Caring for the hospitalized patient with cirrhosis: HM17 algorithms

At HM17 in Las Vegas, hepatology and hospital medicine intersected in sessions addressing one of medicine's most fragile inpatient populations. The Society of Hospital Medicine gathered clinicians from Australia, New Zealand, and the Pacific Rim, all grappling with the same challenge: stabilising a patient whose liver failure is tipping into multi-organ collapse.

Cirrhosis is no longer a quiet outpatient diagnosis. Hospital admissions for decompensated disease have climbed steadily in Australia, driven by chronic hepatitis B, alcohol-related liver disease, and the rising tide of metabolic dysfunction-associated steatotic liver disease. Tertiary centres in Melbourne, Sydney, and Brisbane now run dedicated hepatology wards where these new algorithms shape daily rounds.

The pathways presented at Hospital Medicine 2017 were distilled into practical bedside tools that any generalist can deploy. They cover infection recognition, fluid strategy, encephalopathy management, bleeding risk, and the often-overlooked discharge handoff, marking a shift from reactive rescue to structured, protocolised care.

For clinicians outside specialty liver units, these protocols align with Australian prescribing realities under the Pharmaceutical Benefits Scheme and Medicare funding rules. Embedding them in workflows can shorten length of stay, reduce readmissions, and improve survival in a cohort with historically poor outcomes.

The rising burden of decompensated liver disease in Australia

Australia's hospital coding data shows a clear upward trajectory in admissions for ascites, variceal bleeding, hepatic encephalopathy, and hepatorenal syndrome. In Western Australia and the Northern Territory, where many patients travel hundreds of kilometres for tertiary care, the burden is amplified by delayed presentations and limited rural transplant access.

Indigenous Australians carry a disproportionate share of chronic hepatitis B and related hepatocellular injury. Liver clinics at Royal Adelaide Hospital and Westmead have developed culturally safe pathways, and the new HM17 algorithms complement these by standardising the acute phase response. Aggressive management of the first decompensation event alters the trajectory of subsequent admissions.

The economic impact is substantial. Each inpatient day for a cirrhotic complication in a public hospital attracts a weighted activity unit cost well above the average medical admission. Hospitals across NSW Health and Queensland Health are examining how algorithm-driven care can reduce ICU days, a goal that mirrors efforts to manage COPD exacerbations without ICU overuse as outlined in post-conference COPD pearls.

Early recognition of acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) is the syndrome clinicians fear most. The HM17 faculty devoted considerable time to its bedside diagnosis, and the new algorithm emphasises a structured organ-by-organ assessment within the first six hours of admission, much like the sepsis bundles discussed in implementing recent sepsis protocols.

Three triggers warrant immediate escalation: new renal impairment with creatinine rising above the patient's baseline, any grade of hepatic encephalopathy in a previously clear patient, and a sudden fall in peripheral oxygen saturation suggesting hepatopulmonary syndrome or intrapulmonary shunting. Each trigger activates a discrete bundle of investigations and interventions.

The CANONIC study framework formed the foundation, with Australian modifications for local pathology reference ranges and drug formulary choices. Clinicians at Liverpool Hospital in Sydney have piloted a quick-reference ACLF sticker attached to the observation chart, mirroring visual cues familiar from sepsis care. Early data suggest it shortens time-to-consult and reduces out-of-hours deterioration.

Fluid resuscitation and albumin use

The HM17 algorithm clarifies when to give albumin, when to withhold it, and when to switch to crystalloid. Large-volume paracentesis greater than 5 litres requires albumin replacement at 8 g per litre of ascites removed, a dose aligned with Australian product information and PBS indications.

For spontaneous bacterial peritonitis, day-one albumin at 1.5 g/kg followed by day-three albumin at 1 g/kg remains standard, but the new algorithm adds a ceiling dose and cautions against bolus dosing in patients with established acute kidney injury. This nuance reflects accumulating evidence that indiscriminate albumin expansion can precipitate pulmonary oedema.

Hepatology nurses at Austin Health have integrated this table into their paracentesis trolley checklist, and house officers report faster decision-making at the bedside.

Antibiotic stewardship in spontaneous bacterial peritonitis

Empirical SBP therapy at HM17 favoured third-generation cephalosporins, with a clear de-escalation pathway once ascitic fluid cultures return. The algorithm discourages empirical vancomycin unless methicillin-resistant organisms are suspected, supporting Australia's antimicrobial stewardship priorities under the National Antimicrobial Stewardship Initiative.

Patients with a previous SBP episode, low ascitic protein, or active GI bleeding should receive prophylactic norfloxacin or trimethoprim, though local resistance patterns increasingly favour ciprofloxacin. Hospital pharmacists at the Royal Melbourne are encouraged to review antibiotic choice at 48 hours and document the de-escalation plan in the medication chart.

Culture-negative neutrocytic ascites remains a grey zone, and the HM17 faculty recommended treating it as SBP while awaiting extended culture results. Bedside ultrasound guidance for paracentesis reduces the rate of dry taps and improves diagnostic yield, an approach championed by several Australian emergency departments.

Hepatic encephalopathy management pathways

Lactulose remains first-line, but the new algorithm stratifies dosing by West Haven grade and triggers early rifaximin consideration. In Australia, rifaximin is listed on the PBS for hepatic encephalopathy, simplifying inpatient initiation and outpatient continuation.

For covert or minimal encephalopathy, the algorithm recommends treating any precipitant such as constipation, infection, or electrolyte disturbance, rather than escalating lactulose alone. This pragmatic stance reduces pill burden and aligns with patient-centred goals emphasised in Australian chronic disease frameworks.

Bedside pearls for encephalopathy rounds:

• Examine for asterixis and orientation at every shift change.
• Check ammonia only when the clinical picture is unclear, since trending levels adds little.
• Review the medication chart for sedatives, opioids, and diuretics that worsen confusion.
• Document a clear driver of the episode in the discharge summary.

A short course of rifaximin during the inpatient stay can be continued by the GP under streamlined PBS authority, preventing the bounce-back readmission that often follows incomplete encephalopathy resolution.

Coagulopathy and bleeding risk reconsidered

The old reflex to transfuse any cirrhotic patient with a low INR before paracentesis has been retired. The HM17 algorithm endorses a viscoelastic-guided approach, available in many Australian tertiary centres through rotational thromboelastometry. Routine correction of mild coagulopathy before low-risk procedures such as diagnostic paracentesis is no longer recommended.

For variceal bleeding, the algorithm combines vasoactive agents, prophylactic antibiotics, and early endoscopy within 12 hours. Terlipressin is the vasoactive agent of choice where available, with octreotide as an alternative in centres where terlipressin supply is intermittent. Blood transfusion targets a haemoglobin of 70 g/L in most cases, avoiding the older liberal threshold.

Prophylaxis for venous thromboembolism remains important, and the algorithm specifically warns against omitting low-molecular-weight heparin in immobile cirrhotic inpatients. Pharmacists at Princess Alexandra Hospital have led audits showing VTE prophylaxis is inappropriately withheld in up to a third of cirrhotic admissions.

Discharge planning and outpatient linkage

A cirrhosis admission is incomplete without a structured discharge plan covering medication reconciliation, follow-up imaging, and clear thresholds for re-presentation. The HM17 algorithm mandates a seven-day post-discharge review, in person or via telehealth, which fits Medicare's chronic disease management items.

Medication reconciliation at discharge is critical for patients newly started on lactulose, rifaximin, or diuretics, where dosing errors commonly precipitate readmission. Pharmacist-led discharge counselling, increasingly embedded in Australian hospitals, can catch these errors before the patient leaves.

Discharge readiness checklist:

• Confirm weight, creatinine, and bilirubin are at or trending toward baseline.
• Arrange ascitic fluid surveillance ultrasound within four weeks if ascites was the index admission.
• Provide written dietary guidance consistent with dietitian input, including sodium restriction targets.
• Ensure the GP and liver clinic receive a structured handover within 48 hours.

Linkage to community alcohol care, hepatitis B clinics, and Aboriginal health services is essential where relevant. Victorian networks now embed a liver nurse navigator in the discharge process, and early reports show measurable reductions in 30-day readmission rates.

Before the next ward round, pick one cirrhotic patient currently under your care and apply the ACLF organ-by-organ checklist within the first six hours of admission, documenting triggers and the bundle activated so the team can review the pattern at handover.