Liver Disease and Hepatology
Core concepts
Approach liver disease by pattern: hepatocellular versus cholestatic injury, acute versus chronic, and compensated versus decompensated cirrhosis. Know the Child-Pugh and MELD scores and their roles in prognosis and transplant listing. Understand viral hepatitis serology, autoimmune markers, and metabolic workup (steatosis, iron, copper).
Cirrhosis complications include ascites, variceal hemorrhage, hepatic encephalopathy, spontaneous bacterial peritonitis, and hepatorenal syndrome. Know the management principles: salt restriction and diuretics for ascites, lactulose and rifaximin for encephalopathy, antibiotics for SBP, and vasoconstrictors plus albumin for hepatorenal syndrome. Recognize that a patient with cirrhosis and new ascites needs diagnostic paracentesis with cell count and culture.
Traps
Questions confuse transaminase patterns: an AST/ALT ratio above 2 suggests alcohol-related liver disease, while viral and autoimmune patterns differ. Another trap is attributing encephalopathy to ammonia alone; it is a clinical diagnosis. Also avoid giving NSAIDs or nephrotoxins in cirrhosis with ascites.
Rule of thumb
In any cirrhotic patient with new ascites, fever, or encephalopathy, perform diagnostic paracentesis and assess for SBP before assuming a benign cause.
Worked example
A cirrhotic patient with ascites and confusion: check for SBP with paracentesis, assess for precipitants of encephalopathy, and treat both rather than assuming one cause.