Skip to content

Welcome to Society of Hospital Medicine

Your Browser Is No Longer Supported. Please upgrade your browser from Internet Explorer 10 to Internet Explorer 11 or higher

SHM's Response to Racism in the U.S. — Learn More


More about Clinical Quick Talks

Do you have a clinical topic or resource you like to use while teaching that you want to share with colleagues?

Learn More

Download PDF 


Author: Brad Fedor

Definition: Fibrosis and regenerative nodules resulting from hepatocellular injury à Irreversible architectural changes to liver


  • Alcohol, NASH
  • Viral Hepatitis:
    • Hep B --> HCC w/o Cirrhosis
    • Hep C --> Cirrhosis --> HCC
  • Autoimmune Hepatitis
  • Metabolic Disease: Wilson’s, Hemochromatosis, α-1 AT deficiency
  • Biliary Tract:
    • Primary Biliary Cirrhosis (♀, Anti-mitochondrial Ab, Mononuclear infiltrate + bile duct destruction)
    • Primary Sclerosing Cholangitis (♂, Inflammation, fibrosis, and strictures of hepatic bile ducts)
  • Vascular: Budd-Chiari, R-sided CHF, Sinusoidal obstruction syndrome
  • Meds: Tylenol, Chemo, Supplements
  • Infection: CMV, TB

Decompensated Cirrhosis = Jaundice, Variceal bleed, encephalopathy, ascites

Physical Exam:

  • Liver: Enlarged, firm, eventually shrunken and nodular
  • Asterixis (negative myoclonus, sign of encephalopathy)
  • Ascites
    • Splanchnic Vasodilation à Sequestering of blood à éRAAS
    • Liver also can’t get rid of Aldosterone
    • Shifting dullness (wait 30 seconds to repercuss)
    • Flank dullness (NPV)
    • Fluid shift (PPV)
  • Estradiol excess
    • Gynecomastia (rim of breast tissue around nipple vs cancer), Palmar Erythema, Spider Angiomata, Testicular atrophy
  • Hand: Dupuytren’s contractures, White nail lines (Muehrcke’s lines), White Nail beds (Terry’s nails)
  • Clubbing (Hepatopulmonary syndrome, Megakaryocytes not inactivated when they pass through pulmonary system)
  • Leukonychia (edema under nail from low albumin)
  • Parotid Gland enlargement (Alcoholic cirrhosis)


  • Abdominal U/S w/ Doppler: Liver Size, R/o HCC, Ascites, Patency of Portal, splenic, and Hepatic Veins
  • Determine etiology
    • Viral Hepatitis Panel
    • Autoimmune Hepatitis: ANA, IgG, anti-smooth muscle Ab
    • Hemochromatosis: Iron studies, Liver Bx (Best)
    • Wilson’s Disease: Ceruloplasmin, Liver Bx
    • PSC: MRCP – Beads on a string, Bx – Onion skin fibrosis
  • Ascites
    • Paracentesis
      • Indications
        • New Onset Ascites
        • Progressive Symptoms
        • Tap during new admission
      • Contraindications
        • DIC only
    • Treatment
      • Restrict Na+
      • 100 spirinolactone : 40 furosemide
        • Dose to maintain Eukalemia
        • No response? à Increase Dose (Max 4x starting amount)
        • Still no response? àRepeat paracentesis, TIPs (Increase R side return)
          • TIPS CI: Encephalopathy, Pulm HTN, Portal vein Thrombosis

SAAG >1.1

SAAG <1.1

Total Protein <2.5


Portal HTN/Cirrhosis

Nephrotic syndrome

Total Protein >2.5


Budd chiari, Cor pulmonale





Sinusoidal (within liver, TP <2.5)

Post Sinusoidal (Past Liver, TP >2.5)

Liver Transplant

  • OLD: Child Pugh – Encephalopathy, Ascites (too objective)
  • NEW: MELD – INR, Cr, Bilirubin
  • Indications
    • Recurrent/severe encephalopathy
    • Refractory Ascites
    • SBP
    • Recurrent Variceal bleeding
    • HRS, HPS, HCC
    • Acute liver failure
  • CI: EtOH w/in last 6 months, sepsis, significant comorbidity
  • Survival
    • 1 – year --> 90%
    • 5 – years ..> 80%

Spontaneous Bacterial Peritonitis (SBP)

  • Infection of Peritoneal Fluid without disrupting viscus
  • Causes: Translocation or Sepsis
  • Bowel Wall edema → Lowered immune status
  • Ig/Complement gets diluted in Ascites
  • High mortality rate from Hepatorenal syndrome
  • Treatment
    • Cover GNR for 5-7 days
    • Give Albumin Day 1 + 3 to prevent Hepatorenal syndrome
  • PPx if:
    • GI bleed → Ceftriaxone (7 days)
    • Hx SBP → Fluoroquinolone
    • SAAG <1 → Low immunoglobin (Abx until d/c)
    • Varices → Propanolol or (large) banding
      • Causes: Splanchnic Vein Thrombosis, HVT, Cirrhosis

Hepatic Encephalopathy

  • Failure of Liver to detoxify NH3 à Cerebral edema
  • Stages
    • Confusion
    • Drowsiness
    • Stupor
    • Coma
  • Signs
    • Reversal of sleep-wake cycle
    • Mood changes
    • Asterixis
    • Lethargy, confusion
    • Constructional Apraxia (Can’t draw clock)
  • Treatment
    • Lactulose – Gut bacteria converts drug to lactic acid à Converts NH3 à NH4+ (preventing its reabsorption)
    • Rifaxamin – Inhibits Gut bacterial synthesis (binds to RNA polymerase)