Many liver disease patients, especially those with variceal bleeding and cholangitis, have an extremely high mortality. Early and aggressive management may help reduce mortality. When managing liver disease patients, providers should focus on their institutional resources, such as the availability of ERCP, as sicker patients may need to be transferred to larger facilities. The encephalopathic patient with a high INR, renal failure, and/or a Model for End-Stage Liver Disease (MELD) score greater than 20 should be considered for immediate transfer to a liver transplant center. Patients with advanced hepatic encephalopathy require ICU admission and frequently require endotracheal intubation. Transaminase levels five to ten times above the upper limit of normal frequently require observation or admission, as these transaminase levels raise concern for toxin-induced injury, shock liver, obstructive process, or infiltrative process. Acetaminophen at a dose of 2 grams or less daily is safe.