In this in-depth episode of Hospital Medicine Unplugged, we walk through the evidence-based hospital management of decompensated cirrhosis. From triage to discharge, we cover the full playbook hospitalists need on the wards.

We start with rapid assessment and risk stratification—how to find precipitating factors (infection, GI bleed, alcohol, meds/nephrotoxins), what to order up front (CBC, CMP, INR, cultures), and how to use MELD-Na and ACLF scores to guide level of care.

Next, we hit the time-critical moves:

Early diagnostic paracentesis for any new/worsening ascites—don’t delay. If SBP (PMN ≥250): ceftriaxone 2 g IV daily plus albumin 1.5 g/kg day 1 and 1 g/kg day 2.

Hepatic encephalopathy: lactulose titrated to 2–3 soft stools/day; add rifaximin for recurrence; always fix triggers (bleed, infection, constipation, electrolytes, sedatives).

Ascites/volume: Na <2 g/day; combined spironolactone:furosemide (≈100:40, titrate). Hold diuretics in AKI/hypovolemia. Large-volume paracentesis needs albumin 6–8 g/L removed (>5 L). Hyponatremia: optimize diuretics; fluid restrict only if Na <125 and unresponsive.

Variceal hemorrhage: cautious resuscitation (Hgb ~7), antibiotic prophylaxis (ceftriaxone), vasoactive therapy (octreotide/terlipressin), and urgent EGD with banding. Secondary prevention: nonselective β-blocker (carvedilol/propranolol) + repeat banding. Consider early TIPS in refractory/high-risk bleeds.

Hepatorenal syndrome: albumin plus vasoconstrictor (terlipressin where available; norepinephrine in ICU), avoid nephrotoxins, and start early transplant evaluation.

We then zoom out to supportive care and systems:

Nutrition first—no routine protein restriction; aim 30–35 kcal/kg and 1.2–1.5 g/kg protein with a late-evening snack. Replete thiamine/folate and fat-soluble vitamins when indicated. Use EMR order sets/care bundles to hard-wire best practices and reduce 30-day mortality.

Special populations get focused guidance: ICU/ACLF, pregnancy (protocol tweaks, but standard principles), advanced renal disease, and infection-prone patients—where decisions about vasoconstrictors, antibiotics, and procedures demand tailoring.

We close with transition and long-term care: concrete discharge plans (diuretics, lactulose targets, SBP prophylaxis), linkage to hepatology/transplant, alcohol cessation and viral therapy when appropriate, HCC surveillance every 6 months, vaccinations, and when to loop in palliative care.

No fluff—just a concise, guideline-driven path to safer inpatient cirrhosis management.