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gi.cirrhosis.core.v1PRODUCTION
gi.cirrhosis.core.v1

Cirrhosis (chronic, compensated + decompensated)

hepatologychronicacuteadult
Hard-required inputs
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm cirrhosis scope; distinguish compensated outpatient from decompensated/ACLF inpatient pathway (EASL 2018)

Inputs
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Actions
0
Advance rule
Set
Advance when

compensated vs decompensated assigned

Patient inputs (19)

Transplant eligibility, frailty, MELD-Na age component

Hypotension precipitates HRS-AKI; variceal bleed shock

Hyperdynamic circulation; SBP / sepsis screen

Etiology + abstinence is highest-yield intervention (ACG 2023 ALD)

HCV cure (DAA), HBV suppression (AASLD 2024)

MASH etiology — leading cause; weight, T2DM, lipids, BP control (AASLD 2023 MASLD)

Compensated vs decompensated phenotype (EASL 2018)

Avoid NSAIDs / nephrotoxins; check beta-blocker / lactulose / rifaximin / diuretics (AASLD 2023)

MELD/MELD-Na/MELD3/Child-Pugh component (AASLD 2023 Biggins)

MELD/MELD-Na/MELD3/Child-Pugh component (AASLD 2023 Biggins)

MELD/MELD-Na/MELD3 component; HRS-AKI workup (AASLD 2023)

MELD-Na/MELD3 component; hyponatremia <125 = red flag (AASLD 2023 Biggins)

Child-Pugh + MELD3 component; nutritional status (AASLD 2023)

Portal hypertension surrogate; FIB-4 (Baveno VII 2022)

AST:ALT ratio (alcoholic >2:1); FIB-4 / APRI (AASLD 2023)

HCC surveillance, portal vein patency, ascites (AASLD 2023 HCC)

HE workup (note: not required for HE diagnosis per AASLD 2023)

Variceal screening for portal hypertension (Baveno VII 2022 de Franchis)

HCC surveillance (AASLD 2023 HCC)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateninghe_grade_3_4
    West Haven grade 3-4 HE (somnolence, stupor, coma; airway concern) (AASLD 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningvariceal_bleed_acute
    Hematemesis / melena in cirrhotic (Baveno VII 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghrs_aki_diagnosed
    AKI in cirrhosis after albumin/diuretic withdrawal challenge — bland sediment, no shock, no nephrotoxin (AASLD 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresbp_diagnosed
    Diagnostic paracentesis ANC ≥250/mm³ in cirrhotic with ascites (AASLD 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremassive_ascites_tense
    Tense ascites with respiratory compromise, abdominal pain, or umbilical hernia rupture risk (ACG 2021 ascites)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_hyponatremia
    Na <125 mEq/L in cirrhotic with ascites (AASLD 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_alcoholic_hepatitis
    Maddrey discriminant function ≥32 in alcoholic hepatitis (ACG 2023 ALD)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONrequiredDrives risk stratification
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Recommended regimen

Cirrhosis complication-driven regimen — Baveno VII + AASLD 2024
axis: cirrhosis_complication_axisstep 1 - Step 1 — Compensated cirrhosis (no decompensation history)
Selected step "Step 1 — Compensated cirrhosis (no decompensation history)" — No ascites, no variceal bleed, no HE; primary prophylaxis for varices
  • carvedilol
    first line
    NSBB
    6.25 mg PO daily, titrate to 12.5-25 mg BID • PO • daily/BID
    triggers: CSPH, medium_large_varices_F2_F3, platelet_count_<150_or_LSM_>=20
    Baveno VII — preferred NSBB for primary prophylaxis (better hemodynamic effect than propranolol/nadolol); reduces decompensation
    rxcui 20352
  • propranolol
    first line
    NSBB
    20 mg PO BID, titrate to HR 55-60 or max 320 mg/day • PO • BID/TID
    Alternative NSBB; longer track record (Baveno VII 2022)
    rxcui 8787
  • nadolol
    first line
    NSBB
    20 mg PO daily, titrate to HR 55-60 • PO • daily
    Once-daily NSBB option (Baveno VII 2022)
    rxcui 7226

outpatient playbook — drug actions (7)

  1. 1. NSBB primary prophylaxis
    Carvedilol 6.25 mg PO daily titrate to 12.5 mg BID • PO • daily/BID
    trigger: CSPH or medium-large varices
    Baveno VII
  2. 2. spironolactone + furosemide
    Spiro 100 mg + furo 40 mg PO daily, titrate 100:40 ratio • PO • daily
    trigger: Ascites grade 2-3
    AASLD diuretic regimen
  3. 3. lactulose ± rifaximin
    Lactulose 25 mL PO TID titrate; add rifaximin 550 mg BID for recurrent HE • PO • TID/BID
    trigger: HE history
    AASLD HE secondary prophylaxis
  4. 4. norfloxacin SBP prophylaxis
    400 mg PO daily • PO • daily
    trigger: Prior SBP OR low-protein ascites <1.5 + advanced disease
    AASLD — secondary prophylaxis
  5. 5. tenofovir alafenamide / entecavir for HBV
    TAF 25 mg PO daily OR ETV 0.5 mg PO daily • PO • daily
    trigger: HBV active replication
    AASLD HBV
  6. 6. sofosbuvir-velpatasvir DAA for HCV
    400/100 mg PO daily × 12 weeks • PO • daily
    trigger: HCV viremia
    AASLD/IDSA 2024
  7. 7. thiamine + folate for AUD
    Thiamine 100 mg + folate 1 mg PO daily • PO • daily
    trigger: Active or recent AUD
    Wernicke prophylaxis + megaloblastic anemia

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Jaundice / scleral icterus; New or worsening ascites; Variceal bleed — hematemesis / melena.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Cirrhosis (chronic, compensated + decompensated)** (gi.cirrhosis.core.v1).
Phenotype framing: Etiology — viral, alcoholic, MASH, autoimmune, PBC, PSC, hereditary (HH, Wilson, A1AT), drug-induced, Budd-Chiari, cardiac (AASLD 2023 Biggins)
Scope: Confirm cirrhosis scope; distinguish compensated outpatient from decompensated/ACLF inpatient pathway (EASL 2018)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Cirrhosis complication-driven regimen — Baveno VII + AASLD 2024** — step "Step 1 — Compensated cirrhosis (no decompensation history)".
1. carvedilol 6.25 mg PO daily, titrate to 12.5-25 mg BID PO daily/BID (NSBB, first line) — Baveno VII — preferred NSBB for primary prophylaxis (better hemodynamic effect than propranolol/nadolol); reduces decompensation
2. propranolol 20 mg PO BID, titrate to HR 55-60 or max 320 mg/day PO BID/TID (NSBB, first line) — Alternative NSBB; longer track record (Baveno VII 2022)
3. nadolol 20 mg PO daily, titrate to HR 55-60 PO daily (NSBB, first line) — Once-daily NSBB option (Baveno VII 2022)

Setting playbook (outpatient) — Maintain compensation: etiology treatment (DAA/abstinence/HBV suppression/MASH lifestyle), variceal screening + NSBB, HCC surveillance, vaccinations, transplant referral if MELD ≥15
4. NSBB primary prophylaxis Carvedilol 6.25 mg PO daily titrate to 12.5 mg BID PO daily/BID — CSPH or medium-large varices (Baveno VII)
5. spironolactone + furosemide Spiro 100 mg + furo 40 mg PO daily, titrate 100:40 ratio PO daily — Ascites grade 2-3 (AASLD diuretic regimen)
6. lactulose ± rifaximin Lactulose 25 mL PO TID titrate; add rifaximin 550 mg BID for recurrent HE PO TID/BID — HE history (AASLD HE secondary prophylaxis)
7. norfloxacin SBP prophylaxis 400 mg PO daily PO daily — Prior SBP OR low-protein ascites <1.5 + advanced disease (AASLD — secondary prophylaxis)
8. tenofovir alafenamide / entecavir for HBV TAF 25 mg PO daily OR ETV 0.5 mg PO daily PO daily — HBV active replication (AASLD HBV)
9. sofosbuvir-velpatasvir DAA for HCV 400/100 mg PO daily × 12 weeks PO daily — HCV viremia (AASLD/IDSA 2024)
10. thiamine + folate for AUD Thiamine 100 mg + folate 1 mg PO daily PO daily — Active or recent AUD (Wernicke prophylaxis + megaloblastic anemia)

Non-pharmacologic actions:
- Alcohol cessation counselling + addiction services
- Sodium restriction <2 g/day for ascites (ACG 2021 ascites)
- Free water restriction <1-1.5 L/day if Na <130 (AASLD 2023)
- Frailty/sarcopenia: high-protein 1.2-1.5 g/kg/day + late evening snack (EASL 2018)
- Vaccinations (AASLD 2023)
- Transplant evaluation if MELD >=15 OR refractory complications (AASLD 2023 Biggins)
- Palliative care for advanced (AASLD 2023)

AVOID / contraindication checks:
- NSAID avoid in cirrhosis renal and GI risk (AASLD 2023)
- Aminoglycoside avoid HRS risk (AASLD 2023)
- NSBB hold during active variceal bleed or SBP with hypotension (Baveno VII 2022 de Franchis)
- Opioid caution HE precipitant (AASLD 2023)
- Benzodiazepine caution HE precipitant (AASLD 2023)
- Metformin safe in cirrhosis unless severe renal or lactic acidosis risk (AASLD 2023 MASLD)
- Statin safe in compensated cirrhosis (AASLD 2023)

Monitoring

Regimen monitoring:
- MELD-Na monthly in decompensation (AASLD 2023 Biggins)
- MELD 3.0 for UNOS allocation (AASLD 2023)
- LFT INR albumin q3-6mo compensated (AASLD 2023)
- HCC US AFP q6mo (AASLD 2023 HCC)
- EGD for varices q2-3yr or per Baveno VII LSM PLT rule (Baveno VII 2022 de Franchis)
- daily weight for ascites (ACG 2021 ascites)
- daily Cr Na K on diuretics (AASLD 2023)
- ammonia NOT required for HE diagnosis (AASLD 2023)

Setting (outpatient) monitoring:
- MELD-Na monthly during decompensation, q3mo otherwise (AASLD 2023)
- LFT/INR/albumin q3-6mo (AASLD 2023)
- HCC surveillance US+AFP q6mo (AASLD 2023 HCC)
- EGD q2-3y or per Baveno VII 2022 rule
- Daily weight for ascites; weekly clinic check during diuretic titration (ACG 2021 ascites)

Follow-up plan: Hepatology q3mo decompensated / q6mo compensated; transplant eval at MELD ≥15; addiction services for AUD; vaccinations (HAV/HBV/flu/PNA/COVID); palliative care for advanced (AASLD 2023 Biggins)
- Close-out criterion: follow-up scheduled

Monitoring phase: MELD-Na monthly during decompensation; LFT/INR/albumin q3-6mo compensated; HCC US+AFP q6mo; EGD q2-3yr; weight daily for ascites; daily Cr/Na on diuretics (AASLD 2023; Baveno VII 2022)

Disposition

Current setting: outpatient — Maintain compensation: etiology treatment (DAA/abstinence/HBV suppression/MASH lifestyle), variceal screening + NSBB, HCC surveillance, vaccinations, transplant referral if MELD ≥15

Disposition criteria:
- Maintain compensation if stable outpatient follow-up (AASLD 2023)
- Refer to transplant center if MELD >=15 or refractory complications (AASLD 2023 Biggins)

Escalation triggers (move to higher acuity):
- New ascites / HE / variceal bleed then ED / inpatient (AASLD 2023)
- MELD-Na rise of >=3 in 3 months then expedited transplant evaluation (AASLD 2023 Biggins)
- New HCC on surveillance then multidisciplinary tumor board (AASLD 2023 HCC)

Patient Action Plan

**Cirrhosis decompensation action plan**
Personalised values: baseline_weight, baseline_MELD_Na, home_meds_lactulose_rifaximin_diuretics_NSBB, transplant_status.

**Stable compensated — continue routine care** (green):
Triggers:
- Stable weight (within 1-2 kg of baseline)
- No new confusion, sleep changes, or asterixis
- No abdominal distension or pain
- No bleeding, hematemesis, melena, or hematochezia
- No yellowing of skin/eyes worse than baseline
Actions:
- Take all liver medications as prescribed (lactulose, rifaximin, diuretics, NSBB)
- Daily weight + sodium-restricted diet (<2 g/day)
- No alcohol; avoid NSAIDs and herbal supplements
- Keep all hepatology and transplant clinic appointments
- Continue HCC surveillance imaging

**Caution — early decompensation signs, contact hepatology within 24h** (yellow):
Triggers:
- Weight gain >2 kg in 1 week or new abdominal swelling
- Mild confusion, forgetfulness, or sleep reversal (HE grade 1)
- Decreased urine output
- Constipation or fewer than 2 BMs/day on lactulose
- New leg swelling
- Mild yellowing of skin/eyes worsening
- New nausea or decreased appetite
Actions:
- Increase lactulose to achieve 2-3 soft BMs/day
- Strict sodium restriction <2 g/day; fluid restriction if instructed
- Daily weight tracking — bring to clinic
- Avoid sedatives, opioids, alcohol
- Contact hepatology team within 24 hours
Contact provider when:
- Weight gain >2 kg/week despite diuretics
- Mild confusion or sleep changes
- New leg swelling
- Fewer BMs than usual

**Medical alert — go to ED now** (red):
Triggers:
- Vomiting blood or coffee-ground material
- Black tarry stool or red blood per rectum
- Severe confusion, very sleepy, hard to wake (HE grade 3-4)
- Severe abdominal pain or fever
- Cannot urinate or making very little urine
- Sudden severe shortness of breath
- Falls or stumbling, slurred speech
Actions:
- Call 911 / go to nearest ED immediately
- Bring updated medication list
- Notify hepatology team of admission
- Family/caregiver to accompany if patient confused
Contact provider when:
- Any red zone symptom — ED now, do not wait

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] West Haven grade 3-4 HE (somnolence, stupor, coma; airway concern) (AASLD 2023)
- [LIFE_THREATENING] Hematemesis / melena in cirrhotic (Baveno VII 2022)
- [LIFE_THREATENING] AKI in cirrhosis after albumin/diuretic withdrawal challenge — bland sediment, no shock, no nephrotoxin (AASLD 2023)

Citations

- AASLD 2024 Practice Guidance on Risk Stratification + Portal Hypertension/Varices + AASLD 2023 ACLF + Baveno VII (2022) + AASLD 2023 MASLD + AASLD 2023 HCC + ACG 2023 ALD [PMID:35120736](https://pubmed.ncbi.nlm.nih.gov/35120736/)
- Cited evidence (PMID 33942342) [PMID:33942342](https://pubmed.ncbi.nlm.nih.gov/33942342/)
- Cited evidence (PMID 27786365) [PMID:27786365](https://pubmed.ncbi.nlm.nih.gov/27786365/)

Last reconciled with current guidelines: 2026-05-22.
References
  • AASLD 2024 Practice Guidance on Risk Stratification + Portal Hypertension/Varices + AASLD 2023 ACLF + Baveno VII (2022) + AASLD 2023 MASLD + AASLD 2023 HCC + ACG 2023 ALD — PMID:35120736
  • Cited evidence (PMID 33942342) — PMID:33942342
  • Cited evidence (PMID 27786365) — PMID:27786365