Decompensated Cirrhosis

What does "decompensated cirrhosis" mean?

Cirrhosis is scarring of the liver. For a long time, the healthy part of the liver can make up for the scarred part. Doctors call that compensated cirrhosis, and many people in this phase feel fairly well.

Cirrhosis becomes decompensated when the liver can no longer keep up and a major complication appears. This is a turning point. Large studies found that people with compensated cirrhosis had a median survival of more than 12 years, while people with decompensated cirrhosis had a median survival of less than 2 years without a transplant. Those numbers come from older research and describe groups, not individuals, but they explain why liver doctors treat the first sign of decompensation as urgent.

Decompensation is also the point where many people begin moving toward end-stage liver disease and toward the liver transplant waiting list. For the full picture of how liver disease progresses, see our guide to the stages of liver disease.

The four signs of decompensated cirrhosis

International liver experts (the Baveno VII consensus) define decompensation by three main events: ascites, variceal bleeding and hepatic encephalopathy. Jaundice is the fourth warning sign doctors watch for. Each one has its own cause.

1. Ascites: fluid in the belly

Scarring raises the pressure in the veins that carry blood to the liver (portal hypertension). Fluid leaks out and collects in the belly. You may notice a growing waistline, tight clothes, quick weight gain, or swelling in the legs, ankles and feet. Ascites fluid can become infected, which is a serious infection called peritonitis.

2. Variceal bleeding: bleeding from swollen veins

The same high pressure makes veins in the esophagus and stomach swell. These swollen veins are called varices, and they can burst. Signs of bleeding include vomiting blood and black or bloody stools. This is a medical emergency.

3. Hepatic encephalopathy: confusion

A healthy liver clears toxins from the blood. When it can't, those toxins reach the brain. Hepatic encephalopathy (HE) can start with small changes: poor concentration, forgetfulness, mood changes or a flipped sleep schedule. It can get worse quickly, leading to deep confusion, slurred speech, drowsiness and, in severe cases, coma.

4. Jaundice: yellow skin or eyes

Jaundice is a yellow tint to the skin or the whites of the eyes. It happens when the liver can't clear bilirubin, a yellow waste product. Dark urine and severe itching often come with it. New or quickly worsening jaundice is a sign the liver is failing.

What decompensation means for your MELD score

The MELD score ranks how urgently adults on the waiting list need a liver. The current version, MELD 3.0, is calculated from lab tests (bilirubin, INR, creatinine, sodium and albumin) plus sex.

Several signs of decompensation show up in those labs. Jaundice means a higher bilirubin. A failing liver makes fewer clotting proteins, which raises the INR, and less albumin. As these numbers change, MELD usually rises. You can plug in your latest results with our MELD calculator.

But MELD does not count everything. Someone can have ascites or encephalopathy and still have a fairly low MELD. That is one reason experts do not wait for MELD alone before referring someone for a transplant.

Why decompensation is the time for a transplant referral

The American Association for the Study of Liver Diseases (AASLD) and the American Society of Transplantation advise that evaluation for a liver transplant should be considered once a person with cirrhosis has had a first major complication, such as ascites, hepatic encephalopathy or variceal bleeding, or a MELD score of 15 or higher.

In plain terms: the first episode of decompensation is a good moment to ask, "Should I be referred to a transplant center?" A referral starts an evaluation. It does not commit you to surgery. Read more about who qualifies for a liver transplant.

Transplant centers vary in how many liver transplants they perform and how long patients wait. Comparing liver transplant centers early gives you more options, and some patients register at more than one center. Our dual-listing guide explains how.

Can decompensated cirrhosis get better? Recompensation

Sometimes, yes. The Baveno VII experts describe recompensation: a partial recovery that can happen when the cause of cirrhosis is removed, for example by stopping alcohol, curing hepatitis C or controlling hepatitis B. To count as recompensated, all of the following must be true:

• The cause of cirrhosis has been removed, suppressed or cured.
• Ascites has gone away without water pills (diuretics).
• Hepatic encephalopathy has gone away without lactulose or rifaximin.
• There has been no repeat variceal bleeding for at least 12 months.
• Liver blood tests (albumin, INR and bilirubin) have improved and stayed stable.

Recompensation does not mean cirrhosis is gone. Scarring and high pressure in the liver's veins can remain, so the experts advise continuing pressure-lowering medicine unless that pressure has resolved. Regular follow-up and liver cancer screening still matter. Talk with your hepatologist about whether recompensation is possible in your situation, and keep the transplant conversation open while you find out.

Caregiver tips: spotting hepatic encephalopathy early

People with hepatic encephalopathy often can't tell that their thinking has changed. Family members usually notice first. Early signs described by NIDDK and the 2014 AASLD/EASL hepatic encephalopathy guideline include:

• Changes in sleep, such as being very sleepy during the day or awake at night
• Forgetfulness, mild confusion or a short attention span
• Personality or mood changes, or odd behavior
• Trouble with simple math, such as making change
• Hands that flap when the arms are held out (asterixis)

Practical steps that help:

• Know their normal. Notice how your loved one usually talks, writes and sleeps, so changes stand out.
• Keep a simple daily log of sleep, bowel movements, medicines taken and anything unusual. Bring it to appointments.
• Make sure prescribed medicines are taken as directed. If the team prescribes lactulose or rifaximin, ask what to do if doses are missed.
• Ask the care team about driving. Confusion and slowed reactions can make driving unsafe.
• Report changes in thinking. HE can get worse quickly, so tell the liver team about any new change.

Caregiving is hard work. You don't have to do it alone. Our support page connects families with help.