End Stage Liver Disease (ESLD) - NYSORA

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End Stage Liver Disease (ESLD)

Learning objectives

  • Recognize end-stage liver disease (ESLD)
  • Management of ESLD

Definition and mechanisms

  • Chronic liver failure progresses over months to years
  • Often the result of cirrhosis of the liver
  • ESLD is the final stage of acute and chronic liver failure accompanied by ascites, variceal bleeding, hepatic encephalopathy, or renal impairment 
  • Patients with severe symptoms of cirrhosis may benefit from a liver transplant

Signs & symptoms

  • Weakness
  • Fatigue
  • Loss of appetite
  • Nausea
  • Vomiting
  • Weight loss
  • Abdominal pain and bloating
  • Itching

Decompensated cirrhosis

  • Bleeding varices
  • Ascites
  • Encephalopathy
  • Jaundice


  • Edema and ascites
  • Bruising and bleeding
  • Portal hypertension
  • Esophageal varices and gastropathy
  • Splenomegaly
  • Jaundice
  • Gallstones
  • Sensitivity to medications
  • Hepatic encephalopathy
  • Insulin resistance and type 2 diabetes mellitus
  • Liver cancer

Anesthetic management

End-stage liver disease (ESLD), ascites, alcohol, desflorane, remifentanil, etomidate, propofol, cirrhosis, atracurium, cisatracurium, morphine, fentanyl, alfentanil, vecuronium, IAP, hepatic blood flow, thiopental

End-stage liver disease (ESLD), TIPS, diuretics, hemoglobin, beta-blockers

Keep in mind

  • Patients with end-stage liver disease can also develop kidney failure
  • This is often reversible with a liver transplant but some patients may need a combined liver and kidney transplant

Suggested reading

  • Abbas N, Makker J, Abbas H, Balar B. Perioperative Care of Patients With Liver Cirrhosis: A Review. Health Serv Insights. 2017;10:1178632917691270. Published 2017 Feb 24.
  • Rakesh Vaja, BSc MBChB FRCA, Larry McNicol, MBBS (Hons) FRCA FANZCA, Imogen Sisley, MBChB MRCP FRCA, Anaesthesia for patients with liver disease, Continuing Education in Anaesthesia Critical Care & Pain, Volume 10, Issue 1, February 2010, Pages 15–19

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