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Decompensated Cirrhosis

What is Decompensated Cirrhosis?

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Decompensated cirrhosis is an advanced stage of chronic liver disease in which the liver can no longer perform its essential functions well enough to keep the body stable. Many people live for years with compensated cirrhosis, meaning the liver is heavily scarred but still manages to work sufficiently, often with few or no symptoms.

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Decompensation occurs when the liver’s function declines to the point where serious complications appear. These complications signal that the body can no longer compensate for liver damage.

The shift from compensated to decompensated cirrhosis can be gradual or sudden. It is often triggered by factors such as infections, alcohol use, gastrointestinal bleeding, certain medications, dehydration, or the natural progression of liver scarring. Once decompensation occurs, patients typically experience one or more of four major complications:

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1. Ascites

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Ascites is the abnormal buildup of fluid in the abdomen and is the most common sign that cirrhosis has decompensated.

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Why it happens:
As liver function declines, pressure increases in the portal vein (portal hypertension). At the same time, the liver produces fewer proteins like albumin, which normally help keep fluid in the bloodstream. This combination causes fluid to leak into the abdominal cavity.

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Possible symptoms:

• Increasing abdominal size or bloating
• Shortness of breath due to pressure on the diaphragm
• Early fullness when eating
• Weight gain from fluid, not fat

Ascites can range from mild to severe, and complications like spontaneous bacterial peritonitis (SBP) can develop, which is a medical emergency.

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2. Variceal Bleeding

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Variceal bleeding occurs when swollen veins in the esophagus or stomach—called varices—burst due to high pressure in the portal vein.

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Why it happens:
Portal hypertension forces blood into smaller veins that were never meant to handle such pressure. Over time, these veins enlarge and become fragile.

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Why it signals decompensation:
Once varices bleed, the risk of future bleeding increases, and the overall risk of mortality rises.

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Possible symptoms:

• Vomiting blood
• Black or tarry stools
• Lightheadedness or fainting
• Sudden weakness

Variceal bleeding is a medical emergency and requires immediate treatment.

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3. Jaundice (Icterus)

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Jaundice is yellowing of the skin and eyes due to a buildup of bilirubin, a pigment the liver normally processes and removes.

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Why it develops:
As the liver becomes more damaged, it cannot properly clear bilirubin. Levels rise in the bloodstream, causing visible yellowing and sometimes itching.

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Possible symptoms:

• Yellow eyes or skin
• Dark urine
• Pale stools
• Intense itching
• Fatigue

Jaundice is an important sign that liver function is deteriorating.

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4. Hepatic Encephalopathy (HE)

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Hepatic encephalopathy is a serious neurological complication and a major marker of decompensated cirrhosis. It occurs when toxins—especially ammonia—that the liver usually filters out begin to accumulate in the blood and reach the brain.

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Why HE Happens in Decompensated Cirrhosis

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When the liver can no longer detoxify substances or regulate metabolic processes effectively, toxins build up. At the same time, changes in gut bacteria, inflammation, and altered neurotransmission further disrupt brain function.
Triggers such as infections, constipation, dehydration, gastrointestinal bleeding, or certain medications can rapidly worsen HE.

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How HE Affects the Brain

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HE interferes with attention, memory, coordination, and behavior. Symptoms can range from subtle to life-threatening, and they often fluctuate over time, especially during acute episodes.

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Common Symptoms of HE

• Mild confusion or “brain fog”
• Trouble concentrating or slowed thinking
• Mood changes or irritability
• Sleep disturbances (like reversed day–night cycles)
• Difficulty performing routine tasks
• Tremors or poor coordination
• Asterixis (flapping tremor of the hands)
• In advanced stages, disorientation, extreme drowsiness, or reduced consciousness

Why HE Is So Significant

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HE often indicates that the liver is struggling to perform essential functions.
Frequent or severe episodes may mean that the disease is progressing, and they can significantly affect quality of life, independence, and safety.