Gastroenterology · Chronic Liver Disease
The facts most likely to be tested
Spontaneous bacterial peritonitis (SBP) is diagnosed by an ascitic fluid absolute neutrophil count (ANC) ≥ 250 cells/mm³ and is empirically treated with third-generation cephalosporins like cefotaxime.
Hepatorenal syndrome is a diagnosis of exclusion characterized by pre-renal azotemia in a cirrhotic patient that fails to improve with albumin challenge.
Hepatic encephalopathy is precipitated by increased ammonia levels and is managed with lactulose to acidify the gut lumen and rifaximin to reduce ammonia-producing bacteria.
Esophageal varices require primary prophylaxis with non-selective beta-blockers (e.g., propranolol or nadolol) or endoscopic variceal ligation (EVL) in patients with high-risk features.
Child-Pugh score and MELD-Na score are the standard clinical tools used to assess prognosis and prioritize patients for liver transplantation.
Hepatocellular carcinoma (HCC) surveillance in cirrhotic patients requires abdominal ultrasound with or without alpha-fetoprotein (AFP) every 6 months.
Portal hypertension leads to splenomegaly, caput medusae, and esophageal varices due to increased resistance to portal venous flow.
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A 58-year-old male with a history of alcohol use disorder presents to the emergency department with fever, abdominal pain, and altered mental status. Physical examination reveals jaundice, palmar erythema, spider angiomata, and shifting dullness on abdominal percussion. Laboratory studies show an elevated INR, thrombocytopenia, and hypoalbuminemia. Paracentesis is performed, and the ascitic fluid analysis reveals an absolute neutrophil count of 450 cells/mm³.
What is the most appropriate next step in management?
Initiate intravenous cefotaxime
The patient has spontaneous bacterial peritonitis (SBP), defined by an ascitic fluid ANC ≥ 250 cells/mm³, which requires immediate empiric antibiotic therapy.
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High yield triage
Etiology / Epidemiology
Chronic alcohol use, Hepatitis C, and NAFLD are primary drivers. Progressive fibrosis leads to irreversible architectural distortion.
Clinical Manifestations
Look for spider angiomata, palmar erythema, and caput medusae. Ascites and hepatic encephalopathy are hallmark decompensation signs.
Diagnosis
The liver biopsy is the gold standard. Child-Pugh score and MELD score are used for staging and transplant prioritization.
Treatment
Spironolactone and furosemide manage ascites. Lactulose is first-line for encephalopathy. Avoid NSAIDs due to renal risk.
Prognosis
High risk of hepatocellular carcinoma. Monitor with ultrasound every 6 months. Upper GI bleed is a life-threatening emergency.
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Epidemiology & Etiology
Cirrhosis results from chronic injury, most commonly alcohol, HCV, and non-alcoholic steatohepatitis (NASH). Less common causes include hemochromatosis, Wilson disease, and primary biliary cholangitis (PBC). It represents the final common pathway of chronic liver disease.
Pertinent Anatomy
The liver's portal venous system drains the GI tract; obstruction leads to portal hypertension. Collateral circulation develops at the esophageal varices and caput medusae sites.
Pathophysiology
Chronic inflammation triggers stellate cell activation, leading to excessive collagen deposition and fibrosis. This creates regenerative nodules that compress hepatic veins, causing portal hypertension. Reduced synthetic function leads to hypoalbuminemia and coagulopathy.
Clinical Manifestations
Patients present with jaundice, ascites, and asterixis. Physical exam reveals spider angiomata, palmar erythema, and splenomegaly. Altered mental status indicates hepatic encephalopathy, while hematemesis suggests ruptured esophageal varices.
Diagnosis
The liver biopsy provides definitive histological confirmation. Labs show elevated PT/INR, low albumin, and thrombocytopenia from splenomegaly. Abdominal ultrasound is the initial imaging modality to assess for nodules and portal vein patency.
Treatment
Manage ascites with sodium restriction and spironolactone plus furosemide. Treat encephalopathy with lactulose to lower ammonia levels. Avoid sedatives and NSAIDs which precipitate renal failure. Propranolol is used for primary prophylaxis of variceal hemorrhage.
Prognosis
Patients require ultrasound every 6 months to screen for hepatocellular carcinoma. The MELD score determines transplant eligibility. Spontaneous bacterial peritonitis is a frequent, fatal complication requiring prophylactic antibiotics.
Differential Diagnosis
Alcoholic hepatitis: elevated AST:ALT ratio > 2:1
Budd-Chiari syndrome: hepatic vein thrombosis with acute pain
Hemochromatosis: iron overload with skin hyperpigmentation
Wilson disease: low ceruloplasmin and Kayser-Fleischer rings
Primary biliary cholangitis: positive anti-mitochondrial antibody