Cirrhosis and its complications cause over 40,000 fatalities in the US annually, with a mortality rate of 25.7 deaths per 100,000 persons. This makes them more deadly than kidney disorders and similar to diabetes. As cirrhosis complications continue to rise, the burden of liver disease is expected to increase significantly over time [14]. This study investigates the relation between predictive factors and mortality rates in patients with CLD seeking emergency medical attention. Similar to our study male preponderance was noted in multiple previous studies possibly due to socioeconomic factors contribute to male preponderance in ethanol consumption and access to medical care [9,10,11,12,13,14].

A study by Bhattacharyya M et al. found a comparable pattern in hemoglobin and platelet levels to our study, with 11.8% having hemoglobin levels below 6 g/dl and 28% having platelet counts below 1 lakh per milliliter of blood. Prothrombin time was abnormal in 50% of patients, and 20.7% had serum creatinine levels above 1.5 mg/dl [15]. Pathak et al. found that AST/ALT ≥ 2:1 at presentation is significantly associated with increased mortality and found a significant association between prolonged PT and increased mortality, with PT differences ≥ 5 s causing higher mortality [16].

R Maskey et al. observed that 5.7% of CLD patients attending ED left against medical advice, 67.6% were discharged, and 13.3% had fatalities during ED stay. 80% of the fatalities were caused by liver disease Child-Pugh grade C [10]. Although frequent attendance to the emergency department (more than 4 ED visits in 12 months) due to liver cirrhosis-related symptoms is common, it was not associated with increased mortality during the study period [17]. Retrospective studies in Nepal showed mortalities of 15–19%, which was comparable to our study [14, 16]. Our study included a significant proportion of rural, underprivileged, and illiterate patients who face challenges in accessibility and affordability to healthcare services due to socioeconomic inequalities. Addressing these inequalities is crucial to reducing the number of patients leaving against medical advice. Expanding government involvement in liver disease treatment could help improve access [18].

In our study, 16.9% patients died during hospital stay. Refractory septic shock was the most frequent cause of death (69.2%), followed by grade 4 hepatic encephalopathy (35.9%) and massive UGI bleeding with hypovolemic shock (23.1%).Some studies from Paris and India, the mortality rate was found to be high [13, 19]. Das et al. found that 62% of patients required mechanical ventilation and 19% needed dialysis. Of the deaths, 79% were caused by underlying illnesses such as multiple organ failure or refractory shock, while 21% were due to secondary consequences such as gastrointestinal bleeding (11%), nosocomial infection (5%), or other causes (5%) [6]. Studies conducted in Nepal revealed hepatic encephalopathy and gastrointestinal bleeding as the primary causes of mortality in the majority of cases [10, 14, 16]. In CA Onyekwere et al. found that hepatic encephalopathy had a mortality rate of 48%, with sepsis and related complications accounting for 29% of deaths [20].

Our study shows that refractory septic shock mortality rates are high, possibly due to delayed access, late presentation, and affordability of healthcare. Complications of CLD vary based on cause and geography, and infections pose a significant risk factor for death. Bacteraemia is common in cirrhotic individuals and can lead to fever, abdominal pain, dyspnoea, shock, altered consciousness, and death [17].

The Child-Pugh classification estimates the prognostic stage of cirrhotic patients using four measures: serum albumin, bilirubin, prothrombin time, and ascites. It assigns three grades: Child-Pugh grade “A” with 45% survival chance, Child-Pugh grade “B” with 20%, and Child-Pugh grade “C” with less than 20% survival [21]. The mean Child-Pugh score was 9.12 ± 2.21 in our study, and high Child-Pugh score is significantly associated with blood component transfusion, intubation, UGI endoscopy, oxygen requirement, mortality, ICU admission, ventilator support, and hospital stay.

Maskey et al. and Bhattarai et al. discovered that most cirrhotic patients had Child-Pugh Class C. Among individuals with Child-Pugh Class C, varices were found in 79%. There was significantly different in varices detection across Child-Pugh classes [10, 14]. In a study conducted in North East India by Bhattacharyya M et al., 50% of patients had Child-Pugh class C disease, indicating advanced disease [15]. Hajiani E. et al. [22] reported similar results in Iran. These findings are consistent with our research. Alam et al. reported that 30% of patients were in Child-Pugh class B, and 70% were in class C [23]. Aziz M et al. found that 39.5% of patients were in Child-Pugh class A, 35.3% were in class B, and 25.1% were in class C [24]. Khan H et al. found that the majority (83.3%) were in Child-Pugh class A, possibly because most of the cases were due viral etiology in their study [21]. Yan GZ et al. found significant differences in liver function among Child-Pugh grades; 22% of patients had cirrhosis in grade A, 41% in grade B, and 36% in grade C [25].

Presence of altered mental sensorium, increased respiratory rate, low SpO2 (%), increased heart rate, low systolic blood pressure, low diastolic blood pressure, low GCS and biochemical variables such as low random blood sugar (RBS) (mg/dL), low hemoglobin (g/dL), low hematocrit (%), decreased platelets (x 103 /micro L), increased total leukocyte count (TLC) (X 103 /micro L), low pH, low HCO3 (mmol/L), increased lactate (mmol/L), increased prothrombin time (PT) in seconds, increased INR, increased blood urea (mg/dL), increased serum creatinine (mg/dL), increased AST (U/L), increased ALT (U/L) and low serum albumin (g/dL) are found to have a statistically significant association with mortality. The parameters independently associated with mortality in our study were presence of altered mental sensorium, Glasgow coma scale, Child Pugh class and need for ICU admission.

In cirrhotic patients presenting with altered mental states, there should be a high index of suspicion of HE. A study by Rahimi et al. found that the mortality rate of individuals hospitalised with AMS was higher than those with normal mental sensorium, emphasizing the necessity of screening all patients with cirrhosis for the existence of AMS [26].

Decompensated complications in CLD raise the lactate level by increasing lactate generation and decreasing lactate clearance [27]. Lactate is a reliable predictor of both short-term and long-term mortality in patients with CLD and it is also a poor prognostic indicator for critically ill patients with Liver Cirrhosis (LC) in the Intensive Care Unit [28, 29]. In this study, the lactate level was significantly predictive of mortality in patients with CLD visiting the ED.

Hepatocytes produce albumin in the liver, which is then released into the circulation. A lower albumin concentration can impact the prognosis of CLD patients [30]. Patients with cirrhosis who present to the emergency department with creatinine levels over 1.5 mg/dL and INR levels above 1.65 have an increased risk of mortality, according to a study by R.O. Ximenes et al. [31]. In their study, Jeong et al. investigated the relationship between predictive variables and mortality in ED patients with chronic liver disease and reported that albumin, MELD score, and lactate were associated with in-hospital mortality [32]. Patients with end-stage liver disease displayed lower systolic blood pressure (SBP), elevated serum lactate, lower serum albumin, and a higher incidence of acute kidney injury (AKI), according to a study by E. Okonkwo et al. [33]. As per study by Schopis. M. et al., the blood bicarbonate level at arrival was a significant predictive predictor for poor hospital outcomes for cirrhotic patients. More extended hospital stays, and mortality were strongly associated with low serum bicarbonate levels [34]. Gessolo Lins et al.‘s study revealed that patients with renal dysfunction in progression had more fatalities among cirrhotic patients, emphasizing the necessity of a sequential assessment of renal function [35].

While most studies yielded comparable results, variances were observed in a few cases, attributable to disparities in presentation duration, etiology, follow-up procedures, and treatment compliance.

This study had a small sample size. A more extensive, multicentric study is required before applying the results to the general population. Studies including more variable are required to find a good fit model to predict variance in mortality. The COVID-19 pandemic during the study period might have impacted our patients’ clinical profiles. Poor follow-up compliance among patients hindered our study, and might influence the results. Also, the study did not include patients admitted to the hospital via the outpatient admission system, potentially affecting the results.