Chronic Liver Disease and Cirrhosis — Written Clinical Reasoning

SAQ 1 — Integrated Management of Decompensated Cirrhosis (20 marks, 30 minutes)

Prompt: Outline your integrated management plan for this patient, including immediate resuscitation, management of each decompensating complication with specific drugs and doses, and the role of liver transplant assessment. Justify each decision with reference to evidence. ^[1]

Model Answer

Problem list (4 marks):

1. Decompensated alcohol-related cirrhosis — Child-Pugh C (14), MELD-Na 29
2. Spontaneous bacterial peritonitis (SBP) — ascitic PMN 420 cells/microlitre, sepsis source
3. Acute kidney injury — rising creatinine, likely evolving hepatorenal syndrome precipitated by SBP
4. Grade 3 hepatic encephalopathy — precipitated by infection; airway risk
5. Tense ascites — symptomatic, impairing ventilation
6. Portal hypertension with varices on carvedilol — secondary prophylaxis
7. Alcohol dependence — needs addiction medicine and thiamine
8. Hyponatraemia (Na 128) and coagulopathy (INR 1.9) ^[1]

Immediate resuscitation and sepsis management (4 marks):

• Admit to HDU given grade 3 encephalopathy, sepsis and AKI; nurse semi-recumbent, protect airway.
• Spontaneous bacterial peritonitis — ascitic PMN count of 420 confirms SBP (threshold 250 or higher). Start cefotaxime 2 g IV every 8 hours for 5 to 7 days.
• Add intravenous albumin — 1.5 g/kg on day 1 and 1 g/kg on day 3. The Sort trial proved this reduces renal impairment (33% to 10%) and in-hospital mortality (29% to 10%) in SBP ^[1]. Given he is already AKI and hypotensive, albumin is essential.
• Blood cultures, urine culture, chest X-ray; sepsis bundle with IV fluids cautiously.

Renal management (4 marks):

• Cease all diuretics (spironolactone and frusemide) — diuretics worsen renal hypoperfusion in SBP.
• 48-hour albumin challenge — 1 g/kg/day for 48 hours.
• If creatinine does not improve after 48 hours, diagnose hepatorenal syndrome-AKI (HRS-AKI) and start terlipressin 1 to 2 mg IV every 4 to 6 hours plus albumin. The CONFIRM trial showed terlipressin achieves verified HRS reversal in 32% versus 17% ^[2]. Monitor closely for respiratory failure (a safety signal, more frequent with terlipressin in CONFIRM) and ischaemia.
• If terlipressin is contraindicated or unavailable, noradrenaline in ICU is the alternative.
• Do not give fresh frozen plasma for the INR of 1.9 — the rebalance theory means INR overestimates bleeding in cirrhosis.

Hepatic encephalopathy (3 marks):

• Identify and treat precipitant — the SBP is the driver.
• Lactulose 30 mL three to four times daily, titrated to two to three soft bowel motions per day.
• Add rifaximin 550 mg BID for secondary prophylaxis if encephalopathy recurs despite lactulose — rifaximin is an add-on for recurrent overt HE, not first-line monotherapy. The Bass trial showed rifaximin added to lactulose reduces breakthrough HE ^[3].
• Grade 3 encephalopathy warrants airway observation; avoid sedatives.

Ascites and nutrition (2 marks):

• Once sepsis controlled and renal function stabilised, perform large-volume paracentesis with albumin replacement (8 g per litre removed above 5 L).
• High-protein, high-energy diet — sarcopenia worsens outcomes; do not restrict protein in encephalopathy.
• Thiamine 100 mg IV/IM daily for 3 to 5 days (Wernicke risk in alcohol dependence). ^[1]

Transplant assessment and prognosis (3 marks):

• MELD-Na of 29 is a strong transplant indication (priority threshold generally MELD greater than or equal to 15; greater than 25 is high priority). Refer urgently to a transplant centre.
• Contraindications to address: establish alcohol abstinence (typically 6 months, though early transplant protocols exist for selected ALD); optimise sepsis and renal function first.
• Begin 6-monthly HCC surveillance (ultrasound plus AFP) if not already in place.
• Prognosis without transplant: decompensated cirrhosis with HRS carries roughly 50% mortality at 1 month. ^[1]