IntroductionFirst decompensation event in patients with cirrhosis is associated with worse clinical outcomes and requires prompt referral to transplantation. Little is known about impact of etiology of liver disease in type of decompensation, survival and occurrence of further events.Material and methodsWe consecutively analyzed data from patients admitted to ER from January 2019 to December 2022 for the first episode of decompensation, defined as ascites, hepatic encephalopathy, jaundice and upper digestive bleeding. Patients with previous or active HCC were excluded. We collected baseline features and survival rates, occurrence of further decompensation, transplantation and TIPS placement rates during follow-up.ResultsWe included 105 patients, 70 males (66.6%), with median age of 65 years (range 35-94). Among them 65 (61.9%) were unaware of underlying liver disease. The majority of patients (58, 55.2%) had alcoholic liver disease (ALD), followed by metabolic (17, 16%) and viral etiologies (11, 10%). Ascites was the most frequent event (60.9%), followed by jaundice (19%) and digestive bleeding (14.3%). Median survival was 17 months. After first decompensation only 32 patients (30%) didn't experience further liver events, 7 (6.6%) underwent liver transplantation and in 5 patients (4.7%) TIPS was placed. 53 patients died during the follow-up period. A lower rate of further decompensation, even if not statistically significant, was observed in ALD (45%) when compared to other etiologies (79% in metabolic liver disease, p=0.36).ConclusionsDuring last decades, active control of viral infections has deeply changed natural history of cirrhosis, with alcohol and metabolic disease progressively emerging as major causes of liver disease. Impressively, in our cohort, more than half of patients were unaware of their condition. First decompensation still significantly impacts on survival: therefore, more efforts are needed to increase specialist referral to improve early diagnosis and prevent decompensation.