IM5.15-17 | Liver Disease Management — Summary & Reflection

KEY TAKEAWAYS

Liver disease management centres on six clinical domains:

1. Viral hepatitis: HAV/HEV = supportive; chronic HBV = TDF or entecavir (lifelong; TDF safe in pregnancy); chronic HCV = pan-genotypic DAA (SVR >95%); acute liver failure = emergency NAC + liver unit transfer + King's College Criteria for transplant.

2. Ascites: Sodium restriction (2 g/day) + spironolactone (100 mg) + furosemide (40 mg), 100:40 ratio; refractory: LVP + albumin (6–8 g/L removed) + TIPS; diuretic target: 0.5 kg/day weight loss.

3. SBP: PMN ≥250/mm³ → ceftriaxone IV immediately + albumin 1.5 g/kg day 1 + 1 g/kg day 3 (Sort trial); secondary prophylaxis: norfloxacin indefinitely.

4. Variceal haemorrhage: Terlipressin + ceftriaxone (simultaneously, before endoscopy) + EVL within 12 hours + continue vasoactive drug 3–5 days; target Hb 7–8 g/dL; secondary prevention: propranolol + repeat EVL.

5. HE: Identify and treat precipitant first; lactulose (2–3 soft stools/day); rifaximin for recurrent/refractory HE; protein 1.2–1.5 g/kg/day (do NOT restrict); Grade III–IV: airway protection.

6. HRS: Exclude other AKI causes + albumin trial 1 g/kg/day × 2 days → if no response = HRS → terlipressin + albumin; MELD ≥15 = transplant listing; HCC within Milan criteria = transplant referral.

Vaccination: HBV (0/1/6 months; birth dose within 24h; healthcare workers, chronic liver disease patients, HIV, haemodialysis). HAV (0/6–12 months; chronic liver disease, travellers, food handlers). NO vaccine for HCV or HEV (globally). HBV safe in pregnancy; TDF used if maternal HBV DNA is high.

Transplant indications: MELD ≥15 (decompensated cirrhosis), HCC within Milan criteria (single ≤5 cm or ≤3 nodules ≤3 cm), ALF with King's College Criteria, Wilson disease ALF, Crigler-Najjar type I. Contraindications: active extrahepatic malignancy, active substance use, severe cardiopulmonary disease.

REFLECT

Return to the three 2 AM patients in the opening hook. Patient 1 (variceal haemorrhage, BP 80/50): terlipressin IV + ceftriaxone IV now, resuscitate to Hb 7–8 g/dL, endoscopy within 12 hours — the two drugs save this patient before the scope is in. Patient 2 (grade III HE, dropping GCS): airway assessment first (grade III is one step from grade IV and aspiration); identify precipitants (is there malaena? fever? electrolytes off? diuretic excess?); lactulose via NG. Patient 3 (fever + known ascites): diagnostic paracentesis now — PMN count in 30 minutes determines everything; start ceftriaxone as soon as PMN ≥250 without waiting for culture. In all three cases, the decisive act is not a diagnosis — it is an intervention timed to a physiological threshold. This is the clinical essence of liver disease management at the final-year level.