Mistakes in decompensated liver cirrhosis and how to avoid them

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Mistakes in decompensated liver cirrhosis and how to avoid them

Tammo Lambert Tergast, Benjamin Maasoumy

Summary

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Early chronic liver disease and compensated cirrhosis can remain asymptomatic for years, but progression to decompensated cirrhosis drastically increases morbidity and mortality.

Patients with early chronic liver disease and compensated cirrhosis can present without clinical symptoms, allowing liver disease and damage to remain unidentified for many years.
Decompensated cirrhosis is defined by clinically overt signs of portal hypertension or impaired hepatic function, including variceal bleeding, ascites, or overt hepatic encephalopathy.
Morbidity and mortality drastically increase once decompensated cirrhosis develops.
The first hepatic decompensation event significantly increases the risk of further complications and decompensation episodes.
Individuals with advanced liver cirrhosis are four times more susceptible to infection, which is the most frequent trigger of hepatic decompensation.

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Abstract

Patients with early stages of chronic liver disease and even those with compensated cirrhosis can present without any clinical symptoms, which means that liver disease and ongoing liver damage can remain unidentified for many years. However, morbidity and mortality drastically increase once the stage of ‘decompensated cirrhosis’ has been reached. Decompensated cirrhosis describes the development of clinically overt signs of portal hypertension and/or impairment of hepatic function (e.g. variceal bleeding, ascites or overt hepatic encephalopathy). The first hepatic decompensation event significantly increases the risk that further complications of liver cirrhosis and decompensation episodes will occur.2 Moreover, individuals who have advanced stages of liver cirrhosis are four times more susceptible to infection, which is, in turn, the most frequent trigger of hepatic decompensation.

Topics

Hepatobiliary

Citation

Tergast TL, Beier C and Maasoumy B. Mistakes in decompensated liver cirrhosis and how to avoid them. UEG Education 2019; 19: 25–30.

Published

2019

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EASL Clinical Practice Guidelines on the management of autoimmune hepatitis

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Guideline

Summary

Autoimmune hepatitis (AIH) is a chronic liver disease of unknown aetiology which may affect any patient irrespective of age, sex, or ethnicity. At baseline, the clinical spectrum of the disease varies largely from asymptomatic cases to acute liver failure with massive hepatocyte necrosis. The aim of these EASL guidelines is to provide updated guidance on the diagnosis and management of AIH both in adults and children. Updated guidance on the management of patients with variants and specific forms of AIH is also provided, as is detailed guidance on the management of AIH-associated cirrhosis, including surveillance for portal hypertension and hepatocellular carcinoma, as well as liver transplantation in decompensated cirrhosis.

Keywords

Autoimmune hepatitis; Autoantibodies; Variant syndromes; Immunosuppression; Azathioprine; Mycophenolate mofetil

Publisher

European Association for the Study of the Liver

Guideline

Clinical Practice Guideline

Topics

Hepatobiliary

Citation

Journal of Hepatology, Volume 83, Issue 2, 453 - 501

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EASL Clinical Practice Guidelines on the management of hepatitis B virus infection

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Guideline

Summary

The updated EASL Clinical Practice Guidelines on the management of hepatitis B virus (HBV) infection provide comprehensive, evidence-based recommendations for its management. Spanning ten thematic sections, the guidelines address diagnostics, treatment goals, treatment indications, therapeutic options, hepatocellular carcinoma surveillance, management of special populations, HBV reactivation prophylaxis, post-transplant care, HBV prevention strategies, and finally address open questions and future research directions. Chronic HBV remains a global health challenge, with over 250 million individuals affected and significant mortality due to cirrhosis and hepatocellular carcinoma. These guidelines emphasise the importance of early diagnosis, risk stratification based on viral and host factors, and tailored antiviral therapy. Attention is given to simplified algorithms, vaccination, and screening to support global HBV elimination targets. The guidelines also discuss emerging biomarkers and evolving definitions of functional and partial cure. Developed through literature review, expert consensus, and a Delphi process, the guidelines aim to equip healthcare providers across disciplines with practical tools to optimise HBV care and outcomes worldwide.

Publisher

European Association for the Study of the Liver

Guideline

Clinical Practice Guideline

Topics

Hepatobiliary

Citation

Journal of Hepatology, Volume 83, Issue 2, 502 - 583

Published

2025

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European Consensus on Malabsorption—UEG & SIGE, LGA, SPG, SRGH, CGS, ESPCG, EAGEN, ESPEN, and ESPGHAN. Part 1: Definitions, Clinical Phenotypes, and Diagnostic Testing for Malabsorption

Marco Vincenzo Lenti

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Guideline

ABSTRACT

Malabsorption is a complex and multifaceted condition characterised by the defective passage of nutrients into the blood and lymphatic streams. Several congenital or acquired disorders may cause either selective or global malabsorption in both children and adults, such as cystic fibrosis, exocrine pancreatic insufficiency (EPI), coeliac disease (CD) and other enteropathies, lactase deficiency, small intestinal bacterial overgrowth (SIBO), autoimmune atrophic gastritis, Crohn's disease, and gastric or small bowel resections. Early recognition of malabsorption is key for tailoring a proper diagnostic work-up for identifying the cause of malabsorption. A patient's medical and pharmacological history is essential for identifying risk factors. Several examinations such as endoscopy with small intestinal biopsies, non-invasive functional tests and radiological imaging are useful in diagnosing malabsorption. Because of its high prevalence, CD should always be looked for in cases of malabsorption with no other obvious explanations and in high-risk individuals. Nutritional support is key in the management of patients with malabsorption; different options are available, including oral supplements, enteral or parenteral nutrition. In patients with short bowel syndrome, teduglutide proved effective in reducing the need for parenteral nutrition, thus improving the quality of life of these patients. Primary care physicians play a central role in the early detection of malabsorption and should be involved in multidisciplinary teams for improving the overall management of these patients. In this European consensus, involving ten scientific societies and several experts, we have dissected all the issues around malabsorption, including the definitions and diagnostic testing (Part 1), high-risk categories and special populations, nutritional assessment and management, and primary care perspective (Part 2).

Publishers

European Society for Paediatric Gastroenterology, Hepatology and Nutrition, The European Society for Clinical Nutrition and Metabolism, European Association for Gastroenterology, Endoscopy and Nutrition, European Society for Primary Care Gastroenterology, Società Italiana di Gastroenterologia ed Endoscopia Digestiva

Guideline

Consensus

Topics

Endoscopy Pancreas Primary Care Small Intestine & Nutrition

Citation

United European Gastroenterol J, 13: 599-613

Published

2025

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American Society for Gastrointestinal Endoscopy–European Society of Gastrointestinal Endoscopy guideline on primary endoscopic bariatric and metabolic therapies for adults with obesity

Pichamol Jirapinyo, Alia Hadefi

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Guideline

Abstract

This joint ASGE-ESGE guideline provides an evidence-based summary and recommendations regarding the role of endoscopic bariatric and metabolic therapies (EBMTs) in the management of obesity. The document was developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. It evaluates the efficacy and safety of EBMT devices and procedures that currently have CE mark or FDA-clearance/approval, or that had been approved within five years of document development. The guideline suggests the use of EBMTs plus lifestyle modification in patients with a BMI of ≥30 kg/m², or with a BMI of 27.0–29.9 kg/m² with at least 1 obesity-related comorbidity. Furthermore, it suggests the utilization of intragastric balloons and devices for endoscopic gastric remodeling (EGR) in conjunction with lifestyle modification for this patient population.

Publisher

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Guideline

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Citation

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EASL Clinical Practice Guidelines on the management of extrahepatic cholangiocarcinoma

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Guideline

Summary

Recent years have witnessed significant advances in the imaging, molecular profiling, and systemic treatment of cholangiocarcinoma (CCA). Despite this progress, the early detection, precise classification, and effective management of CCA remain challenging. Owing to recent developments and the significant differences in CCA subtypes, EASL commissioned a panel of experts to draft evidence-based recommendations on the management of extrahepatic CCA, comprising distal and perihilar CCA. Particular attention is given to the need for accurate classification systems, the integration of emerging molecular insights, and practical strategies for diagnosis and treatment that reflect real-world clinical scenarios.

Publisher

European Association for the Study of the Liver

Guideline

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Topics

Digestive Oncology Hepatobiliary

Citation

Journal of Hepatology, Volume 83, Issue 1, 211 - 238

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2025

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Management of Hepatitis B Virus Infection and Prevention of Hepatitis B Virus Reactivation in Children With Acquired Immunodeficiencies or Undergoing Immune Suppressive, Cytotoxic, or Biological Modifier Therapies

Giuseppe Indolfi

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Guideline

Abstract

Reactivation of hepatitis B virus (HBV) is a known complication of immune-suppressive, cytotoxic, and biological modifier therapies in patients currently infected with HBV or who have had past exposure to HBV. Nowadays, newer and emerging forms of targeted biologic therapies are available for the management of rheumatologic conditions, malignancies, inflammatory bowel disease, dermatologic conditions and solid-organ, bone marrow, or haematologic stem cell transplant but there is currently a lack of a systematic approach to the care of patients with or at risk of HBV reactivation. The Hepatology Committee of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) together with a working group of ESPGHAN members with clinical and research expertise in viral hepatitis developed an evidence-based position paper on reactivation of HBV infection in children identifying pertinent issues addressing the diagnosis, prevention, and treatment of this condition. Relevant clinical questions were formulated and agreed upon by all the members of the working group. Questions were answered and positions were based on evidence resulting from a systematic literature search on PubMed and Embase from their inception to July 1, 2019. A document was produced and the working group and ESPGHAN Hepatology Committee members voted on each recommendation, using a formal voting technique. A recommendation was accepted provided upon agreement by at least 75% of the working group members. This position paper provides a comprehensive update on the diagnosis, prevention and treatment of HBV reactivation in children.

Publisher

European Society for Paediatric Gastroenterology, Hepatology and Nutrition

Guideline

Consensus

Topics

Hepatobiliary Immunology Paediatrics

Citation

Journal of Pediatric Gastroenterology and Nutrition, 70: 527-538

Published

2020

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