The liver makes proteins (albumin, clotting factors), clears ammonia and bilirubin, stores glycogen, and metabolizes drugs and hormones. Injury leads to inflammation (hepatitis), then scarring (fibrosis), and finally cirrhosis — distorted architecture with regenerative nodules.

Viral hepatitis

Other causes of liver disease: alcohol-associated liver disease, metabolic dysfunction–associated steatotic liver disease (MASLD, formerly NAFLD), drug-induced injury (acetaminophen overdose is the leading cause of acute liver failure in the US), autoimmune hepatitis, hemochromatosis.

Consequences of cirrhosis

• Portal hypertension → esophageal and gastric varices, splenomegaly with low platelets, ascites
• Low albumin → edema and ascites; low clotting factors → prolonged INR and bleeding
• Failure to clear ammonia → hepatic encephalopathy (HE)
• Failure to clear bilirubin → jaundice; failure to metabolize estrogen → spider angiomas, palmar erythema, gynecomastia
• Kidney failure (hepatorenal syndrome), infection (spontaneous bacterial peritonitis), and hepatocellular carcinoma (HCC)

• Fatigue, anorexia, nausea, RUQ discomfort, weight loss with muscle wasting
• Jaundice, pruritus, dark urine, pale stools
• Ascites (increasing abdominal girth, shifting dullness), peripheral edema
• Spider angiomas, palmar erythema, gynecomastia, testicular atrophy
• Bruising, bleeding gums, nosebleeds
• HE: early — personality and behavior change, poor attention, reversed sleep–wake cycle, subtle confusion; later — asterixis (flapping tremor), lethargy, fetor hepaticus, coma
• Variceal bleeding: hematemesis, melena, shock

Hepatitis B serology

After liver biopsy: position on the right side (to compress the site) for several hours as ordered; monitor vital signs for bleeding; report right shoulder pain, hypotension, or tachycardia.

Viral hepatitis

• Hepatitis B: tenofovir or entecavir for those meeting treatment criteria — long-term, usually lifelong. Tenofovir disoproxil: kidney and bone toxicity (monitor creatinine, phosphate); tenofovir alafenamide has less. Stopping therapy can cause a severe hepatitis flare (boxed warning). Test for HIV before starting (monotherapy causes HIV resistance)
• Hepatitis C: direct-acting antivirals for 8–12 weeks cure more than 95%. Test for hepatitis B first — HBV reactivation can occur during HCV therapy (boxed warning). Sofosbuvir with amiodarone can cause severe bradycardia

Acetaminophen hepatotoxicity

• Healthy adults: no more than 4 g/day (many labels and clinicians advise 3 g/day); about 2 g/day with cirrhosis or regular alcohol use
• Count acetaminophen in combination products (cold remedies, opioid combinations)
• Overdose: serum level drawn at 4 hours or later after ingestion and plotted on the Rumack–Matthew nomogram; N-acetylcysteine is most effective within 8–10 hours but is still given when treatment is late

Alcohol-associated hepatitis — abstinence, nutrition, corticosteroids for severe cases, treatment of alcohol use disorder; monitor for alcohol withdrawal. Withdrawal is still treated with benzodiazepines; in cirrhosis, lorazepam or oxazepam (no active metabolites) with symptom-triggered dosing is preferred.

Varices and portal hypertension (current consensus, Baveno VII)

• Nonselective beta blocker — carvedilol preferred (propranolol or nadolol alternatives) to prevent first bleeding and decompensation. Check pulse and BP; hold per parameters (e.g., low heart rate or systolic BP below about 90 mmHg); may mask hypoglycemia; do not stop abruptly unless ordered; avoid in severe asthma. The dose is reduced or stopped in refractory ascites with systolic BP below 90 mmHg, serum sodium below 130 mEq/L, or acute kidney injury
• Endoscopic variceal ligation for large varices or intolerance of beta blockers
• After a variceal bleed: nonselective beta blocker plus band ligation to prevent rebleeding

Acute variceal hemorrhage

• Airway protection (intubation if massive hematemesis or altered mental status), two large-bore IVs
• Restrictive transfusion (hemoglobin target about 7–8 g/dL, 70–80 g/L) — overtransfusion raises portal pressure and rebleeding
• Vasoactive drug (octreotide) — can cause hypo- or hyperglycemia and bradycardia
• IV antibiotic prophylaxis (e.g., ceftriaxone) — lowers infection and death
• Endoscopic ligation within 12 hours; balloon tamponade as a temporary bridge; TIPS for refractory or high-risk bleeding (can worsen HE)

Ascites

• Sodium restriction about 2 g (88 mmol) per day; fluid restriction only for significant hyponatremia (serum sodium below about 125 mEq/L)
• Spironolactone with furosemide (usual ratio 100 mg : 40 mg). Monitor sodium, potassium (spironolactone raises K⁺, furosemide lowers it), creatinine, and weight; spironolactone causes gynecomastia
• Target weight loss about 0.5 kg/day without peripheral edema (up to 1 kg/day with edema)
• Large-volume paracentesis; give IV albumin about 6–8 g per liter removed when more than 5 L is taken off to prevent circulatory dysfunction
• TIPS for refractory ascites

SBP — IV third-generation cephalosporin (cefotaxime or ceftriaxone) plus IV albumin; long-term antibiotic prophylaxis after an episode.

Hepatic encephalopathy

• Find and treat the trigger: GI bleeding, infection, constipation, dehydration, hypokalemia, over-diuresis, sedatives (benzodiazepines, opioids)
• Lactulose titrated to 2–3 soft stools per day — traps ammonia in the colon and speeds its elimination; too much causes diarrhea, dehydration, hypokalemia, hypernatremia
• Rifaximin added to prevent recurrence
• Do not restrict protein: current guidelines recommend about 1.2–1.5 g/kg/day, spread through the day with a late-evening snack, to prevent muscle loss; vegetable and dairy protein may be better tolerated

Hepatorenal syndrome — stop diuretics and nephrotoxins; albumin plus a vasoconstrictor (terlipressin — risk of serious respiratory failure; avoid with hypoxemia or volume overload — or norepinephrine); transplant evaluation.

Hepatocellular carcinoma — resection, ablation, transarterial chemoembolization (TACE), systemic therapy, transplant. After TACE, expect post-embolization syndrome (fever, RUQ pain, nausea, fatigue), usually self-limited.

Liver transplant — immunosuppression with tacrolimus: take at the same times each day, consistently with or without food; trough level monitoring; nephrotoxicity, tremor, hyperglycemia, hyperkalemia, hypertension; avoid grapefruit; many CYP3A4 interactions; infection precautions.

Drug safety in cirrhosis — avoid NSAIDs (kidney injury, bleeding); avoid ACE inhibitors and ARBs in clients with ascites (hypotension, kidney injury); limit acetaminophen to about 2 g/day; avoid sedatives; use nephrotoxic drugs such as aminoglycosides only when essential, with level and kidney monitoring.

Listed in priority order.

1. Airway and bleeding — for hematemesis: side-lying or head elevated, suction ready; vital signs, hemoglobin, stool for blood; bleeding precautions (soft toothbrush, electric razor, pressure on puncture sites)
2. Breathing with ascites — semi-Fowler's or high-Fowler's; measure abdominal girth at the same marked site
3. Neurologic status and safety — assess orientation, handwriting, asterixis each shift; fall and aspiration precautions; avoid sedatives
4. Fluid and electrolytes — daily weight, intake and output, sodium, potassium, creatinine
5. Paracentesis care — empty the bladder before; upright position; after: monitor BP and pulse, site leakage, and give albumin as ordered
6. Infection — monitor for fever, abdominal pain, or confusion (SBP may present only as worsening HE)
7. Skin — pruritus relief (cool baths, emollients, short nails); reposition edematous skin
8. Nutrition — small frequent meals, late-evening snack, adequate protein, sodium restriction, vitamin and zinc supplements; no alcohol

• Complete abstinence from alcohol; support programs for alcohol use disorder
• Avoid NSAIDs and herbal supplements; limit acetaminophen as instructed; check with the provider before any new drug
• Low-sodium diet; weigh daily and report gain of more than about 1 kg (2 lb) in a day or increasing girth
• Take lactulose daily to keep 2–3 soft stools; report confusion, sleepiness, or constipation
• Report vomiting blood, black stools, fever, abdominal pain, or reduced urine output immediately
• Hepatitis B: household and sexual contacts should be tested and vaccinated; do not share razors or toothbrushes; cover cuts; condoms; do not donate blood; infants of infected mothers need hepatitis B vaccine and HBIG within 12 hours of birth
• Hepatitis A and B vaccination for clients with chronic liver disease who are not immune
• Keep HCC surveillance (ultrasound every 6 months) appointments

• Earliest HE signs: personality and behavior change, sleep reversal; later asterixis
• HE: lactulose to 2–3 soft stools/day, rifaximin; do not restrict protein (1.2–1.5 g/kg/day)
• Nonselective beta blocker (carvedilol preferred) = prevention of first variceal bleed
• Acute variceal bleed: octreotide + IV antibiotics + ligation within 12 h; restrictive transfusion
• SBP diagnosis: ascitic PMN ≥ 250 cells/mm³
• Ascites: sodium 2 g/day, spironolactone + furosemide; monitor Na⁺, K⁺, weight
• Paracentesis more than 5 L → albumin; void before the procedure
• Anti-HBs alone = vaccinated; HBsAg = current infection
• Elastography stages fibrosis noninvasively
• Tacrolimus: consistent timing, trough levels, nephrotoxicity
• Avoid NSAIDs and nephrotoxic drugs (e.g., aminoglycosides) in cirrhosis