ICU Decoded › Library › Ward Pathways › Gastroenterology › Decompensated Cirrhosis (Ascites, SBP, Encephalopathy)Decompensated Cirrhosis (Ascites, SBP, Encephalopathy)Emergency
Gastroenterology · Ward Pathways · Locked — free with a referral
By Dr Javed Akhtar · Last reviewed 2 October 2026
Presentation Alcohol-related cirrhosis; tense ascites, fever 38.2 °C, drowsy with asterixis; creatinine 1.9 mg/dL (baseline 0.9), Na⁺ 128
Red flags Grade 3–4 encephalopathy Fever or abdominal pain (SBP) Rising creatinine GI bleeding Na⁺ <125 Differential diagnosis Secondary bacterial peritonitis (perforation — multiple organisms, very high neutrophils) Alcoholic hepatitis Portal vein thrombosis HCC Other causes of confusion (hypoglycaemia, subdural, Wernicke) When to admit, call ICU or discharge Admit: SBP, encephalopathy grade ≥2, AKI, GI bleed, tense ascites with symptoms, hyponatraemia <125ICU: Grade 3–4 HE, variceal bleed, septic shock, ACLFIntubate: Grade 3–4 HE with airway risk, massive haematemesisDialysis: Transplant candidates with refractory AKI; otherwise per goals of careKey points SBP can be silent — every admitted cirrhotic with ascites gets a diagnostic tap. Albumin with antibiotics in SBP halves renal failure and mortality. Terlipressin causes hypoxia and fluid overload — avoid if SpO₂ <90% or ACLF grade 3 (CONFIRM). India: alcohol, hepatitis B and C, and MASLD are the main causes — treat HBV (tenofovir/entecavir) and HCV (sofosbuvir-based) once stable. Never Give NSAIDs, aminoglycosides or IV contrast casually in cirrhosis Restrict protein in hepatic encephalopathy Continue diuretics during AKI or SBP Remove >5 L of ascites without albumin Use ammonia level to diagnose or grade encephalopathy Common mistakes No diagnostic tap Missing albumin in SBP Diuretics during AKI Protein restriction Sedatives for agitation Disposition and follow-up Ward/HDU; ICU for grade 3–4 HE, bleeding, shock. Hepatology follow-up; transplant referral when eligible.
Locked ABCDE first moves The step-by-step decision sequence Order set Monitoring timeline and escalation triggers Treatment doses and preparation Discharge package Open the full pathway in Ward Pathways
Free with a referral from any ICU Decoded member, or by applying with your medical registration. How access works .
← Acute Pancreatitis · Acute Kidney Injury — Prerenal →
More Gastroenterology pathways
Part of Gastroenterology in Ward Pathways — open the interactive version .