30, INR above 3.0 on day 2 for paracetamol cases or above 1.8 for non-paracetamol cases, renal impairment, hypoglycaemia and rising lactate.

Is N-acetylcysteine only for paracetamol?

No. EASL recommends N-acetylcysteine early in acute liver failure even in non-paracetamol cases, where it improved outcomes in adults with mild encephalopathy, and advises limiting it to a maximum of 5 days.

Liver Failure — IMT Interview Clinical Station Answer

A liver scenario at the IMT (Internal Medicine Training) clinical station is answered by first deciding which of two diseases you are treating. Decompensated cirrhosis is jaundice, ascites, hepatic encephalopathy or suspected variceal bleeding in someone with chronic liver disease, and is run through the BSG/BASL care bundle. Acute liver failure, as the EASL guideline defines it, is coagulopathy with an INR usually above 1.5 plus encephalopathy in a patient with no pre-existing liver disease, and belongs in a conversation with a transplant unit from the first hour.

Key takeaways

The BSG/BASL bundle (version 2.0, 2025) covers the first 6 hours: bloods including lactate and glucose, a septic screen, an ascitic tap in everyone with clinical ascites irrespective of clotting, ultrasound with Doppler, VTE prophylaxis unless platelets are below 50 or there is bleeding, and early GI or liver review.
Spontaneous bacterial peritonitis is an ascitic neutrophil count above 250 per cubic millimetre, treated with antibiotics and 1.5 g/kg of 20% human albumin solution.
Acute kidney injury in cirrhosis means suspending diuretics and nephrotoxics, crystalloid in 250 mL boluses, strict urine output, and senior review with critical care in mind at 6 hours if deteriorating.
Suspected variceal bleeding gets terlipressin 2 mg IV stat then 2 mg four times daily, prophylactic antibiotics, and a haemoglobin target of 70 to 80 g/L; INR is not routinely corrected.
Hepatic encephalopathy gets lactulose 20 to 30 mL four times daily or a phosphate enema, and a CT head if there is any concern about a subdural.
EASL says transfer to a specialist unit early if INR is above 1.5 with any encephalopathy or other poor prognostic features, and discuss with a transplant unit even before transfer is needed.

How do you recognise decompensation and acute liver failure?

Decompensated cirrhosis is recognised by any of jaundice, ascites, hepatic encephalopathy or suspected variceal haemorrhage, which the BSG/BASL bundle lists as the four presentations of acute decompensation. According to the bundle's authors, in-hospital mortality is 10 to 20 per cent.

Acute liver failure is recognised differently: a previously well patient, often after paracetamol, with jaundice, an INR above 1.5 and any change in mental state. EASL classifies it by the interval from jaundice to encephalopathy: hyperacute within 7 days, acute at 8 to 28 days, subacute at 5 to 12 weeks. Say which one you are looking at, because it changes the prognosis and the urgency.

What does the A to E assessment and first hour look like?

The first hour of a decompensated cirrhosis scenario is an A to E assessment and the bundle started in parallel, because the bundle is written to be completed within 6 hours of arrival. Airway protection matters early in encephalopathy and in a large variceal bleed.

Bloods: full blood count, liver function, urea and electrolytes, clotting, calcium, phosphate, magnesium, CRP, lactate and glucose
Septic screen: chest X-ray, urine dipstick and blood cultures
Clinical ascites: a diagnostic tap with a green needle, irrespective of clotting, sent for cell count, culture in blood culture bottles, protein and albumin
Ultrasound of the abdomen with Doppler of the hepatic and portal veins
VTE prophylaxis unless platelets are below 50 or there is active bleeding, a dietetic referral, and early referral to the GI or liver team
Ongoing alcohol intake: intravenous Pabrinex or thiamine, a CIWA or GMAWS score, and monitoring for refeeding

Which investigations decide the pathway?

The investigation that decides the pathway in decompensated cirrhosis is the ascitic tap: a neutrophil count above 250 per cubic millimetre, or above 0.25 x 10^9/L, is spontaneous bacterial peritonitis. In acute liver failure the deciding tests are the INR, arterial pH, lactate, creatinine, glucose and a paracetamol level.

That said, say the tap is done irrespective of clotting results. The bundle prints that word in capitals because the commonest error is waiting for an INR before a diagnostic aspiration that carries almost no bleeding risk.

What are the thresholds and criteria you must say?

The thresholds in decompensated cirrhosis are the ascitic neutrophil count of 250, the albumin dose of 1.5 g/kg of 20% solution in spontaneous bacterial peritonitis, the KDIGO definition of acute kidney injury, and the transfusion target of 70 to 80 g/L in a variceal bleed. The thresholds in acute liver failure are EASL's referral criteria.

EASL, paracetamol or hyperacute: arterial pH below 7.30 or bicarbonate below 18, INR above 3.0 on day 2 or above 4.0 thereafter, oliguria or raised creatinine, altered consciousness, hypoglycaemia, or a lactate that does not fall with fluid
EASL, non-paracetamol: pH below 7.30 or bicarbonate below 18, INR above 1.8, oliguria or renal failure or sodium below 130 mmol/L, encephalopathy, hypoglycaemia or metabolic acidosis, bilirubin above 300 micromol/L, or a shrinking liver
KDIGO in the bundle: creatinine rise of 26 micromol/L or more within 48 hours, a 50 per cent rise over 7 days, urine output below 0.5 mL/kg/hour for more than 6 hours, or clinical dehydration

What is the definitive management?

Definitive management of decompensated cirrhosis is the bundle's complication-specific arms: albumin and antibiotics for spontaneous bacterial peritonitis, fluid and drug review for acute kidney injury, terlipressin, antibiotics and endoscopy for a variceal bleed, and lactulose for encephalopathy. Definitive management of acute liver failure is N-acetylcysteine, intensive care and, where indicated, transplantation.

The four bundle arms

Spontaneous bacterial peritonitis: antibiotics per hospital guidelines and 1.5 g/kg of 20% human albumin solution
Acute kidney injury: suspend all diuretics and nephrotoxic drugs, crystalloid in 250 mL boluses, strict urine output monitoring, senior review at 6 hours and consider ITU or HDU if deteriorating
Suspected variceal bleed: terlipressin 2 mg IV stat then 2 mg four times daily if no contraindication such as a creatinine of 442 micromol/L or above, septic shock or acute respiratory distress; octreotide 50 micrograms then 25 to 50 micrograms per hour as the alternative; prophylactic antibiotics; suspend beta-blockers; target haemoglobin 70 to 80 g/L, above 80 if massive; do not routinely correct INR
Hepatic encephalopathy: lactulose 20 to 30 mL four times daily or a phosphate enema, and a CT head if there is clinical concern about a subdural haematoma

Acute liver failure

In acute liver failure, EASL recommends N-acetylcysteine early, even in non-paracetamol cases, limited to a maximum of 5 days; avoiding sedatives and hepatotoxic or nephrotoxic drugs; glucose infusions to prevent hypoglycaemia; and restricting clotting factors unless there is active bleeding, because correcting the INR removes your prognostic marker.

When and to whom do you escalate?

Escalate decompensated cirrhosis to the GI or liver team at the earliest opportunity, to the GI bleed team for varices, and to critical care for a patient whose kidney injury is worsening at 6 hours or who cannot protect their airway. Escalate acute liver failure to a specialist unit as soon as INR exceeds 1.5 with any encephalopathy, hypoglycaemia or metabolic acidosis, with critical care involved before transfer.

EASL adds one sentence worth quoting: the finding of contraindications to transplant should not preclude transfer to a tertiary unit. Do not decide that for them on the ward.

How do you hand over a liver patient in one minute?

The decompensated cirrhosis handover names the bundle arms opened. Situation: a 58 year old with alcohol-related cirrhosis, jaundiced and drowsy, haematemesis this morning. Background: known varices, still drinking. Assessment: suspected variceal bleed with grade 2 encephalopathy, haemoglobin 74 g/L, creatinine 160 and rising, ascitic tap sent. Recommendation: terlipressin and antibiotics given, endoscopy requested, lactulose charted, diuretics stopped, 250 mL boluses with hourly urine output, Pabrinex given; please review urine output at 6 hours and involve critical care if he is worse.

What does the panel listen for in a liver answer?

The panel listens for the distinction between decompensated cirrhosis and acute liver failure, the ascitic tap irrespective of clotting, terlipressin and antibiotics before endoscopy, stopping the diuretics, and the phrase 'transplant unit' said early in acute liver failure. In practice they also mark whether you ask about alcohol and prescribe thiamine unprompted. The internalmedicineinterview bank, 361 questions with AI-marked spoken practice, is built to make the bundle arms a reflex.

What are the common mistakes in a liver station?

Waiting for clotting results before the ascitic tap
Giving fresh frozen plasma to correct a stable INR, which the bundle advises against and which raises portal pressure
Continuing spironolactone and furosemide in a patient with rising creatinine
Over-transfusing a variceal bleed above 80 g/L
Sedating an encephalopathic patient, or treating acute liver failure as cirrhosis and never calling the transplant unit

How this comes up at the IMT interview

Liver failure maps onto the IMT clinical station as a structure test. Investigations and diagnosis is the tap, the INR and the split between decompensation and acute liver failure; management is the four bundle arms or the EASL referral criteria; communication is the alcohol conversation and the ceiling-of-care discussion with a patient who may not be a transplant candidate. The handover minute is scored on naming what has been given, what has been stopped, and when the next review is due.

Acute Liver Failure and Decompensated Cirrhosis: The BSG/BASL Six-Hour Bundle and When to Call the Transplant Unit