Chronic Liver Disease & Cirrhosis.
Chronic liver disease and cirrhosis are common causes of admission in the NHS.
Patients often present with complications rather than the liver disease itself, and can deteriorate quickly if problems are missed.
This guide focuses on how to recognise cirrhosis, assess severity, and manage patients safely on the ward and on-call.
What is chronic liver disease and cirrhosis?
Chronic liver disease (CLD)
Long-term liver damage over months to years.
Cirrhosis
Advanced scarring of the liver leading to loss of normal function and portal hypertension.
In simple terms:
The liver becomes stiff, scarred, and unable to cope.
Once cirrhosis develops, patients are at risk of life-threatening complications.
How does it present?
Some patients are asymptomatic early.
Common presentations on the ward:
- Ascites
- Peripheral oedema
- Jaundice
- Confusion (encephalopathy)
- GI bleeding
- Fatigue
- Weight loss
- Recurrent admissions
Often, cirrhosis is discovered only after the first decompensation.
Common causes (think practically)
Most common causes you will actually see:
- Alcohol-related liver disease
- MASLD / NAFLD (metabolic)
- Chronic hepatitis B or C
Also important:
- Autoimmune hepatitis
- PBC / PSC
- Haemochromatosis
- Drug-induced
In the NHS, alcohol and metabolic disease account for the majority.
Typical examination findings
Look carefully — the exam often tells you the diagnosis.
Signs of chronic liver disease:
- Spider naevi
- Palmar erythema
- Bruising
- Muscle wasting
- Gynaecomastia
- Caput medusae
Signs of portal hypertension:
- Ascites
- Splenomegaly
- Oedema
Signs of decompensation:
- Jaundice
- Encephalopathy
- GI bleeding
On the ward, always ask
Is this patient compensated or decompensated?
This changes everything.
Compensated:
- No complications yet
- Often stable
Decompensated:
- Ascites
- Encephalopathy
- Variceal bleeding
- Jaundice
Decompensation = higher mortality and closer monitoring.
First priority = assess severity
Before adjusting medications or plans, assess how sick they are.
Check:
- Observations / NEWS
- Mental state
- Fluid status
- U&E (AKI common)
- Bilirubin, INR, albumin
- Sodium
Trend matters more than single values.
If available, calculate:
- Child-Pugh score
- MELD score
But clinically:
Rising creatinine, bilirubin, or INR = bad news
Immediate management on the ward (what juniors should actually do)
When reviewing a patient with cirrhosis:
Do early:
- A–E assessment
- Bloods: FBC, U&E, LFTs, INR, CRP
- Infection screen if unwell
- Review medications
- Strict fluid balance
- Nutrition review
Practical steps:
- Avoid nephrotoxins (NSAIDs, ACEi)
- Avoid over-diuresis
- Give thiamine if alcohol-related
- Treat complications early
Always think:
What complication am I missing?
Key complications you must actively look for
These are the things that actually harm patients:
- Ascites
- SBP
- Hepatic encephalopathy
- AKI / HRS
- Variceal bleeding
- Hyponatraemia
- Infection
- Malnutrition
Most admissions are due to these, not “abnormal LFTs”.
When to escalate
Escalate early if:
- New confusion
- AKI
- Sepsis
- GI bleeding
- Hypotension
- Rapidly worsening bloods
- NEWS ≥5
- Concerned nursing staff
These patients often need:
- Gastro/hepatology input
- HDU/ICU
- Early consultant review
Cirrhosis patients can deteriorate suddenly.
Common mistakes juniors make
- Focusing only on LFT numbers
- Missing infection triggers
- Not tapping ascites
- Continuing diuretics during AKI
- Ignoring nutrition
- Delayed escalation
Remember:
Most harm comes from missed complications, not the cirrhosis itself.
Take-home concept
Cirrhosis is not just a diagnosis — it is a high-risk physiology.
Your job is to recognise decompensation early, look for complications proactively, and escalate promptly.