ACG/ASGE Best Practices 2026
Dr. Jasmohan S. Bajaj, VCU
Liver
Ten Best Practices in Management of Decompensated Cirrhosis With ACLF
A systematic, organ-by-organ approach to preventing and managing acute-on-chronic liver failure.
10 Best Practices6 Quiz QuestionsACG ACLF Guidelines 2022 · Gastroenterology 2025
#1: Recognizing Cirrhosis
Often silent until too late
Cirrhosis is Increasing — and We're Missing It
Driven by the obesity and alcohol pandemic with residual viral hepatitis, cirrhosis is rising globally. The danger: a long asymptomatic phase means diagnosis often comes too late.
Why We Miss It
Long asymptomatic phase — diagnosis requires decompensation or HCC
10–13% of patients diagnosed with dementia had undiagnosed cirrhosis (possible HE)
Greater burden clinically and financially than other chronic diseases
Very rapid progression from missed infection to ACLF and death
Who's at Risk — Everyone's a Suspect
Diabetes mellitus
Other metabolic syndrome components
Alcohol use disorder
Look for: low platelet + low albumin + high FIB-4
Clinical Pearl
Needs early engagement with liver transplant teams and referral centers — don't wait for ACLF to make the call.
Case Study: Mr. PS
58-year-old veteran with decompensated cirrhosis. Stable HE on lactulose/rifaximin, ascites controlled. MELD 3.0 of 16 outpatient. Now admitted with confusion not responding to lactulose.
| Lab | Outpatient (1M) | On Admission | Interpretation |
|---|---|---|---|
| WBC | 2.6 | 5.4 | ⚠️ Doubled → infection |
| Creatinine | 0.8 | 1.2 | ⚠️ ↑>0.3 mg/dL = New AKI |
| INR | 1.5 | 1.7 | Worsening liver function |
| Bilirubin | 3.0 | 4.8 | Worsening liver function |
| Sodium | 139 | 134 | Hyponatremia |
| Albumin | 3.3 | 2.6 | Significant decline |
| MELD 3.0 | 16 | 23 | ⚠️ Rapid progression |
Confusion + Doubling WBC + New AKI + Worsening Liver = INFECTION UNLESS PROVEN OTHERWISE
Obradović et al. Hepatology 2025; Huang et al. Nat Rev Gastro Hep 2023; ACG ACLF Guidelines 2022; Bajaj et al. JAMA Network Open 2024