A 35-year-old woman seeks evaluation at a clinic with a complaint of right upper abdominal pain for greater than 1 month. She says that the sensation is more of discomfort than pain. She denies any history of weight loss, changes in bowel habit, or nausea. Her medical history is unremarkable. She takes oral contraceptive pills and multivitamins every day. Her physical examination reveals a palpable liver mass that is 2 cm in diameter just below the right costal margin in the midclavicular line. An abdominal CT scan reveals 2 hypervascular lesions in the right hepatic lobe. The serum α-fetoprotein level is within normal limits. What is the next best step in the management of this patient’s condition?

Discontinue oral contraceptives

A 52-year-old man comes to the physician because of progressive abdominal distention and weight gain over the last 2 months. He was diagnosed with alcoholic liver cirrhosis with large ascites 1 year ago. He has congestive heart failure with a depressed ejection fraction related to his alcohol use. For the last 6 months, he has abstained from alcohol and has followed a low-sodium diet. His current medications include propranolol, spironolactone, and furosemide. His temperature is 36.7°C (98°F), pulse is 90/min, and blood pressure is 109/56 mm Hg. Physical examination shows reddening of the palms, telangiectasias on the face and trunk, and prominent blood vessels around the umbilicus. The abdomen is tense and distended; there is no abdominal tenderness. On percussion of the abdomen, there is dullness that shifts when the patient moves from the supine to the right lateral decubitus position. When the patient stretches out his arms with the wrists extended, a jerky, flapping motion of the hands is seen. Mental status examination shows a decreased attention span. Serum studies show: Sodium 136 mEq/L Creatinine 0.9 mg/dL Albumin 3.6 mg/dL Total bilirubin 1.9 mg/dL INR 1.0 Which of the following is the most appropriate next step in treatment?

Perform large-volume paracentesis

Refer for liver transplantation

Refer for peritoneovenous shunt

Change propranolol to carvedilol

Refer for transjugular intrahepatic portosystemic shunt

A 54-year-old man with alcoholism comes to the emergency department because of vomiting blood for 6 hours. He has had 3–4 episodes in which he has vomited dark red blood during this period. He has had no epigastric pain or tarry stools. On arrival, his temperature is 37.3°C (99.1°F), pulse is 134/min, and blood pressure is 80/50 mm Hg. He is resuscitated with 0.9% saline and undergoes an emergency upper endoscopy, which shows actively bleeding varices. Band ligation of the varices is done and hemostasis is achieved. He is diagnosed with Child class B cirrhosis. He is concerned about the possibility of recurrence of such an episode. He is asked to abstain from alcohol, to which he readily agrees. In addition to non-selective beta-blocker therapy, which of the following is the most appropriate recommendation to prevent future morbidity and mortality from this condition?

Transjugular intrahepatic portosystemic shunt

A 55-year-old man presents to urgent care for weakness and weight loss. He states for the past several months he has felt progressively weaker and has lost 25 pounds. The patient also endorses intermittent abdominal pain. The patient has not seen a physician in 30 years and recalls being current on most of his vaccinations. He says that a few years ago, he went to the emergency department due to abdominal pain and was found to have increased liver enzymes due to excessive alcohol use and incidental gallstones. The patient has a 50 pack-year smoking history. His temperature is 99.5°F (37.5°C), blood pressure is 161/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 95% on room air. Physical exam reveals an emaciated man. The patient has a negative Murphy's sign and his abdomen is non-tender. Cardiopulmonary exam is within normal limits. Which of the following is the next best step in management?

Right upper quadrant ultrasound

Smoking cessation advice and primary care follow up

A 49-year-old man presents to the emergency department with abdominal discomfort, fever, and decreased urination. He has a history of liver cirrhosis due to chronic hepatitis C infection. His blood pressure is 90/70 mm Hg, pulse is 75/min, and temperature 38°C (100.4°F). On physical examination he is jaundiced, and he has tense ascites with generalized abdominal tenderness. There is pitting edema to the level of his upper thighs. Which of the following excludes the diagnosis of hepatorenal syndrome in this patient?

Presence of 30 red cells/high powered field in the urine

Cirrhosis management for USMLE Step 3: High-Yield Internal Medicine Lessons

Diagnosis & Staging - The Scorecard

Gold Standard: Liver Biopsy for fibrosis staging.
Non-Invasive:
- Elastography (FibroScan) measures liver stiffness.
- Serum biomarkers (APRI, FIB-4).
Prognostic Scores:
- Child-Pugh: Assesses 1-2 year survival. 📌 PAABE: PT/INR, Ascites, Albumin, Bilirubin, Encephalopathy.
- MELD-Na: Predicts 3-month mortality; prioritizes for transplant. Uses $f(\text{Bilirubin, INR, Creatinine, Na})$.

⭐ A MELD score >15 is a common threshold for liver transplant referral.

Decompensation Management - Leaky Pipes & Brain Fog

Ascites ("Leaky Pipes")

Initial: Sodium restriction (<2 g/day) & diuretics.
- 📌 Mnemonic: Spironolactone to Furosemide ratio 100mg:40mg.
Refractory Ascites:
- Large-Volume Paracentesis (LVP): Albumin infusion (6-8 g/L removed >5L).
- Transjugular Intrahepatic Portosystemic Shunt (TIPS).
Spontaneous Bacterial Peritonitis (SBP):
- Treat with Ceftriaxone. Prophylaxis with Fluoroquinolones/TMP-SMX.

⭐ Spontaneous Bacterial Peritonitis (SBP) is diagnosed with an ascitic fluid absolute neutrophil count of >250 cells/mm³. Empiric treatment with a third-gen cephalosporin (e.g., Cefotaxime/Ceftriaxone) should be initiated immediately.

Hepatic Encephalopathy ("Brain Fog")

Acute: Identify & treat precipitants (e.g., infection, GI bleed).
Chronic:
- Lactulose: Titrate to 2-3 soft stools/day.
- Rifaximin: Add-on therapy if refractory.

Pathophysiology of Cirrhosis Complications

Varices & Bleeding - Code Red Protocol

Immediate Steps: Secure airway (ABC); 2 large-bore IVs.
Hemodynamic Support:
- Transfuse PRBCs if Hb <7 g/dL.
- IV fluids (crystalloids) for resuscitation.
Pharmacotherapy:
- Octreotide (somatostatin analog) bolus then infusion to ↓ splanchnic blood flow.
- Prophylactic Antibiotics (e.g., Ceftriaxone) for 7 days.
Urgent Endoscopy (EGD): Within 12 hours.
- Diagnosis & therapy (endoscopic variceal ligation/banding).
Refractory Bleeding:
- Balloon Tamponade (Sengstaken-Blakemore tube) as a bridge.
- Transjugular Intrahepatic Portosystemic Shunt (TIPS) if endoscopy fails.

Endoscopic view of esophageal varices with active bleeding

⭐ Prophylactic antibiotics (e.g., ceftriaxone) are critical, as they are proven to reduce mortality in acute variceal bleeds by preventing infections like SBP.

Long-Term Care - Surveillance & Solutions

HCC Surveillance:
- Ultrasound (US) +/- Alpha-fetoprotein (AFP) every 6 months.
Variceal Surveillance:
- EGD (esophagogastroduodenoscopy) at diagnosis.
- Repeat EGD every 1-2 years if varices are present, or 2-3 years if absent.
Vaccinations:
- Hepatitis A & B series if not immune.
- Pneumococcal (PCV13, PPSV23), annual influenza.
General Management:
- Abstain from alcohol.
- Avoid NSAIDs and other hepatotoxic drugs.
- Nutritional support to prevent malnutrition.
Definitive Therapy:
- Liver transplantation is the only curative option.

⭐ High-Yield Fact: Patients with cirrhosis who develop a new hepatic mass on ultrasound should undergo a triple-phase CT scan or MRI for definitive diagnosis of hepatocellular carcinoma (HCC). Biopsy is often deferred due to bleeding risk.

Ultrasound: Liver with HCC and portal vein thrombosis

High‑Yield Points - ⚡ Biggest Takeaways

Ascites is managed with sodium restriction and diuretics like spironolactone and furosemide.

For Hepatic Encephalopathy, use lactulose and rifaximin; always correct the precipitating cause.

Suspect SBP with ascitic fluid PMN > 250/mm³; treat with ceftriaxone.

Acute variceal bleeding requires octreotide and endoscopic band ligation.

Use non-selective beta-blockers like propranolol for variceal bleeding prophylaxis.

Hepatorenal syndrome is treated with albumin, midodrine, and octreotide pending transplant.

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