Cirrhosis is the end result of long-term liver damage, where healthy tissue is replaced by scar tissue. Globally, the main causes are hepatitis B and C, alcohol, and increasingly metabolic dysfunction-associated steatotic liver disease (MASLD, formerly called non-alcoholic fatty liver disease), linked to obesity and diabetes. In many African and Asian countries, chronic hepatitis B is a leading cause. Patients with cirrhosis can deteriorate quickly, and nursing care has a big impact on outcomes.
Compensated vs decompensated
Many people live for years with compensated cirrhosis and few symptoms. Decompensation occurs when complications develop: ascites, variceal bleeding, hepatic encephalopathy, or jaundice. Decompensation marks a significant worsening of prognosis.
Signs to look for
- Jaundice (yellow eyes and skin), dark urine, pale stools, itching.
- Abdominal swelling (ascites), leg oedema.
- Spider naevi, palmar erythema, muscle wasting.
- Easy bruising and bleeding (the liver makes clotting factors).
- Confusion, drowsiness, a flapping tremor (asterixis).
- Vomiting blood or black stools.
Ascites
- Daily weight and measured abdominal girth at the same point.
- Fluid balance chart. See our fluid balance guide.
- Salt restriction (moderate, as advised) and diuretics such as spironolactone and furosemide; monitor sodium, potassium and kidney function.
- Watch breathing: large ascites pushes on the diaphragm. Sit the patient up.
- Spontaneous bacterial peritonitis (SBP): infection of ascitic fluid. Fever, abdominal pain or unexplained deterioration, including new confusion, should prompt urgent review.
Paracentesis
- Drainage of ascitic fluid through a needle or drain.
- Record observations before, during and after.
- For large-volume drainage, IV human albumin is often given to prevent circulatory dysfunction, as per local protocol.
- Monitor drain output and clamp or remove according to protocol; watch the site for leakage or bleeding.
Hepatic encephalopathy
When the liver can’t clear toxins such as ammonia, brain function is affected, ranging from subtle changes in sleep pattern and concentration to confusion, drowsiness and coma.
- Look for triggers: infection, GI bleeding, constipation, dehydration, electrolyte imbalance, sedatives and opioids, alcohol.
- Lactulose: titrate to produce 2–3 soft stools a day. Record bowel movements accurately. Too little is ineffective; too much causes dehydration.
- Rifaximin may be added to reduce recurrence.
- Neurological observations; ensure safety (falls risk, airway if drowsy).
- Avoid sedatives where possible.
- Don’t restrict protein routinely; patients with cirrhosis are often malnourished.
Variceal bleeding
High pressure in the portal vein leads to swollen veins (varices) in the oesophagus and stomach, which can bleed catastrophically. Signs: vomiting fresh blood or coffee grounds, melaena, tachycardia, hypotension.
- Emergency: call for help, A–E, two large-bore cannulae, bloods including crossmatch.
- Medicines often include terlipressin and IV antibiotics; urgent endoscopy for banding.
- Careful transfusion: over-transfusing can raise portal pressure and worsen bleeding; follow medical targets.
- See our upper GI bleeding guide.
Nutrition
- Malnutrition and muscle loss are very common.
- Small, frequent meals and a late-evening snack to reduce overnight muscle breakdown.
- Dietitian referral.
Stopping alcohol is the most important treatment. In hospital, watch for withdrawal and give thiamine. See our alcohol withdrawal guide. Approach patients without judgement; stigma stops people seeking help.
Medicine safety
- Many medicines are metabolised by the liver; doses may need adjusting.
- NSAIDs (ibuprofen, diclofenac) can cause kidney injury and bleeding in cirrhosis and are generally avoided.
- Paracetamol is usually acceptable at reduced maximum doses, as advised.
- Ask about herbal remedies, some of which are hepatotoxic.
Prevention and screening
Hepatitis B vaccination (including the birth dose), testing and treatment for hepatitis B and C, reducing harmful alcohol use and tackling obesity can prevent much cirrhosis. People with cirrhosis also need regular screening for liver cancer (usually ultrasound every 6 months) and for varices. See our hepatitis B guide.
Based on EASL Clinical Practice Guidelines on decompensated cirrhosis, BSG guidance and WHO hepatitis guidance. Educational content: follow local protocols.