Recognition and organ-support of decompensated cirrhosis and acute-on-chronic liver failure, including bleeding, infection, encephalopathy and transplant triage
Decompensation includes ascites, variceal hemorrhage, hepatic encephalopathy and infection. ACLF adds acute deterioration with extrahepatic organ failure and high short-term mortality; actively search for precipitating infection, bleeding, alcohol-associated hepatitis, drug injury, thrombosis and ischemia.
Resuscitate with a restrictive transfusion strategy in most patients, start vasoactive therapy such as octreotide or terlipressin where appropriate, give short-course antibiotic prophylaxis, and arrange urgent endoscopy. Consider early/pre-emptive TIPS in selected high-risk patients after specialist assessment.
ACLF prognosis depends on number and trajectory of organ failures. Early hepatology/transplant-center involvement is essential; prognostic scores support but do not replace dynamic clinical assessment and transplant candidacy evaluation.
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