A 56-year-old man who drinks half a bottle of illicit liquor daily for 10 years presents with haematemesis and altered behaviour for 3 days. He has icterus, palmar erythema, ankle oedema, a flapping tremor, ascites and splenomegaly; BP 80/60, pulse 120. What is the unifying diagnosis?

Answer: B. Decompensated cirrhosis

Decompensated cirrhosis

This patient has chronic alcohol use with multiple overt clinical signs of hepatic decompensation occurring together: variceal bleeding (haematemesis), hepatic encephalopathy (altered behaviour, flap), ascites, jaundice and signs of chronic liver disease (palmar erythema, splenomegaly).

Compensated versus decompensated

What ties it together

• Years of alcohol cause cirrhosis; the diffusely abnormal architecture produces portal hypertension (varices, ascites, splenomegaly) and impaired hepatocellular function (jaundice, coagulopathy, encephalopathy).
• The combination of bleeding, encephalopathy and ascites defines decompensation.

Initial priorities

• Resuscitate the unstable bleed first, then manage each complication and look for precipitants (e.g. infection).